Rating References(Part 3, Part 4, Live Manual, Trainings, Notes, Glossaries and some Paragraphs)

INDEX

Rating References (Part 3, Part 4, Live Manual, Trainings, Notes, Glossaries and some Paragraphs) & Rating References ARCHIVE are saved at H:\VSC\Rating Reference

http://digital.dav.org/publication/?i=341034 – American Veterans Disabled for Life Memorial

1. Useful Links and Locations 2. System/Computer Notes 3. Types of Claims

a. Clear and Unmistakable Error (CUE) b. Claims for Increase c. Reopened Claims

4. Evaluation Builder, VBMS-R & VBMS Info a. VBMS-R System-Generated Text b. Denial Reasons c. Denial Rationales d. Denial Free Text e. Notes

5. Effective Dates 6. Rating Notes

a. Misc Rating Notes b. Diagnostic and Analogous Codes c. Common Medications

7. Direct Service Connection a. Service b. Reserves c. 1151 d. Asbestos

8. Aggravation 9. Presumptive Service Connection

a. Claim Clarification and Solicitation b. Agent Orange/Herbicides c. Mustard Gas d. Gulf War e. Amyotrophic Lateral Sclerosis (ALS) f. Cancer

10. Secondary Service Connection 11. Evaluations

a. Reorganization of III.iv.4, Rating Specific Disabilities

b. Musculoskeletal , III.iv.4.A & III.iv.4.Bc. Eye , III.iv.4.C

d. Auditory/Hearing Loss and Tinnitus , III.iv.4.De. Infectious/Immune/Nutritional , III.iv.4.Ef. Respiratory , III.iv.4.Fg. Cardiovascular , III.iv.4.Gh. Digestive , III.iv.4.Hi. Genitourinary , III.iv.4.Ij. Gynecological , III.iv.4.Jk. Hemic/Lymphatic , III.iv.4.Kl. Scars and Skin , III.iv.4.Lm. Endocrine , III.iv.4.Mn. Neurological/Convulsive , III.iv.4.N (including

Traumatic Brain Injury (TBI))o. Mental , III.iv.4.O (including PTSD)p. Historic Part 4 Sections q. Improvement, Future Exams & Reductions

12. Other Decisions a. Individual Unemployability (IU) b. Pension/Permanent and Total c. Special Monthly Pension (SMP) d. Special Provision Determinations e. Competency f. Ancillary Decisions

13. Special Monthly Compensation (SMC) a. Part 3 - 3.350 b. VBMS-R Paragraph Codes c. Codes d. Aid and Attendance e. Blindness f. Two or More Extremities g. Examples

14. Family Member Ratings 15. Dental Decisions 16. Evidence

a. Deferral & Exam Request Info 17. Reasonable Doubt 18. Death Decisions

W. Rees 1 updated 7/25/18

USEFUL LINKS AND LOCATIONS –

eCFR - Part 3

eCFR - Part 4 - Appendix A has changes

Rating Schedule Quick Summary [spreadsheet] (from 2013) is saved at H:\VSC\Rating Reference

Compensation Service Intranet Home Page

Publications Index (References, etc.)

CPKM (incl Live Manual) – reload or F5 if times out, use quotation marks if want 2+ words

o Use http://www.knowva.ebenefits.va.gov/ when CPKM is down

o includes Compensation Service Bulletins (CSBs), Fast Letters(all rescinded), FAQs, M21-1, M21-4, Policy (DADs & OGCs), Rate Tables, Tip Sheets (all rescinded), Training Letters (all rescinded)…

Rating Job Aids o Effective Date Builder [and it’s User Guide and the Notes]

o Evaluation Builder [and it’s User Guide and the PowerPoint]

o Hearing Loss Calculator [and it’s User Guide] – for increases, generated language does not always list speech discrimination,unclear if this is intentional, might be related to using 4.86 & Table IVa (as recently as 1/17)

o Medical EPSS / MEPSS - Glossary, Acronyms & Abbreviations, Symbols, Graphics

o Index of DBQ/Exams by Disability & DBQ Switchboard

o Medical Abbreviations

VBN Broadcast Transcripts

VA Regional Office of Jurisdiction Lookup Tool CAVC-DAD

TBI, Case Law and Nehmer Timeline [spreadsheet with Case Summaries] is saved at H:\VSC\Rating Reference

Precedent GCOP (General Counsel Opinions) Compensation Service Weekly Calendar

VA Forms QRT – this is all old

Training

C&P Training VBA Learning Catalog

RVSR Assistant RVSR Flow Charts

JRVSR Skills Certification TMS [formerly LMS] – to reset assessments, send email to dir.vbasdc@va.gov ; under Favorites - VA

Shortcuts – National

H:\VSC\FY2013 LANES\Training\NTC Training Recordings\RVSR Self Study

*some sites under cptraining.vba.va.gov ask for a username & password, use vba\vsc…. and your LAN password

W. Rees 2 updated 7/25/18

Informational websites: VBMS (H:\VSC\Training\VBMS) [VBMS Resources (includes Fact Sheets & FAQs; Job Aids; Release Notes & Tips & Tricks)]; Minute Videos

VBMS Evidence Document Categories and Types is saved at H:\VSC\Rating Reference

STAR Narrative Reports (password is “narrative”) [or http://vbaw.vba.va.gov/bl/21/star/reports/star_rpts17.htm & choose Narrative Summary of Errors]

NWQ info -

National Work Queue (NWQ) - H:\VSC\Training\NTC Class Material\National Work Queue (NWQ), April 2016 Training:

Corporate Flashes - Homeless, Foreign, Restricted Access/RACC at St. Paul, Pre-Discharge at Winston-Salem, SD & ?, Congo [not kept at RO]

Special Issues - MST [put on PTSD contention], JSRRC Request, Specialized Records Request, RVSR Examination [when VSR asks us to write-up & input request for complex medical opinions – 1151, AGG (incl NSC AGG), diagnostic variation, conflicting medical opinions, question of credibility], Local Mentor Review for trainees [5 days to review, 2 days to correct], Rating Decision Review Levels 1 & 2 for 2nd & 3rd signatures [2 days to review, 2 days to correct], Local Quality Review for IPRs & IQRs, Local Quality Review Correction [have 5 days to correct or rebut, then 5 days more if upheld; if have 930, use Claim Label instead of Special Issue, if need to CLOSE 930, use “Clear tracking EP,” I think]; III.ii.4.G.2.m – RVSR must enter details of quality review error correction (incl specific corrective action taken, date & station # [EP 930]), December 2017 Quality Call Notes – more on 930s

Corporate Flashes are most important to keep file at correct station (M21-4, Appendix C); for all Special Issues except MST, if status changes, NWQ will still pull

RFDs – check VBMS Notes - if (1) NWQ Batch, will stay with you; (2) locally assigned by Coach, will be pulled by NWQ if VSR made RFD that same day; need to take action within 5 business days (or keep Coach apprised of issues), Coach can turn off your queue, don’t pull into VBMS-R until ready to work & only pull if in your queue

VSRs must upload emails, DPRIS responses, CAATS cancellations/emails (per III.iv.3.C.1.e)

National Work Queue – Phase 1 & 2 Playbook (revised 3/31/17 & 5/12/17) – may have to request access

Calculator: Add to or subtract from a date

CAPRI – as of 6/11/18, only open from shortcut on Desktop - You need to log into CAPRI often, as it will lock you out due to inactivity on the 30th day. If your CAPRI account gets locked due to inactivity you will need to create a “YourIT” (YourIT@va.gov) ticket AND attach a copy of your current HIPPA certification from TMS.

Joint Legacy Viewer (JLV) (CAPRI username & password), SharePoint-based JLV Training Resources available at: JLV Resources - All Documents, JLV - Home, JLV Network | VA Pulse 

Rating Tool / Rating Combinator –

http://vbaw.vba.va.gov/bl/21/rating/rat00.htm (it was gone from this page from 10/16 to 7/17, then they said “A corrected combinator calculator is now available”) *I have the 7/17 “corrected” version saved it at H:VSC/Rating Reference as “combinator.doc”) (the old combinator is saved at H:\VSC\Core Lanes\Rating One\RatingTool.exe)

WATRS –starts 7/3/17, “All excluded time and premium pay time must be entered into WATRS beginning July 1, 2017,” if this link doesn’t take you directly to WATRS, click on “App Launcher” (the 9 dots on the top left corner) & choose WATRS – EPR is in WATRs, to download, use Crosstab, then can open in Excel

If you have any login issues with WATRS system, please create a ticket with the Help Desk at:https://vacommunity.secure.force.com/helpdesk

Employee Performance Report (EPR) (starts 7/3/17) – one day lag on information

NSD Service Desk Manager tool / CA Service Desk Manager - National Service Desk (NSD) (855) NSD-HELP, (855) 673-4357 [option 3 for VBA support] or non-urgent requests can be emailed to National Service Desk – Philadelphia at ITSC@va.gov (processed w/i 24 hrs) - INCLUDE CURRENT PHONE #, AS OFTEN

W. Rees 3 updated 7/25/18

INCORRECT; changed to ESD@va.gov in 9/17 (sent email 9/6/17 & they do not allow encrypted emails, so still sending anything with file # to itsc@va.gov) – AS OF 1/6/18, ESD@va.gov CAN now get encrypted emails

If you receive a (phishy) message … you have likely been targeted by a cybercriminal, and you should follow these steps:o Expand the email to fill your computer screen.o Take a screenshot of the message by pressing the Print Screen (PRTSCR) button.o Open a Word document and paste your screenshot into it by simultaneously pressing the

“Control” and “V” keys.o Save the document to your desktop.o Open a new email to cdco-nsd@va.gov (the National Service Desk DevOps Center) with the

subject line “Suspicious Email Screenshot Attached.”o Delete the email from your inbox and Deleted Messages folders.

NSD VBMS Service Desk– vbmssvcdesk.vbaco@va.gov

as of 3/28/18, YourIT Services - https://vaww.oit.va.gov/yourit/ (should be on your desktop), YourIT@va.gov

From: Braden, Dwayne (OI&T - San Diego) On Behalf Of VAVBASDC/IRMHDSent: Friday, March 30, 2018 7:41 AMSubject: ServiceNow Ticketing SystemNow that we have transitioned over to the new ServiceNow ticketing system, please be aware of the following:*Emailed tickets should be sent to YourIT@va.gov (no longer ITSC@va.gov), requesting that the ticket be routed to ‘San Diego Regional Benefits Office’. This will ensure we receive your ticket faster*You can still use the (855) 673-4357 number to call in tickets, ensuring you inform them of your location (San Diego Regional Benefits Office)*When using the “Self Service” portal (https://yourit.va.gov/va), always click the “Ask for Help” icon to create an incident, even when requesting additional hardware or software. Do not use “Make a Request” icon at this time.

From: US Department of Veterans Affairs Sent: Thursday, April 26, 2018 8:42 AMSubject: Protect Veteran and Employee Data When Using Your IT Services

Your IT Services: How to protect Veteran and Employee data

This week is Information Security and Privacy Awareness Week and we wanted to remind everyone how to protect Veteran data when asking for help or requesting services from Your IT Services.

Ensure personally identifiable information (PII) and protected health information (PHI) is only shared securely. Do not enter PII and PHI text or attach documents with PII and PHI when submitting a ticket. If PII and PHI are needed for the resolution of your issue, please keep that information secure outside of

Your IT Services, but do make a note about it in your ticket.o State that you have PII or PHI necessary for the technician who will be assigned to resolve your issue

and that they should contact you when they need it.  o The technician will reach out to you when the data is needed and you can exchange it securely, such as

over encrypted email. To report Privacy or Security related events in accordance with VA Handbook 6500.2, Management of

Breach’s involving Sensitive Personal Information:o Immediately contact your Facility Privacy Office (PO) or Information Security Officer (ISO).o At no time should actual or suspected Privacy or Security related events be reported within Your IT

Services.

Always access Your IT Services by clicking on the “Your IT” icon on your desktop. If you can’t access Your IT Services or prefer to talk to someone, please call the Enterprise Service Desk at 1-855-673-4357. TTY users may dial 1-512-326-6638. For user guides and training videos visit the Your IT Services intranet page.

Protecting the sensitive personal information of the Veterans we are entrusted to protect is of the utmost importance, ensuring that proper protocols are followed will assist in the timely mitigation of any events.

The Office of Information and Technology

W. Rees 4 updated 7/25/18

From: Riggs, William A. (OI&T - San Diego) Sent: Monday, May 07, 2018 3:19 PMSubject: Assistance Requesting IT Tickets

There is a new requirement when submitting a ticket using the youtIT self-portal to include hostname (PC/Computer Name) and EE number of the of the affected system.

To help make finding the Computer Name easier IRM has added a utility in the LOCAL APPS folder called Computer Name.

It will show the following information, sample provided is from my workstation.

When providing the EE number please provide the EE number from the specific equipment you are reporting; laptops, PCs, printers and monitors all have a different EE tag.  See the below screen shot as a sample.  Please do not provide the EE number to your monitor if the problem being reported is for the PC.

W. Rees 5 updated 7/25/18

eOPF – previously https://eopf.nbc.gov/va

MyPay VATAS (eff 10/22/15; flast6789 [last 4 of SSN]; 12 char, 1 upper, 1 lower, 1 #, 1 spec char; change every 90

days) - https://www.vapulse.net/groups/vatas; under Favorites - VA Shortcuts - National

https://vaww.portal.fsc.va.gov/FSS/PSSD/CVATASOPS2/SitePages/Home.aspx - tried 10/6/15, but access was denied

https://vaww.fsccollaboration.fsc.va.gov/VATAS%20Support/SitePages/Home.aspx

enter requests involving different pay periods in different requests (do not cross pay periods)

Jury Duty is under Administrative

Check AWS code (0=no AWS & can’t earn credit hours; 6=9 hour shifts; 8=10 hour days)

VA Pulse – under Favorites - VA Shortcuts – National; How to Copy and Paste into VA Pulse: https://www.vapulse.net/docs/DOC-2363 ; How to Upload A File or Document: https://www.vapulse.net/docs/DOC-1754

VA Notification System (VANS) Problems Steps Recorder (PSR)

SDRO Links: Start – All Programs – LOCAL APPS – User Backup

\\vbasdcfpc2\shared

Station Directives and Policies SharePoint Site VSC Policy Memos folder

H:\VSC\Rating Reference with “Rating References” document folder of DBQ Call Meeting Minutes from http://vbacodmoint1.vba.va.gov/bl/21/dbq/DBQcall.asp

(discontinued per August 2015 Quality Call Notes, only August 2011 to March 2015) folder of Quality Call Notes from http://vbaw.vba.va.gov/bl/21/star/star_call.htm (as of March 2015, no

longer called “Rating” & “Authorization,” just Quality Call, subsequently names all changed), per VA Pulse, https://www.vapulse.net/message/6232, will not be in Live Manual

folder of Quality Call Trainings from http://vbaw.vba.va.gov/bl/21/star/star_call.htm (links no longer on page, only 2009 to 2013)

folder of IRR Consistency Studies from http://vbaw.vba.va.gov/bl/21/data/quality/consis/consis_irrs.htm (nothing since January 2013)

Training (H:\VSC\Training\NTC Class Material)

All NTC training recordings are located here: H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18 OR You can find the recorded training library HERE. Also, don’t forget to sign the Muster Sheet

H:\VSC\Training\Education & Training Library H:\VSC\Training\Class Schedules\

VSC Training SharePoint – might be old, so might want to use Muster Sheet link above

Click on + next to your name

Click on the square next to your name, then Edit Item, then Completed, then Save

Projected OT Sign IN-OUT for OT This link can be used to map any network printer on the San Diego network and can be

very useful after moving cubicles. Click Here to Map a Network Printer

W. Rees 6 updated 7/25/18

From: VAVBASDC/RO/DIR Sent: Monday, October 30, 2017 9:41 AMSubject: San Diego VARO PIV Outlook MailboxColleagues,We have established a new corporate mailbox for PIV-issue related questions to make it easier for you. Please send all PIV-issue related questions to piv.vbasdc@va.gov moving forward.  The phone number for PIV questions remains 619-400-1500.

From: VAVBASDC/RO/DIR Sent: Friday, February 09, 2018 11:02 AMSubject: HR Corporate MailboxColleagues,For your awareness, when contacting HR you no longer have to individually type every HR employee’s name; please email the corporate HR mailbox: hrm.vbasdc@va.gov and the applicable HR employee will follow-up . Thank you.

WAH Links: VA Remote Access (RA) Information and Media Portal

Remote Access Portal (RAP)

Terminal Server/Citrix link – click on Log On, DO NOT CHOOSE “Switch to smart card,” select “R05-VBApp Desktop,” Permit Use & Don’t ask me again; do not use Disconnect, instead do Start – Log off; to get in both monitors, from drop down at top of screen, select Window to reduce vba apps desktop screen, then drag so that it is partially on both monitors, then select Full-Screen to enlarge

o As of 12/21/16, only use https://citrixaccess.va.gov (available in IE under Favorites – VA Shorcuts – National)

VA Resources Guide [from VA101] is saved at H:\VSC\Rating Reference

www.va.gov

Homeless Veteran Hotline – 877-4AID-VET (4243-838)

Veteran Crisis Hotline – 800-273-8255, option 1

VHA

www.va.gov/healthbenefits/, 877-222-VETS (8387), www.va.gov/healthbenefits/apply/veterans.asp, www.1010ez.med.va.gov, http://explore.va.gov/health-care, www.va.gov/landing2_locations.htm; www.myhealth.va.gov/index.html, 877-327-0022; www.womenshealth.va.gov, 855-VA-WOMEN (829-6636); www.ruralhealth.va.gov; www.mentalhealth.va.gov, www.mentalhealth.va.gov/docs/MHG_English.pdf, http://maketheconnection.net/, https://www.vetranscrisisline.net/; www.va.gov/directory/guide/vetcenter.asp, 877-WAR-VETS (927-8387);

Veterans Employment Services Office (VESO) – www.vaforvets.va.gov, 855-824-8387, http://explore.va.gov/employment-services

Transition Assistance Program (TAP) – www.benefits.va.gov/TAP/

NCA

www.cem.va.gov, 800-827-1000, http://explore.va.gov/,

VBA

www.benefits.va.gov/benefits, 800-827-1000, http://explore.va.gov/, www.va.gov/opa/publications/benefits_book.asp, www.ebenefits.va.gov/, www.benefits.va.gov/BENEFITS/videos.asp; www.benefits.va.gov/homeloans/index.asp, 877-827-3702, http://explore.va.gov/home-loans-and-housing; www.benefits.va.gov/vocrehab, http://explore.va.gov/employment-services; www.benefits.va.gov/gibill/, 888-GIBILL-1 (422-4551), http://explore.va.gov/education-training, https://www.vets.gov/gi-bill-comparison-tool; www.benefits.va.gov/pension/, http://explore.va.gov/pension; http://www.benefits.va.gov/fiduciary; www.benefits.va.gov/insurance, 800-419-1473, http://explore.va.gov/life-insurance; www.benefits.va.gov/compensation/types-disability.asp, http://explore.va.gov/disability-compensation; www.benefits.va.gov/compensation/types-dependence_and_indemnity.asp, http://explore.va.gov/spouses-dependents-survivors

BVA

www.bva.va.gov, www.bva.gov/docs/Pamphlets/How-Do-I-Appeal-Booklet-508Compliance.pdf

W. Rees 7 updated 7/25/18

W. Rees 8 updated 7/25/18

SYSTEM/COMPUTER NOTES:

Keyboard shortcutsCTRL + SHIFT + A = to get SNL codes

CTRL + A = select allCTRL + B = boldCTRL + C = copyCTRL + F = find (search)CTRL + N = new document/spreadsheet in Word/Excel (also works in PowerPoint)CTRL + O = openCTRL + S = saveCTRL + V = pasteCTRL + W = closeCTRL + X = cutCTRL + Z = undo (works in VBMS-R)

CTRL + Backspace = deletes entire wordCTRL + Left arrow = moves cursor to beginning of previous wordCTRL + Right arrow = moves cursor to beginning of next wordDouble click = selects wordTriple click = selects paragraphALT + Tab = cycles through currently open windowsALT + F4 = close current programWindows + Left arrow = current window moves to left side of monitorWindows + Right arrow = current window moves to right side of monitorWindows + L = lock computerWindows + M = minimize allCTRL + Enter = adds www. and .com to a URLCTRL + Shift + T = reopens most recently closed tab

VBMSYou can open multiple documents without navigating away from the documents screen by holding “Ctrl” when clicking on the docunents you want (it will open each document in another tab without leaving the documents screen).

To automatically launch a website when starting your computer: Right click anywhere inside the open website window & select Create Shortcut from the drop down list, then confirm

that you want to add the website by clicking Yes The shortcut icon will appear on your desktop Click on Start button – All Programs – right click on Startup folder, then select Open Drag the shortcut icon from your desktop into the Startup folder, then close the folderWhen you restart your computer, the webpage will open automatically

Please ensure you Backup correctly by completing the following steps:

Click START All Programs>LOCAL APPS>User Backup

W. Rees 9 updated 7/25/18

Electronic Signature Procedures (i.e. how to sign a .pdf document)1. Open the .pdf document you wish to electronically sign.2. Make sure your PIV card is attached to your computer3. Click on “Fill & Sign” button in the top right corner 4. Click “Sign with Certificate” option in the right column5. The following message will appear. It basically tells you when you make a rectangle this will be the area where your signature will appear.

Click “Drag New Signature Rectangle”

6. Click and drag your cursor to make a rectangle. The space within the rectangle is where your electronic signature will appear.7. The Sign Document dialog box will appear, click on the “Sign” button.8. Save the new document with your electronic signature. Note, you may overwrite the previous .pdf document for the newer one with the electronic signature.

With the upgraded Adobe (in early 2018):o Click on “Tools” located on the menu baro Select “Certificates” icono Click on “Digitally sign” located in the middle of the screen at the top under the menu bar

If the following prompt displays – click ok

W. Rees 10 updated 7/25/18

o Using your mouse, draw the box in the PDF where you want your digital signature to appear (additional prompts will populate to ensure the signature is correct)

o Save the PDF document to your desktop, if you do not already have a designated folder for PDF documents

Outlook –

To set to automatically encrypt:

File > Options > Trust Center > Trust Center Settings > Email Security > check “Encrypt contents and attachments for outgoing messages” & “Add digital signature to outgoing messages”

as of sometime before July 2018, we are no supposed to unencrypt emails that do not contain sensitive info:

To find a person by their “vscflast” or “adjflast” name listed on the RD:

New Email – To – Advanced Find – type the above name in Alias.

Always email the prior RVSR if you get a case assigned to you that is locked in VBMS-R:

This message means prior RD was not promulgated. Click “Cancel” (if you click OK, the prior RD will be lost), check VBMS to see if the prior RD was promulgated. If not, notify your Coach that the RD needs to be promulgated before another RD can be done (or it needs to go back to the prior RVSR to correct their RD & now add the deferred issues). It’s also best to make a Claim Note so that everyone knows what’s going on with the case: W. Rees 11 updated 7/25/18

If you get a message you are unsure of, always email the prior RVSR to see if you should work the case.

Microsoft Lync –

Online MeetingsEnsure you are connected either at a port in the office or at home through VPN (apparently being connected through Citrix causes problems).

When you get the appointment, choose  (usually you can choose “Do Not Send a Response”), then you will automatically get a reminder 5 minutes before the meeting.

When the reminder pops up, click on:

If you don’t get the reminder, open the email or the calendar entry & click on:

(at the top of the email/calendar entry)or click on:

(inside the actual email/calendar entry)

Then select:

Do not select either of the other two choices!

If you disconnect accidentally, you can click on Rejoin:

Then select Lync:

W. Rees 12 updated 7/25/18

Do not select any of the other choices!

You can tell sound is coming from your line/computer if you see this: 

If anyone did not connect as above & is incorrectly having Lync call them, the presenter should be able to mute the audience & you will see this:

Conversation HistoryTools/gear icon - Personal – uncheck “Save instant message conversations in my email Conversation History folder”

Excel – Freeze Panes is under “View” tab

VBMS FIXESFrom Start Menu – Clear Browser Cache & IE Clear Cache (for more info: http://vbaw.vba.va.gov/VBMS/docs/VBMS_Job_Aid_Clear_Browser_Cache_20131001.pdf)

From Start Menu – Control Panel (can do View by: Small Icons; or View by: Category, then under Programs) – Java – General – Settings – Restore Defaults, then Delete Files (ensure all 3 are checked), OK, OK, Apply, OK (clear Java cache - https://yourit.va.gov/va?id=kb_article&sys_id=a29cfe5ddb778b00da3330ca7c961952)

Close IE & reopen [#1 step for adobe memory issue]

In IE (with only one tab/window open) –Tools Icon or Tools from Menu – Internet Options – General tab – Browsing History - Delete – uncheck “Preserve Favorites website data” & check “Temporary Internet Files” and “Cookies” (this clears cache & cookies; another direction says to check everything but “Preserve Favorites website data”)– Delete – Apply – OK [#2 step for adobe memory issue (did not say anything about what to check, probably can check everything but “Preserve Favorites website data” & “Tracking Protection, AxtiveX Filtering and Do Not Track”))]

Tools Icon or Tools from Menu – Internet Options – Advanced tab – Reset – Reset - Close (it might close automatically) – then go in again & Restore advanced settings – Apply – OK – OK – Close IE [#3 step for adobe memory issue]

From Start Menu – type in CMD - a black window will open - type gpupdate /force - wait to receive the message “Computer Policy has completed successfully.” then X out [#4 step for adobe memory issue]

W. Rees 13 updated 7/25/18

In IE (with only one tab/window open) –Tools Icon or Tools from Menu – Compatibility View Settings – make sure all 3 (at some point just 2) boxes are unchecked (especially important is “Display intranet sites in compatibility view”) & ensure va.gov is not in the box “Websites you’ve added to Compatibility View” If cannot find Tools – Compatibility View Settings, ensure that the Menu bar is showing (right-click on top of browser bar & put a check next to Menu bar) [#5 step for adobe memory issue]

***Might need to do this again: From Start Menu – Clear Browser Cache & IE Clear Cache

*Might have to right-click on top of browser bar & choose “Show tabs on a separate row”

If still having trouble with VVA Tab after the above...

From Start Menu – Control Panel (can do View by: Small Icons; or View by: Category, then under Programs) – Java – Security tab – Certificates – select “Daeja Image Systems Ltd” – Remove – OK – Close – OK

If still having trouble, reboot.

If still having trouble, call NSD.

Possible solutions for “Insufficient Data for an Image” issue, per VA Pulse https://www.vapulse.net/thread/36527:

Zoom out until you can see the contents of the document.

OR

Open an Adobe document, click on “Edit,” then “Preferences,” then “Page Display,” then “Zoom,” then “Fit Page,” then click OK in the bottom right corner.

OR

CTL-ALT-DELETE, then “Start Task Manager,” click on “Processes” tab, find anything using a lot of memory, click on it & do “End Process”

As of 12/13/17 (updated 1/23/18):VBA users have encountered numerous issues over the last several weeks when running production applications that use Adobe Reader and Internet Explorer.  Applications such as VBMS, TIMS, and CAATS have experienced application crashes and hangs, latency issues, and error messages that have impacted production work.  SME have identified a setting that needs to be changed.

All users must perform the steps below at least once a day to ensure your application experience is optimized.

Beginning of the day or after the workstation is rebooted, close all current running applications, if any. Open Adobe Acrobat Reader DC Click on the Edit menu and select Preferences to open the Preferences window In the left pane, click on Security (Enhanced) In the Sandbox Protections section at the top of the window, check the box for Enable Protected Mode at startup User will be prompted with below message when “Enable Protected Mode at startup” setting is checked.  Click on

Yes button to continue. Click the OK button at the bottom of the window to save the Preferences and close the window. Close all instances of Adobe products to ensure that the setting change is applied. Repeat step 1 thru 8 as necessary prior working on your applications, especially when you need to have your

workstation rebooted.

The setting will still revert each time a user logs in to his/her Windows session. Therefore our customers need to be informed to turn Protected Mode on at least once per day.

As of 3/18 upgrade to Adobe Acrobat Reader DC, to get block to enter page #, float mouse over top middle of pdf & it will

show: (Show Adobe Acrobat Reader Toolbar (Ctrl+H))

VBMS workarounds after 9/17 “upgrade”:W. Rees 14 updated 7/25/18

For wide columns – with the VBMS window maximized, click on the top grey area & pull it so it minimizes, then drag it back up to the top of the screen so it maximizes again (re-snap); it’s temporary, but it helps ; OR just click on the “Save Preferences” button

For Document Types that won’t save changes – instead of changing it inside the open document, check the box for that document on the document screen & in the drop down for Actions, select “Edit Properties” (can only do one document at-a-time)

Permanent Search BAR in VBMS (after 3/18 upgrade):Gear icon in VBMS top Right - User Preferences – leave “None” for Line of Business – check “Always show the Search Bar” – Save

Snipping Tool:

TYPES OF CLAIMS -

To establish a claim in VBMS.

Put the claim number in and Open eFolder Actions drop down Select ‘New Claim’ Scroll to the bottom under ‘Claim Information’ EP & Claim Label – type in 310 Select which best fits (Future routine exam, 4140, ect.) Date of Claim – enter same as EP 810 Segmented Lane – Core Click submit

Decision Ready Claim (DRC) –need special issue on one contention:

• Decision Ready Claim• Decision Ready Claim – Deferred• Decision Ready Claim – Partial Deferred

*take off special issue if excluded**claim must be signed by veteran

Decision Ready Claim (DRC) Initiative Standard Operating Procedures and DRC FAQs for VSC Employees are saved at H:\VSC\Rating Reference

III.i.3.CIII.i.3.D

December 2017 Quality Call Notes – expansion of DRCApril 2018 Quality Call Notes – DRC info (PowerPoint has lots of info too)

W. Rees 15 updated 7/25/18

3.103 Procedural due process and appellate rights –

I.2 III.iv.8

3.104 Finality of decisions –

Hamilton et al v. Brown (4/15/93) - finality issues & informal claims III.iv.2.B.1

3.105 Revision of decisions, III.iv.2.B – CUE: 3.105(a); III.iv.2.B.7, III.v.1.I.3 (updated 4/17/18, administrative error, doesn’t seem this is for rating errors, but does have info on waiving overpayments), IV.ii.3.A (updated 5/17/18)VA Pulse discussions on CUEs & proposals/due process - https://www.vapulse.net/message/178138, https://www.vapulse.net/message/167093, https://www.vapulse.net/thread/7934 (this one includes a nice chart that isn’t approved, but is helpful); My Notes: Guidance is unclear in the manual (even with the 4/17/18 & 5/17/18 updates), but CO has said that due process is still necessary for CUEs that do not impact the current payment (i.e. effective dates), as they impact a past payment & the correction of the error will create an overpayment. Proposals are not needed if a CUE does not change future or past benefits.DOO: 3.105(b), 3.400(h); III.iv.2.B, III.vi.1.A.1Severance of SC: 3.105(d); III.iv.8.E.2, IV.ii.3.A.2.l; includes COD from 3.105(c)Reduction in evaluation: 3.105(e), III.iv.3.B, III.iv.8.B&D, IV.ii.3.A.3Liberally construing evidence: I.5.D & Harris v. Shinseki (2013)

Cotant, 17/not published - pre-existing condition and aggravation; Clear and Unmistakable standard; Judicial notice; Absurd results; merely having greater probative value does not raise to the level of their being Clear & Unmistakable evidence

Henderson 12/11 - why CUE claims are separate issues to be adjudicated when claimed

Burris v. Principi 15 Vet. App. 348 - CUE not applicable where the claimant is not entitled to receive the benefit [usually with accrued]

Schutte v. Gober 4 Fed.Appx. 787 (15 Vet. App.) - CUE requires heightened pleading requirement, “persuasive reasons must be given as to why the result would have been manifestly different but for the alleged error.”

Gross (1992) Hill (1992) Murincsak v. Derwinski (4/24/92) & Bell v. Derwinski (7/21/92) - get VAMC records [GC Opinion 12-95

(5/10/95) – can find CUE on decisions final on or after 7/21/92 based on constructive notice of medical records, based on Bell case]

Russell v. Principi (10/6/92) - decision makers have no authority to revise determinations on the same evidentiary record or factual basis in the absence of "clear and unmistakable error"; definition of CUE (6 criteria must be met: 1- facts known at the time were not before the adjudicator or the law was incorrectly applied, 2- error was based on the record and law at the time, 3- outcome would have been manifestly different; other 3?); claimant must be specific and assert “more than a disagreement as to how the facts were weighed or evaluated”; appellant “bears an extra-heavy burden” of persuasion; cannot apply benefit of the doubt in CUEs

Newman v. Brown (5/12/93) - NWG if doesn’t meet criteria, so it was not a CUE

Fugo v. Brown (11/16/93) – more on CUEs, need (from claimant) specificity of error & persuasive reasons for why result would be different, cannot allege a CUE based on improperly weighing and evaluating evid, not a mere broad allegation of a failure to follow the regulations, or the failure to give due process, or any other general, nonspecific allegations of error; how evidence was developed (duty to assist), weighed (benefit of the doubt), or explained (reasons & bases) are not valid; need different result for it to be CUE

Please note that per Fugo v. Brown your allegation of "a clear and unmistakable error on (your) previous claim for perforated eardrum" is not specific enough, as an allegation of a clear and unmistakable error must state the specific error, as well as persuasive reasons for why the result would be different.

W. Rees 16 updated 7/25/18

Allin v. Brown (2/14/94) – failure to follow the procedures in the Physician’s Guide for Disability Evaluation Examinations is not a CUE; not retroactively applying changes in the law concerning POW presumptives is not a CUE

Sondel v. Brown (2/16/94), Link v. West (11/18/98), and Grover v. West (1/5/99) - good CUE discussion Caffrey v. Brown (3/31/94) - not assisting in development is not a CUE, evidence not on record is not a

basis for a CUE- just incomplete, not incorrect

Mindenhall v. Brown (12/20/94) - a claim of CUE must be specific and not a mere broad allegation of a failure to follow the regulations, or the failure to give due process, or any other general, nonspecific allegations of error

Phillips v. Brown (1/13/97) – cannot allege a CUE based on improper weighing of evidence or wrong decision (need specifics)

Simmons v. West (8/30/00) – “The veteran’s claim is thus a request of a reweighing of the evidence, which is not a permissible basis for a CUE claim…when there is evidence both pro and con on the issue it is impossible for the appellant to succeed in showing that the result would have been manifestly different.”

DAV, NOVA, PVA & VVA v. Gober (12/8/00) - once there is a final decision on a CUE claim there can be no further CUE claim; cannot deny a claim of CUE for lack of meeting pleading requirements- denial must be on the merits.

Andre v. Principi (8/29/02) - CUE discussion, specificity

Jordan v. Principi (9/24/03) - good discussion of issue of whether a condition existed prior to enlistment and aggravation; CUE “does not include the otherwise correct application of a statute or regulation where, subsequent to the Board decision challenged, there has been a change in the interpretation of the statute or regulation.”

proposereduc - proposed reduction

3.105(e) – please note that this is different than 3.655III.iv.3.B.2.gIII.iv.8.B.1 (III.iv.8.B.1.b – proposed combined evaluation is required)III.iv.8.D (III.iv.8.D.2.d – check prior evals too; if at 40% for fewer than 5 years, but was at 20% before that for a few years (over 5 years, but not 20 years total) & current DBQ shows 10%, need to CCEVAL & get RFE (but if will be 55 before RFE, CCEVAL & no RFE); do not reduce to 20% based on current DBQIV.ii.3.A.3

Issue: Evaluation of {} currently evaluated as {} percent disabling.

Decision: Evaluation of {}, which is currently {} percent disabling, is proposed to be decreased to {} percent.

Reasons for Decision:The evaluation of {disability name} is proposed to be decreased to {} percent disabling. The DBQ shows improvement/you are in remission/you are status post prostatectomy and in watchful waiting status. You have been evaluated at {} percent for fewer than 5 years and there is no other evidence to support this {} percent evaluation.ORThe evaluation of {disability name} is proposed to be decreased to {} percent disabling because the prior DBQ, the treatment records and the current DBQ show sustained improvement. Although you have been evaluated at {} percent for more than 5 years, sustained improvement is shown and there is no other evidence to support this {} percent evaluation.

This proposal is based on:…

If the proposed reduction takes effect, your combined evaluation will be {} percent.if multiple issues: If the proposed reductions take effect, your combined evaluation will be {} percent.

Add this, per QRT/Konane Stradling, 1/16 (but not in manual & not technically required in narrative):As this is a proposed action, you will have 60-days from the date of this notification letter to provide additional evidence to support why this action should not be taken or request a hearing. If we do not receive a request for a hearing or additional evidence supporting the continued evaluation or entitlement to service connection for

W. Rees 17 updated 7/25/18

this condition, a new rating will be sent finalizing this proposed rating. The effective date assigned will be the first of the month following 60-days from the date of that final notification letter to you.

November 2017 Quality Call Notes & December 2017 Quality Call Notes - When proposing a reduction/discontinuance under 38 CFR 3.105(e) for improvement, the notification letter should not provide a proposed effective date, but rather should discuss the 60-day period during which new evidence may be submitted. If the Veteran does not respond, the final rating assigns an effective date which is the first of the month following a 60-day period from the final rating. See M21-1 Part III.iv.8.D.1 and M21-1 Part IV.ii.3.A.3. Unclear if above paragraph is still required.VSR: This is a proposed reduction under 3.105(e). Per III.iv.8.D.1, IV.ii.3.A.3 & November 2017 Quality Call Notes, the notification letter should not provide a proposed effective date, but rather should discuss the 60-day period during which new evidence may be submitted.

**********************

If condition is considered static, but there is evidence of sustained improvement shown under ordinary circumstances (make sure the current exam is as thorough as the exam that established the evaluation):We are proposing to decrease the evaluation of {} to {} percent. You have been evaluated at 20 percent since {} [more than 5 years]. However, the January 2005 and December 2006 Rating Decisions showed improvement in this disability and the current DBQ shows sustained improvement. There is no other evidence to support the {} percent evaluation.III.iv.8.D.2.b

Hearing information – 3.103(c) - The right to a hearing

III.ii.2.F – reconsideration of claim that has not yet become final (the veteran files again & it has not been one year since notification of denial), requests for reconsideration do not require prescribed form (i.e. missed exam & is willing to report during the one year appellate period), III.ii.2.B.1.co III.ii.2.F.1.b – use Reconsideration 020 so it is not associated with an ITF, unless non-reconsideration

contentions are also claimed

o III.ii.2.F.1.c – development of reconsiderations, table addressing reconsideration with no or duplicate evidence & info on distinguishing reconsideration from CFI (refers to III.ii.2.E.3, also should see III.iv.5.C.5.e, III.iv.5.C.5.f, III.iv.5.C.5.g, III.iv.5.C.5.h); says can reorder missed exam without good cause on reconsiderations, but DO need statement of willingness to report. Per QRTGiaBao Nguyen, 5/25/17 – We do not rate reconsideration issues if the only VATRs uploaded by the VSR are not relevant to the reconsideration issue.

o III.ii.2.F.1.e - table added 9/26/16 [was III.ii.2.F.1.d], which confirms above VA Pulse info about EP 400s

VSR: The {} claim is a reconsideration, as {} was/were addressed on the {} RD. Per III.ii.2.F, which was updated prior to the {} claim, a letter should have been sent under an EP 400 since the veteran submitted no evidence with the reconsideration claim.

Rating Note: III.ii.2.F.1.c. does not cover reconsiderations on prescribed forms with no evidence that are for service connection (not involving the possible issue of an increase), but III.ii.2.F.1.e says that these reconsiderations should be handed under an EP 400 with an administrative denial & should not be rated.

From: VAVBASDC/RO/VSC Sent: Monday, August 24, 2015 11:20 AMSubject: Quality Tip: Claims for reconsideration

Good morning all employees,

The following is a Quality Tip provided by the QRT regarding the delineation between claims for reconsideration vs. a reopened claim as it applies to Standardized Forms and Intent to File guidance effective March 24, 2015.

A claim to reopen is any claim received after the appeal period has expired.

A claim to reconsider is a claim received before the appeal period expires.

Effective 3/24/15, the Veteran must submit the claim to reopen in one of the approved forms.   A claim to reconsider does not require to be submitted on a specific form.  

W. Rees 18 updated 7/25/18

For “reopened” claims, an EP 020 is CEST, and the claim is administratively denied if the Veteran did not submit new and material evidence. {M21-1 III.iv.2.B.3.j}

For “reconsideration” claims, the VSR / CA should not control with a Rating EP unless the Veteran submitted new evidence or identified new evidence.  The VSR / CA will CEST an EP 400 and send the Veteran a letter stating that we cannot take further action unless he/she provides new evidence for the reconsideration {M21-1 III.ii.2.F.1.e}

In any case the Veteran identifies new evidence for us to obtain, we should make all efforts to obtain that evidence before determining if it is new or material.

If the Veteran submits a 526EZ no further “N&M evidence” development is needed.  WTEMS are provided with the form.

If the Veteran submits a claim to reopen (after the year) and does not submit new and material evidence, the VSR will administratively deny the claim.

If the Veteran submits a claim for reconsideration (within the year) and does not submit new evidence, the VSR will administratively deny the claim.

If the Veteran submits a claim to reopen a claim (after the year) and submits new and material evidence, the claim is forwarded to the Rater.

If the Veteran submits a claim for reconsideration (within the year) and submits new evidence, the claim is forwarded to the Rater.

If the Veteran sends us a 21-4142 that is new then we will should develop for the records identified.   If the 21-4142 is for the same provider and same period of treatment that we have already obtained then there is no further development because this is not new evidence.

An exam or medical opinion may be indicated if it is triggered by the new evidence. 

From: VAVBASDC/RO/VSC Sent: Tuesday, October 25, 2016 11:23 AMSubject: FW: Q-TIP: When to use (and not use) "N&M" language in rating decisions

Attention RVSRs and DROs:

A request for reconsideration is a request from a claimant for VA to reconsider one of its decisions that has not yet become final (the one-year appeal period has not yet expired). 

A claim to reopen is a request to review a previously finally decided claim or other determination.  Under 38 CFR 3.156(a), new and material evidence is required before VA will reopen a finally denied claim. 

When there is rating jurisdiction over these issues, please keep in the mind the following:

The term “reopened” does not apply to new claims, including claims for reconsideration of a prior non-final decision and for individual unemployability (M21-1 III.ii.2.D.1.b).  Therefore, ratings that do not pertain to claims to reopen should not contain the “new and material evidence” language in the decision section or the narrative. 

In requests for reconsideration, although evidence received after a decision and prior to the expiration of the appeal period must be analyzed to determine if it is new and material under 38 CFR 3.156(b), it is not necessary to necessary to include the standard new and material language in the rating narrative (M21- III.iv.2.B.3.b). The “new and material” generated texts in VBMS-R discuss evidence in the context of a finally adjudicated claim and therefore should not be used.  Furthermore, a claimant may appeal a determination that evidence is not new and material.  Consequently, it is important that the correct language and determination be provided in rating decisions.  See attached document on how users should address request for reconsiderations in VBMS-R.

In claims to reopen, if it is determined that the evidence submitted is not both new and material, the rating decision should indicate that the claim is not considered to have been successfully reopened and must explain why the submitted evidence is not considered to be new and/or material.  Use of a “NM” denial reason glossary fragment in VBSM-R requires additional free text. 

References:M21- III.ii.2.D. – Reopened ClaimsM21-1 III.iv.2.B.3 – Reopening a Previously Denied Claim Based on New and Material EvidenceM21- III.ii.2.D. – Requests for ReconsiderationM21-1 III.iv.6.F – ADL Rating Decisions

W. Rees 19 updated 7/25/18

*attachment says do not use “Confirmed and Continued decision” under Supplementary Decision, but leave that blank & deny as if it is a new claim

…

3.151 Claims for disability benefits – (6/24/85) - comp claim MAY be considered pension claim, and pension claim MAY be considered comp claim [per November 2015 Compensation Service Bulletin (CSB) – 3.151 not changed by standardized claims & appeals forms]; cannot pay pension prior to date of receipt of claim unless veteran specifically claims entitlement to retroactive benefits within 1 year of the date he/she became P&T (see 3.400(b) & III.iv.6.B)

See 3.151 for effective dates for FDC

I.1.B – I.1.B.1.c now says “Because the law permits a generic Section 5103 notice, it is not required that ROs include diagnostic criteria for a specific disability in the notice even if the claimant asserts entitlement to a specific evaluation level. See Wilson v. Mansfield , 506 F.3d 1055, 1062 (Fed. Cir. 2007).” Wilson v. Mansfield (10/15/07); Dingess/Hartman v. Nicholson (3/3/06).

III.ii.2.B.1 - III.ii.2.B.1.f says correspondence or 4138 rec’d with 526 is part of the pending claim

Clegg v. Principi 8 Fed.Appx 935 (15 Vet. App.) - entitlement to compensation requires evidence of a disability

Jones v. West (12/22/98) - non adjudicated claim

Sanchez-Benitez v. West (12/29/99) - pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted [PVA said pain is a disability, Court did not rule on it, so Sanchez-Benitez is still good] – overturned by Saunders v. Wilkie (4/3/18)

Fully Developed Claims (FDCs) Public Law 112-154 allows up to one-year retroactive effective date for awards for original/initial, formal

compensation claims from veterans separated more than one year ago, on 21-526EZ & VONAPP, received from 8/6/13 through 8/5/15

III.i.3.A – must use appropriate form & cannot be outdated version (more on outdated forms at III.ii.1.C.8); can use EZ & select no FDC (excluded); form includes these WTEMS: SC (incl active & inactive duty for training), Reopen (N&M), Secondary, Increase, Temporary Total, IU, 1151, SMC (incl Spousal), SAH/SHA, Auto, Helpless Child; includes references for what to do if didn’t sign (for originals and subsequent) or cannot identity the claimant or determine the contentions; timeliness; III.i.3.A.2.k – incomplete FDC prior to 3/24/15 gets one year from notification that incomplete to preserve effective date

III.i.3.B - exclusion reasons (*selects no FDC; *has claim already pending; *has appeal pending & claim folder not at RO; *does not simultaneously submit additional, completed items [for NG/Res members-STRs & MPR in custody of unit; for dependents-21-686c, 21-674, TRs for helpless child; for PTSD-VA Form 21-0781 or 21-0781a (unless has medal or fear, per III.i.3.B.2.a); for IU-VA Form 21-8940; for SAH/SHA-VA Form 26-4555; for Auto-VA Form 21-4502; for A&A or spousal A&A-VA Form 21-2680]; *needs COD determination; *needs dev for evid [from claimant, private medical care provider or Reserve/Guard unit]; *needs NA Form 13055; *needs income verif from FTI; *submits additional evidence; *fails to report & asks to reschedule [unless VA is at fault, i.e. did not give correct address]; *submits additional claim; *submits NOD; *incomplete form; *predischarge claim); if excluded, will need to send 5103 Notice if 1-not on EZ form; 2-non-original claim on EZ form but didn’t sign (so didn’t certifiy that got notice); 3-submitted a subsequent claim & no 5103 Notice w/i last year; we will get *Federal records in custody of Federal govt (except those in custody of Reserve/Guard unit or records needing NA Form 13055)- DO NOT request from veteran, if unava, add extra FDC paragraph to final notification letter & *VAE.

III.i.3.B.3.d – special issue development (herbicide, asbestos, radiation, GW, hepatitis C, fire STRs, MST, special operations, homeless; do not exclude at CEST, do not develop if evid is sufficient to decide the claim)

Effective date assigned via Section 506 of PL 112-154.

III.i.3.B.4.c says if assigning earlier effective date under FDC, but not using PL 112-154, use: The one year retroactive effective date for FDC claims was considered, but we were able to assign an earlier

W. Rees 20 updated 7/25/18

effective date under [insert effective date rule applied and explanation].

Rating Note: III.i.3.B.4.a, III.i.3.B.4.b & III.ii.2.C.2 say we can apply Section 506 of PL 112-154 to the date of the ITF.

III.i.4 - Veterans Online Application (VONAPP) Direct Connect (VDC) Program & (eff 8/11/17) Vets.gov III.i.4.C.2.d – “For the purposes of determining the effective date, decision makers should consider the

application initiated or intent to file (ITF) date as the date of claim.”

III.i.4.C.3 (added 6/23/16) – VDC Application Initiation Review

III.ii.2.C.1.a – “Claims received prior to March 24, 2015, via VONAPP or VDC that are initiated but not completed are not informal claims.  However, the date the application was initiated may be considered when determining the effective date in certain circumstances.”

VSR: No exclusion letter has been sent, but the veteran {did not provide a VA Form 21-0781 for his PTSD claim (and does not have one of the recognized combat decorations); did not provide a VA Form 21-8940 for his IU claim…}, which is an exclusion reason, per III.i.3.B.2.{a or b}, so the claim does not meet FDC criteria. Please include the exclusion information (see III.i.3.B.2.d) in the notification letter.

*No exclusion letter needed if indicated they did not want claim processed under the FDC program, per III.i.3.B.2.d

III.i.4.B.2, III.ii.1.C.2, III.ii.2.B.3.f – signatures

III.ii.2.B.3.f says unsigned original claims prior to 3/24/15 & ALL claims on/after 3/24/15 are incomplete claims

III.i.3.A.2.i says, for the FDC program, unsigned EZ form for original claim & unsigned EZ form for non-original claim on/after 3/24/15 is an incomplete claim - follow I.1.B.1.g for incomplete claims (except if electronic through VONAPP, VDC or Vets.gov)

Note to File: The claim is substantially complete even though the veteran did not sign in block 27A, as the signature is in block 28A.

February 2017 Quality Call Notes -

Question: In the following basic sequence of events, what is the correct effective date to assign? An ITF is received; an incomplete application is received within one year of the ITF; a letter is immediately sent requesting a completed application; and, a completed application is received within a year of the date of the letter, but more than one year after the ITF was received. Is the correct effective date the date of the ITF, the date the incomplete application was received, or the date the completed application was received?Answer: The correct effective date would be the date of receipt of the incomplete application. M21-1, III.ii.2.C.2.d directs that an ITF is ‘active’ until either VA receives a substantially complete application for benefits or the one-year period following VA’s receipt of the ITF ends, whichever comes first. In this case, the substantially complete application was not received within one-year, so the earliest date we could award benefits would be the date of receipt of the incomplete application.

Per QRT/Carlos Rosario, the regulation is 38 CFR 3.155(d)(1). In the event that VA receives both an intent to file a claim and an incomplete application form before the complete claim as defined in §3.160(a) is filed, the complete claim will be considered filed as of the date of receipt of whichever was filed first provided it is perfected within the necessary timeframe, but in no event will the complete claim be considered filed more than one year prior to the date of receipt of the complete claim.

March 2017 Quality Call Notes -

Question: When a Veteran submits a VAF 21-526 (not an original claim) along with a VAF 21-4138, and the VAF 21-4138 is signed, but the VAF 21-526 is not signed, can it be accepted as a substantially complete claim?Answer: The criteria to consider a claim complete include the requirement for a signature, which is very directly stated in 38 CFR 3.155(d). Therefore, in most cases the claim itself must be signed. If an extraordinary circumstance arises in this regard, it may be appropriate to submit a request for an advisory opinion as directed in M21-1 III.vi.1.A.

March 2017 ITF Training

W. Rees 21 updated 7/25/18

If ... Then ... VA receives communication of a claimant’s ITF

between March 24, 2015, and August 5, 2015, and

VA subsequently receives an original, fully developed claim (FDC) from the claimant within one year of the date VA received the communication of an ITF

the earliest, potential effective date of entitlement to benefits is one year prior to the date VA received the communication of an ITF.

VA receives communication of a Veteran’s ITF within one year of the date he/she separated from service, and

VA subsequently receives a substantially complete application within one year of the date VA received the communication of an ITF

the earliest potential effective date of entitlement to benefits is the day after the Veteran separated from service.

3.155 Informal claims – (6/21/87) any communication/action (in writing per 3.1(p)) indicating an intent to apply with the benefit sought identified; not for new claims!!! cannot go before DOC for new claims unless 3.114 (if had condition at time of law change) changed 3/24/15 - How to file a claim 3.155(c) Incomplete application form. Upon receipt of a communication indicating a belief in entitlement to

benefits that is submitted on a paper application form prescribed by the Secretary that is not complete as defined in §3.160(a) of this section, the Secretary shall notify the claimant and the claimant's representative, if any, of the information necessary to complete the application form prescribed by the Secretary. If a complete claim is submitted within 1 year of receipt of such incomplete application form prescribed by the Secretary, VA will consider it as filed as of the date VA received the incomplete application form prescribed by the Secretary that did not meet the standards of a complete claim. See §3.160(a) for Complete Claim.

Hamilton et al v. Brown (4/15/93) - finality issues & informal claims

Hazen v. Gober (11/14/97) - request for treatment at VAMC is not specific enough to constitute an informal claim (benefit sought is not identified) [can go back 2 years max, 1 year prior to informal claim]

Buckley v. West (2/3/98) - reasonably raised claims; claim for increase is not subject to new and material criteria

Judicial Call 4/2/98 (see Hazen v. Gober above)

Lalonde v. West (5/11/99) - TRs not informal claim for secondary condition, but if an informal claim is filed, we will treat it like a claim for increase (and the date of treatment can be used for the effective date)

Rodriguez v. West (8/25/99) - has to be in writing & a conversation with an employee, which is put on a 119, can be an informal claim if it identifies the benefit sought

Hurd v. West (4/25/00) - abandoned claims for increase; effective date for increases; failure to provide duty to assist does not necessarily render a decision non final [in response to Hair/Hare, which was thrown out, there are no grave procedural errors]

VAOPGCPREC 12-2001 (7/6/01) - Roberson v. Principi held that once a veteran submits evidence of a medical disability, makes a claim for the highest rating possible and submits evidence of unemployability, the requirement in 38 CFR 3.155(a) that an informal claim “identify the benefit sought” has been satisfied and VA must consider whether the veteran is entitled to total disability based upon individual unemployability (TDIU); and a veteran is not required to submit proof that he or she is 100% unemployable in order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 CFR 3. 340(a).

Ellington v. Nicholson (7/25/07) - III.ii.2.C.1.a says the Court of Appeals for Veteran Claims (CAVC) (in Ellington v. Nicholson ) ruled that complaints noted by a Veteran during a VA examination (and included in the corresponding examination report) do not constitute an informal claim unless "the veteran sufficiently manifested an intent to apply for benefits for a particular disease or injury."

Brokowski v. Shinseki (2009) - in identifying the benefit sought, the Veteran must describe the nature of the disability for which he is seeking benefits, which may be satisfied by referring to the body part or system that is disabled or by describing symptoms of the disability.

III.ii.2.C.4 – incomplete 0966 / incomplete ITF (cannot use unsigned 0966 for eff date, only complete 0966 / W. Rees 22 updated 7/25/18

complete ITF)

III.ii.2.E III.iv.5.C.10 January 2015 Rating Quality Call Notes – Brokowski v. Shinseki (2009) applies to reopened claims,

claims for increase & new claims (all 020s). Only original disability compensation claims (110s & 010s) allow the informal claim to contain a general indication of seeking entitlement to compensation benefits

Standard Claims and Appeals Form Rules, 3/24/15, AO81 https://www.ttande.org/VBA_Learning_Catalog/Comp_svc/Add_Ref/3914064_Add_Ref.pdf: Standard VA-prescribed forms effective 3/24/15 (on & after this date), including NOD form (21-526EZ,

21-526, 21-526b, 21-526c, 21-8940 (IV.ii.2.F.2.h - NSC issues listed on 8940 are a Request for Application (RFA), then updated 1/17/17 & per March 2017 Quality Call Notes - treat as reconsideration if notified of denial within last year), 21-4502, 26-4555, 21-527EZ, 21-527, 21-534EZ, 21-534, 21-535, SNOD, 21-0958; plus include all symptoms/disabilities listed on any attached letters/statements as contentions); complete claim 3.160(a) [see below]

Eliminates 3.157 (medical treatment records are not claims, but can still assign effective date of increase if claim filed on standard form within 1 year of hospitalization/examination/treatment, applies to federal and private TRs; incorporated in 3.400(o)(2)) [if VATRs dated prior to 3/24/15 constitute claim under 3.157, consider it for effective date; per VA Pulse, https://www.vapulse.net/message/9403, https://www.vapulse.net/message/11293 & https://www.vapulse.net/message/51221, if you find info warranting increase in SC disability that was NOT claimed, you cannot grant increase, but per https://www.vapulse.net/message/30382, you should solicit a claim]

3.155 How to file a claim 3.160 Status of Claims - all claims must be signed

3.400(o)(2) General - Increases – Disability Compensation

(2) Disability compensation. Earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date, otherwise, date of receipt of claim. When medical records indicate an increase in a disability, receipt of such medical records may be used to establish effective date(s) for retroactive benefits based on facts found of an increase in a disability only if a complete claim or intent to file a claim for an increase is received within 1 year of the date of the report of examination, hospitalization, or medical treatment. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established.

New intent to file (ITF) process (21-0966, have one year to file complete claim; if electronic, use date initiated as ITF date; can also give oral intent to file to VA personnel & the must record it; only one active ITF per general benefit at a time is valid, ITF is no longer active once completed claim received, any subsequent completed claims are not associated with the ITF but use date that completed claim was rec’d; if have complete 526, but subsequently receive letter/4138 with new contentions, the letter/4138 is a request for an application not a complete claim); 5 ITF statuses (active, incomplete, expired, claim received, duplicate, 6th status “canceled” added 6/16/17)

Standard Forms Cheat Sheet (from 2015) is saved at H:\VSC\Rating Reference

I.1.B – Handling Claims under 38 USC 5103 – claims not previously denied (including claims for specific evaluations or effective dates; EEDs – need to claim CUE or it’s not a claim, developing for records) & claims to reopen previously denied claims; all claims must be signed

I.2.E.3.a, I.5.A.2.d, I.5.B, I.5.I – Appeals references changed for Standard Claims & Appeals Forms

April 2015 Intent to File (ITF) Training (Carlos Rosario) –

A NOD must be on the prescribed form (the VA Form 21-0958 that was provided to the veteran in the decision notice) for any decision notification on or after 3/24/15. If the NOD is received any other way, including a formal or informal conference, it does not constitute a NOD, but is a request for NOD. See I.5.B.1.a & I.5.B.1.c (he may mean 1.5.c)

W. Rees 23 updated 7/25/18

ITFs do not apply to predischarge claims. The claim was received while on active duty or it was not.

The POA or representative can sign any claim form for the veteran except an original claim, which must be signed by the claimant. If the POA or representative signs the prescribed form on a non-original claim, a 5103 notice must be sent to the veteran. Confirmed by April 2015 Compensation Service Bulletin (CSB), & on VA Pulse, https://vapulse.net/thread/3436; I.1.B.1.d, III.i.3.A.2.i (My Notes: This does not seem to apply to electronic claims through VONAPP, VDC or Vets.gov, as no signature is required on those, per III.i.3.A.1.i.)

III.ii.2.B – prescribed forms – list of all forms, how to determine which benefit veteran is seeking, how to interpret original claim not on prescribed form (informal or Request for Application (RFA)), claim on obsolete form is valid (per III.ii.2.B.3.h deleted 6/22/17, per VA Pulse, https://www.vapulse.net/message/9818, an obsolete form is a former version of a prescribed form under III.ii.2.B.1.b), non-original claims (informal or Request for Application (RFA)); per VA Pulse, https://www.vapulse.net/thread/3860, submission of a DBQ is a Request for Application (RFA) & if the veteran does not identify the disability for which they are seeking SC, it is an incomplete application

III.ii.2.B.3.h changed 8/12/16, deleted 6/22/17, now see III.ii.1.C.8 for outdated forms, outdated but acceptable under III.ii.1.C.7.b = valid claim if complete; outdated & unacceptable under III.ii.1.C.7.b = reject the form per III.ii.1.C.7.d & consider it an RFA

Intent to File (ITF), 3/24/15, AO81 https://www.ttande.org/VBA_Learning_Catalog/Comp_Svc/Add_Ref/3923748_Add_Ref.pdf (also at https://www.vapulse.net/docs/DOC-5608)

III.ii.2.C - informal claims received prior to 3/24/15 , ITFs, and RFAs

My Notes:

o Incomplete application [can hold effective date] – on prescribed form, but not signed (effective date can be preserved if completed application rec’d w/i one year); veteran does not identify disability; Ref: I.1.B.1.b, I.1.B.1.e, I.1.B.1.g, III.ii.2.B.3

o Request for Application (RFA) [cannot hold an effective date] – submission of a DBQ; any other correspondence requesting a benefit but not on a prescribed form; contentions added at VAE; 4138; NSC conditions listed on an 8940, what we previously called an informal FDC (III.i.3.A.2.j says should be “incomplete FDC” instead of “informal FDC”); only on or after 3/24/15; Ref: I.1.B.1.i, III.ii.2.B.1.e, III.ii.2.B.3.g, III.ii.2.C.3, III.ii.2.d.2.b

o Informal claim – only before 3/24/15; Ref: III.ii.2.C.1.h

o Intent to File (ITF) [can hold effective date] – has to be (1) on 21-0966 , or (2) initiation of application online (nothing will be on file, but letter will be sent from Hines, see LCM (formerly VVA) documents), or (3) oral intent to file to VA personnel (need authorization from veteran to enter ITF, per III.ii.2.C.2.b), only on or after 3/24/15 (if before, review to see if informal claim); has to identify benefit sought (compensation or pension), identify claimant & be signed by claimant or rep; if incomplete, then made complete, can use date; Ref: III.ii.2.C.2

More ITF Notes:

CM = Centralized Mail (paper process)EBN = Electronic Benefits Network (eBenefits, SEP or Digits to Digits (D2D)), I.1.B.1.b says digital signatures are only allowed from these 3 programsCRM [from National Call Center (NCC)] = Customer Relationship Management

III.ii.2.C.2.h – can apply an active ITF to more than one claim (i.e. one in mail & one online) received on the same day

III.ii.2.C.2.j – ITF linked to claim, so if claim is withdrawn, ITF cannot be applied to any other claim

III.ii.2.C.2.l - ITFs only apply to compensation, pension, Survivors Pension & DIC (not to dependency, ancillary benefits, reconsiderations, duplicate claims, claims for CUE), III.ii.2.C.5.a says need to fix ITF if it as associated with reconsideration (also applies to claim for ancillary benefits, duplicate claims, claims for CUE)

Per III.ii.2.C.5.d, use YourIT to change ITF (i.e. if ITF submitted while claim already pending, there is

W. Rees 24 updated 7/25/18

no new EP established, so ITF does not change from “Active” to “Claim Received”; or if ITF associated with reconsideration, claim for ancillary benefits, duplicate claim, claim for CUE; or if affected by Time Zone issue per III.ii.2.C.5.h):

VBMS shows an “Active” Compensation Intent to File received {date} from "CRM." The {date} Compensation claim should have changed the ITF status to "Claim Received,” but since an EP was already pending from {date}, the ITF did not update. Please change the status of the ITF received {date} from "Active" to "Claim Received." *I will give the file number (PII) to the technician assigned to resolve the issue. They can contact me when they need it & I will send it in an encrypted email.

There is an 0966 on file, date-stamped {date}, received by Janesville {date} & uploaded {date}, but there was no ITF in VBMS. I created the ITF, but it shows “Active.” It should show “Claim Received” since a 526EZ was received {date}. *I will give the file number (PII) to the technician assigned to resolve the issue. They can contact me when they need it & I will send it in an encrypted email.

VBMS shows the Compensation Intent to File received {date} is in "Claim Received" status as of {date of reconsideration, duplicate claim, claim for CUE}, but since the {date} claim was a reconsideration, duplicate claim, claim for CUE, it should not have been associated with the {date} ITF. Please change the status of the ITF received {date} from "Claim Received" to "Active." *I will give the file number (PII) to the technician assigned to resolve the issue. They can contact me when they need it & I will send it in an encrypted email.

III.ii.2.C.3.e – ITF on same date as application through eBenefits/VDC, SEP or D2D depends on timing (VBMS will figure it out depending on if ITF was before or after application)

III.ii.2.C.3.f – ITF on same date as application for non-electronic claims remains active (2/16/17 change said we had to call veteran, 6/5/17 change says the ITF remains active)

use YourIT system

VBMS shows a “Duplicate” Compensation Intent to File received {date} from "CENTMAIL." That ITF should be “Active,” per III.ii.2.C.3.f, which says an ITF on same date as application for non-electronic claims remains active. Please change the status of the ITF received {date} from "Duplicate" to "Active." *I will give the file number (PII) to the technician assigned to resolve the issue. They can contact me when they need it & I will send it in an encrypted email.

III.ii.2.C.5.g says there are incorrect dates of receipt in Share/eBenefits & on acknowledgement letters between 6/26/15 & 12/13/15 & other isolated incidents outside that date range, need to date from note in MAPD/VBMS or 0966 date (if have neither, use VBMS date)

Rating Note: III.ii.2.C.5.g says to use the actual 0966 receipt date instead of the incorrect date of receipt in Share/eBenefits & on the acknowledgement letter.

Note to File: The ITF letter in Virtual VA Documents says the ITF was received 1/24/16, but the VBMS ITF screen shows received date of 1/25/16. We have been advised the the VBMS ITF date is correct and the one we should be using. See March and August Quality Call Notes & https://www.vapulse.net/message/101387.

March 2016 Quality Call Notes – Shows ITF screen & letter in VVA, reminder to use ITF for effective date; discussion also in Q&A section including…

Question: If the RO cannot locate the actual ITF form, should the decision maker still base the effective date of the grant by using the date shown in eFolder and/or VVA?Answer: The decision maker should rely on the “ITF received-date” listed in VBMS or Share when there is no ITF form in the eFolder. ITFs created through an application initiation in eBenefits and the Stakeholder Enterprise Portal (SEP) will not generate an ITF form for the eFolder, so the ITF received date listed in VBMS or Share is all there is to rely upon.

There was a past defect with ITF that resulted in conflicting dates between VBMS and Share. That issue has since been resolved; however, if a user encounters an ITF received date in VBMS that is one day earlier than the ITF date in Share, and there is not an ITF form to confirm the actual date the ITF was received, the user should use the VBMS ITF date for effective date purposes. M21-1,

W. Rees 25 updated 7/25/18

III.ii.2.C.1.g & k

August 2016 Quality Call Notes

Question: Is there guidance on the ITF glitch where the system gives one date but the Veteran's letter had the date one day prior?Answer: A similar question was posed during the Quality Call on March 9, 2016. The Q&A in the Call Notes shows this:

Question: If the RO cannot locate the actual ITF form, should the decision maker still base the effective date of the grant by using the date shown in eFolder and/or VVA?Answer: The decision maker should rely on the “ITF received-date” listed in VBMS or Share when there is no ITF form in the eFolder. ITFs created through an application initiation in eBenefits and the Stakeholder Enterprise Portal (SEP) will not generate an ITF form for the eFolder, so the ITF received date listed in VBMS or Share is all there is to rely upon.

There was a past defect with ITF that resulted in conflicting dates between VBMS and Share. That issue has since been resolved; however, if a user encounters an ITF received date in VBMS that is one day earlier than the ITF date in Share, and there is not an ITF form to confirm the actual date the ITF was received, the user should use the VBMS ITF date for effective date purposes. M21-1, III.ii.2.C.1.g & k

My Notes: The “ITF date in Share” is the date on the letter.

Febuary 2017 Quality Call Notes –

Question: In the following basic sequence of events, what is the correct effective date to assign? An ITF is received; an incomplete application is received within one year of the ITF; a letter is immediately sent requesting a completed application; and, a completed application is received within a year of the date of the letter, but more than one year after the ITF was received. Is the correct effective date the date of the ITF, the date the incomplete application was received, or the date the completed application was received?Answer: The correct effective date would be the date of receipt of the incomplete application. M21-1, III.ii.2.C.2.d directs that an ITF is ‘active’ until either VA receives a substantially complete application for benefits or the one-year period following VA’s receipt of the ITF ends, whichever comes first. In this case, the substantially complete application was not received within one-year, so the earliest date we could award benefits would be the date of receipt of the incomplete application.

III.ii.2.D – reopened claims – N&M evid, need to use prescribed form after 3/24/15, duplicate claim if previously denied & does not furnish N&M evid, duplicate medical evidence should be date-stamped & returned

o III.ii.2.D.3.i – mixed issue claims, can admin deny reopens before RD if no evid submitted, but if evid submitted do RD first & let RVSR direct any admin denial

III.ii.2.F – reconsiderations – request from claimant to reconsider a decision that is not yet final

III.iii.7 – helpless child claims – 3.315(a)

III.iv.2.B – revision of decisions – CUE, EED, N&M (after finally denied III.iv.2.B.3.a, before finally denied/finally adjudicated III.iv.2.B.3.b; presume it is credible), no benefit-of-the-doubt rule for reopening claims, Appeals, BVA decisions

III.iv.6.B – identifying claimed issues on a prescribed form, “issues within the scope” (formerly “reasonably raised,” formerly “sympathetic”) and soliciting claims for chronic disabilities shown by the evidence of record – types of issues & claims; III.iv.6.B.1.g (added 7/12/18) says don’t misconstrue or make generalized assumptions about the veteran’s intent and/or narrow the scope of potential (examples: if previously denied for depression & now files for PTSD, don’t assume they’re filing to reopen depression; if SC for asthma & now files for OSA, don’t assume they’re filing a CFI for asthma)

III.ii.2.B.4, III.v.6.D & IV.ii.2.J.2 – reports of hospitalization – 4.29, EP 320, hospitalized in excess of 21 days; effective dates based on hospitalization/exam reports – 4.29

W. Rees 26 updated 7/25/18

III.ii.2.B.4.f - Accept the date of admission for treatment, date of outpatient treatment, or date of examination for an SC disability as the DOC for increased evaluation.

IV.ii.2.A – soliciting claims for chronic, unclaimed disabilities – considering SC (intent, 3.157, exposures, lab results, chronic disabilities, supplemental STRs)

Boston RO Tip Sheet - https://www.vapulse.net/docs/DOC-9924

III.ii.2.B.1 & IV.ii.2.H.1.j - 21-2680 may be sympathetically read as claim for increase if worsening is shown, III.ii.2.B.1.g says if 0% combined, 21-2680 is a RFA

Rating Note: III.ii.2.B.1 & IV.ii.2.H.1.j say 21-2680 may be accepted as/considered a claim for increase if worsening is shown, but to "Only address the condition in the rating decision when examination confirms a change in the disability evaluation of the SC issue is warranted or confirms the presence of the condition that is within the scope of another SC condition." There is no evidence of worsening of {}, so they are not being addressed here. {} shows worsening, so it is being addressed. {} shows improvement, so is being reduced.

Per VA Pulse, https://www.vapulse.net/message/15493, a 21-2680 with no indication of whether the claim is for SMC or SMP is considered an incomplete application; https://www.vapulse.net/message/18224 says if files standard form 526, 527 or 527EZ for pension & says also SMP but no 21-2680, develop for 21-2680 (if not rec’d, do not consider SMP at issue)

III.ii.2.B.1.e – changed 8/12/16, cannot accept medical evidence as a claim, even if received with a prescribed form; if prescribed form is signed by veteran, but additional correspondence received with prescribed form is signed by POA, treat any issues on POA documents as an RFA

Rating Note: III.ii.2.B.1.e says if the prescribed form is signed by the veteran, but additional correspondence received with prescribed form is signed by a POA, treat any issues on the POA documents as an RFA. So, {} and {} are not part of the application package and are not addressed in this decision. Please send the veteran a “Request for Application” letter. *Please note that a RFA cannot hold an effective date.

III.ii.2.B.1.g – changed 5/5/16 & 8/12/16, table for interpreting if claim 21-2680 is claim for SMC or SMP; no signature of claimant needed on 21-2680 per III.ii.2.B.3.f

…

3.158 Abandoned claims – if disappear/whereabouts unknown, resume “effective the day following the date of last payment”; no exam is needed unless a future was due while missing, no rating needed, authorization starts up date last paid (DLP) (per Dawn Provost)

3.656 III.ii.2.G – withdrawal details/procedures (can retract withdrawal w/i 30 days of VA letter; cannot use

withdrawn claim for effective date unless retracted w/i 30 days; Per January 2016 Quality Call Notes, eff 11/30/15, use FAQ 4/1/09 for withdrawals prior to 11/30/15; notes also cover other withdrawal scenarios, including IU), III.ii.2.G.1.c discusses when examining facility says veteran wants to withdraw claim (we must clarify, phone first, letter if phone unsuccessful), then added 8/10/16 – if the claim is RFD but the claimant cannot be contacted via telephone, wait 15 days for response to letter before deciding claim

VSR: Please send the appropriate withdrawal letter under III.ii.2.G.3.

III.ii.2.H – renouncements

III.ii.1.B – address issues / returned mail / undeliverable mail / telephone contact / 27-0820 (including unsuccessful attempts)

3.160 Status of claims – Judicial Call 4/2/98- SMC & SMP are claims for increase; 931-939 allowed from 2/15/02 to 7/1/02 only, - http://www.ecfr.gov/cgi-bin/text-idx?SID=6724204e8449257b09cc0b7de09943c2&node=se38.1.3_1160&rgn=div8

3.203 Service records as evidence of service and character of discharge – need original or certified document from service department

3.656 Disappearance of veteran – if disappear/whereabouts unknown, resume “effective the day following the date of W. Rees 27 updated 7/25/18

last payment”; no exam is needed unless a future was due while missing, no rating needed, authorization starts up date last paid (DLP) (per Dawn Provost)

3.158(c) III.iii.1.B III.iv.8

Notes from March 2012 Inferred Issues (later called Subordinate Issues) Training:

Types of IssuesExpressly claimed – listed on a claim form or other communication from veteran.Implied – i.e. Congressional inquiry indicates the Veteran’s job is in jeopardy due to service-connected (SC) disability or disabilities. (need to solicit)Informal – A Veteran indicates that he cannot work due to one or more SC conditions. Potential – (need to solicit)

- The VA exam indicates that the Veteran believes a new condition should be SC. – In September 2013, Kevin Burton said that Erin said grant when you can but if you invite it is not an error. Kevin also said he would not consider it an error either. However, most times when something new is brought up at the Gen Med, there is no intent shown so you have to invite rather than rate. But if a good examiner took the time to say the vet wants to claim something, which shows intent, you can rate. Per VA Pulse, https://www.vapulse.net/message/15934 after 3/24/15 it’s a Request for Application (RFA); prior to 3/24/15, it’s an informal claim

- The VA exam shows an undiagnosed illness that was not previously claimed in a Gulf War case.- Medical evidence shows that a lumbosacral strain may be due to SC knee instability.- Prisoner of War (POW) exam notes additional disability that may be related to service.- Service Treatment Records (STRs) show epididymectomy due to epididymitis that could quality for Special

Monthly Compensation (SMC) at the (k) rate.Mandated - Aid and Attendance (A&A) or Housebound (HB) benefits when a 100% SC or non-SC rating is assigned.Ambiguous – (need to clarify)

- The VA exam indicates that the Veteran or examiner mistakenly assumes disability is already SC.- Veteran mentions a new disability in his Individual Unemployability (IU) claim without elaboration.- Hypertension without a date of onset is noted during a general medical examination, 16 months after service

III.iv.6.B – changed 6/30/15, inferred issues

Notes from March 2014 Subordinate Issues Training:Expressly claimedReasonably Raised – claiming increase, then says can’t workUnclaimed subordinate issues and Ancillary benefits – 3.324 (must infer, even if deny), III.iv.4.M.2.f - do not infer hypertension secondary to DM with diabetic nephropathy to deny), 1318 (must infer, even if deny), A&A, Auto & Adaptive Equip, DIC, extra-schedular, HB, competency, IU, retroactive pension, SAH, SHA, SMC, 1702

VA Form 21-2680:  Claim for SMC aid and attendance (A&A) is also a SMC housebound (HB) AND a claim for SMP A&A & HB; form is actually called “Examination for Housebound Status or Permanent Need for Aid and Attendance”; July 2017 Quality Call Notes – per video, even if 526 or other attachment only says A&A, still have to address HB if get 21-2680 & deny A&A

III.v.2.B.10.b - If A&A benefits are denied but Housebound benefits are awarded, inform the claimant of the denial as well as the award. 

If the following exceptions apply, do not invite a claim for benefits:• Acute and transitory disorders without residual disability• Non-compensable residual disabilities from venereal disease• Disabilities noted only during an induction examination• Disorders noted by history only• Disabilities that authorization activity determines were not incurred in the line-of-duty • Abnormal clinical findings, such as cholesterol or blood sugar levels, that are not generally recognized as

disabilities or subject to service connection

My Notes: If a prior RD has issues inferred & deferred that were not claimed & they aren’t within the scope or complications that can be granted (i.e. DM was claimed, neuro exam was unclear, PN UEs were deferred & now

W. Rees 28 updated 7/25/18

examiner has said they don’t exist), it’s best to clear the deferrals off the codesheet & address it in the Introduction with something like: Rating Decision dated {} deferred the issues of {} and {}. However, we do not have a claim for {} and {}. Therefore, no further action is to be taken. {maybe include this if can grant: If you would like to claim {} and {}, 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.}Note for codesheet: VSR: Please attached a Where to Send Your Written Correspondence chart to the notification letter.

Clear and Unmistakable (CUE) –

III.iv.7.B.3III.ii.2.B.1.c – claim does not need to be on prescribed form

STAR Errors VSC Review (spreadsheet, 10/15 to 5/16) is saved at H:\VSC\Rating Reference

VA Form 21-0961, Electronic Signatures – for CUEs, use the “21-0961 for CUEs (use eff 3-14-16)” at H:\VSC\Rating Referencehttp://vbaw.vba.va.gov/bl/20/cio/20s5/forms/VBA-21-0961-ARE.pdf

Effective 4/1/16, 2 signatures required (RVSR & RQRS) for: SMC greater than “L”

Effective 4/1/16, 3 signatures required (RVSR, RQRS & VSCM designee with Name & Title ) for: POW ratings

Extensions of hospitalization rates under 4.29 & convalescent ratings under 4.30

CUEs

proposals to sever SC

III.iv.6.D.7.d – Two Signature Ratings

RVSR & “designated reviewer” signatures required for: SMC greater than “L”

extra-schedular pension (not listed on 4/1/16 SDRO Memo, but listed on Quality Checklist)

POWs

proposals to sever SC

*also lists TBI until 90% or greater accuracy on at least 10 TBI cases (*for at least the last year, this is taken care of before single-signature authority is authorized for a trainee RVSR)

RVSR & VSCM (or designee at Coach level or higher) signatures required for: CUEs

RVSR & VSCM signatures required for: extensions of hospitalization rates under 4.29 & convalescent ratings under 4.30

Note: Follow locally established policies to obtain a third signature, when required.

Signatures should read:Stacey Bonnett, VSCME. Townsend, AVSCMKristina Morabito, AVSCMW. Rees 29 updated 7/25/18

E. Croft, AVSCMRQRS, QRTeSign: certified by [decision maker’s LAN ID, job title]  (changed 6/9/17)

From: VAVBASDC/RO/VSC Sent: Friday, June 30, 2017 3:39 PMSubject: FW: Q-Tip: Updated VBMS routing procedures for ratings requiring 2nd/3rd signatures

VSC – Forwarded for your information.

Q-Tip:  Updated VBMS routing procedures for ratings requiring 2nd/3rd signatures

Target Audience:  RVSRs and DROs

M21-1 III.iv.6.D.7.e was revised on June 9, 2016 to update the routing procedures in VBMS for ratings requiring 2nd/3rd signatures.  Per the June 2017 Compensation Service Quality Call, these instructions incorporated those provided by the NWQ Playbook and supersede where they differ.

Notable changes include updating the claim level suspense and assigning the case to the next reviewer in VBMS.  These updated procedures takes into consideration Time In Queue (TIQ) expectations for employees. 

Please see the attached document for details on how to update the claim level suspense and how to assign the case to the next reviewer in VBMS.  These procedures currently do not apply to rating decisions by trainees/mentees that require second signature by their mentors. 

Reminders: The “Rating Decision Review – Level 1” special issue should be added to the first contention of the claim in VBMS. Ratings must remain in draft status until all signatures are obtained. Continue to email the QRT mailbox (VAVBASDC/RO/QRT) for ratings that require review by the QRT as determined

by VSC Policy Memo 21-16-08.  Also attached for reference are previously provided local instructions on how to refer a rating to the QRT for 2nd/3rd signature review. 

Reviews and corrections are expected to be completed within 2 business days of assignment.

For any questions relating to this topic, please contact the QRT or your Coach.Updated NWQ routing procedures for rating decisions requiring second or third signatures – Final.pdf is saved at H:\VSC\Rating Reference*as of sometime before 3/18, someone deleted Local instructions for referring 2nd-3rd signatures.pdf

1. Create folder at H:\\VSC\2nd&3rd Signature\1 - SUBMISSION TO QRT– Last6789

2. Save draft pdfs – Last6789 0961, Last6789 codesheet, Last6789 narrative

3. Add “Rating Decision Review – Level 1” special issue to first contention

4. Pencil / “Update Claim Details” – change to “Second Signature Review” with 2 day suspense & Save

5. Add Claim Note: *Emailed QRT that rating needs 3 signatures. Documents saved at H:\\VSC\2nd&3rd Signature\1 - SUBMISSION TO QRT. Added Rating Decision Review - Level 1 Special Issue under {} issue & assigned to QRT.

6. Green check mark / “Complete Work Item” – change to “RATING_INCOMPLETE,” choose Amanda Matthews, add “Pending second signature review” & Submit

7. send email:

To: QRT mailbox / VAVBASDC/RO/QRT <qrt.vbasdc@va.gov>

cc: Charlene Eckstein, Sheena Jennings

Subject: {3rd /2nd / ALS} - Doe1234

CUE: C# / SS#RQRS: First name and Last name, if applicable

8. When hear back that 0961 is signed by everyone, remove Rating Decision Review – Level 1 Special Issue, upload the

W. Rees 30 updated 7/25/18

0961, delete folder from H:\\VSC\2nd&3rdSignature\3- RETURN TO RATING EMPLOYEE (My Notes: As of 2/1/18, I am unable to access any folders within this folder, as of 3/2/18 have access again) & Finalize.

III.iv.6.D.7.e – A rating decision should not be finalized until all necessary 2nd and 3rd signatures have been obtained.

This email was not included in Local instructions for referring 2nd-3rd signatures.pdf:From: Matthews, Amanda L., VBASDGO Sent: Monday, January 23, 2017 3:40 PMSubject: 2nd/3rd Signatures - update

Afternoon Coaches,

Per discussion with the AVSCMs we need to be more uniformed when requesting 2nd/3rd Signatures.

The CUE signature requests should be consistently saved with Veteran’s last name and last four. If not saved properly, it conflicts with previous saved Rating Decisions in the Queue. Please request all employees use one of the below examples for the subject line in order to identify the type of signature required and to cc their coach. Example: 3rd -  Doe1234 or 2nd -  Doe1234 or ALS - Doe1234

Please include a narrative/details on the VA Form 21-0961. 

Please follow the 2nd/3rd signature policy procedures by uploading the VA Form 21-0961, Rating Narrative, and Code Sheet to H:\VSC\2nd&3rd Signature\1 - SUBMISSION TO QRT and notifying the QRT mailbox for proper assignment. Example: Doe1234 0961, Doe1234 Codesheet, Doe1234 Narrative

Finally, if applicable, indicate the name of the RQRS that called the correction for an error in the body of the email, so it can be assigned accordingly.

Example Email:

To: VAVBASDC/RO/QRT Cc: Team Coach or CoachesSubject: 3rd -  Doe1234 or 2nd - Doe1234 or ALS - Doe1234

Body of emailCUE: C# or SS#RQRS: First name and Last name

USE VBMS-R System-Generated Text or CU1

Also see:

3.105 – Revision of Decisions (discussion above)

III.iv.2.B.7 III.iv.8.E CUE training by STAR (February 2012) – a CUE cannot be based on additional evidence submitted, have to identify

law/regulation violated (cannot be based on policy or a training guide)

Per June 2012 CUE Training – a CUE:

Training documents are under “Understanding Clear and Unmistakable Errors” & Clear and Unmistakable Errors versus Difference of Opinion” at http://hvnc.gdit.com/lc/

Must be a mistake of law or facts, NOT judgment or weighing evidence (if a manual reference is substantive, it can be considered law and an error is a CUE, but if a manual reference is administrative, it is not law and an error is not a CUE).

Must be outcome determinative (if the decision does not change, it is not a CUE).

W. Rees 31 updated 7/25/18

Has no time limit (can be called within a year of the decision or anytime after a decision).

Cannot be based on evidence not requested/on file (that’s a failure to comply with Duty to Assist rather than a CUE).

Can only be claimed ONCE by the Veteran.

If a law cannot be applied, there is no CUE!

On the Profile page in VBMS-R, check the 38 CFR 3.105(a) box under Templates, then summarize the error in the box. Add the 38 CFR 3.105(a) Grant Clause (ONLY IF IT IS APPLICABLE TO YOUR CASE). This will show up toward the top of the codesheet.

3.105(a) Grant Clause says: Each assigned effective date of this corrected rating corresponds to the date from which benefits whould have been payable if it had been made on the date of the reversed decisions (38 CFR 3.400(k)).*says it’s a grant clause, but verbiage is generic enough to apply to non-grants

3.400(k) says: Date from which benefits would have been payable if the corrected decision had been made on the date of the reversed decision.

Also check the Special Approval Signature box.

If there are no other issues but the CUE, can use Admin review for jurisdiction & the intro.

Need to use Supplementary Decision* drop-down within issue & choose the appropriate selection.*if you don’t do this, you won’t get the correct Issue & Decision lines, or the correct Generated Text

Taming the CUE BeastSubmitted by: Paul Jonsson and Chris Mannion

Animal, Mineral, or Vegetable: is a CUE an “original” or a “reopened” claim?A claim for CUE is an original claim, not a reopened one. The CAVC has explained that a claim of CUE in a prior decision is “not being reopened…[Rather] it is being revised to conform to the ‘true’ state of the facts or law that existed at the time of the original decision.” Russell v. Principi 3 Vet. App. 310, 313 (1992)(en banc).

When can a Veteran claim a CUE?There is no time limit for requesting that a previous final decision be reviewed for CUE; such a request may be made at any time, even decades after the RO decision becomes final.

What’s the effect of a finding of CUE?Revision of a prior final denial based on CUE is powerful because it “relates back” to an earlier decision and often confers an earlier effective date, i.e., if successful the veteran’s effective date would be the date that would have been given to the previously denied claim had it been granted instead of denied. 38 U.S.C. 5109A.

What is a CUE? A clear and unmistakable error is present when noted in previous determinations, which are final and binding. Note - the key term “final and binding.” Where evidence establishes such error, the prior decision will be reversed or amended. For the purpose of authorizing benefits, the rating or other adjudicative decision which constitutes a reversal of a prior decision on the grounds of clear and unmistakable error has the same effect as if the corrected decision had been made on the date of the reversed decision. (38 CFR 3.105)

What is a final and binding determination?The decision of a duly constituted rating agency or other agency of original jurisdiction shall be final and binding on all field offices of the Department of Veterans Affairs as to conclusions based on evidence on file at the time VA issues written notification in accordance with 38 U.S.C. 5104. (38 CFR 3.104 Finality of decisions).

Sometimes there is confusion in believing that a decision must be “Finally adjudicated” in order to be a CUE. What is a finally adjudicated claim?

A finally adjudicated claim is an application, formal or informal, which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of 1 year after the date of notice of an award or W. Rees 32 updated 7/25/18

disallowance, or by denial on appellate review, whichever is the earlier. (§3.160 Status of claims).

What constitutes a CUE?To constitute a CUE the claimant must show that the error was outcome-determinative, i.e., the error was so important that if it had not occurred it would have manifestly changed the outcome of the prior decision containing the CUE. Yates v. West, 213 F. 3d 1372 (Fed Cir 2000); and Bustos v. West 179 F. 3d 1378 1380 (1999).

What if there is a disagreement on how the facts were weighed?A disagreement on how the facts were weighed or evaluated by the VA cannot amount to a CUE. Simmons v. West 13 Vet App 501 (2000); Crippen v. Brown 9 Vet. App. at 418, Russell v. Principi, 3 Vet App 310, 313 (1992).  This means that even if a decision is unfavorable to a veteran (e.g., there is no nexus between the veteran’s current disability and an in-service event, injury or disease) and even if it is against the overwhelming weight of the evidence, it is not a CUE if there is some evidence in the record that supports the adverse decision no matter how weak the subsequent rater believes that evidence to be.  The CAVC has stated "When there is evidence both pro and con on the issue it is impossible… to succeed in showing that 'the result would have been manifestly different'"  Simmons v. West, 13 Vet. App. 501 quoting Fugo v. Brown 6 Vet App 40, 44 (1993) (emphasis supplied by the Court).

What about fact versus opinion?"Difference of opinion" v. "error of fact": CUE can occur where evaluation granted is too low but the CUE must be supported by "clear and undisputed evidence of record" Myler v. Derwinski 1 Vet App at 574 and Berle v. Brown, 9 Vet App 377 (1996).  This is essentially an "error of fact" where evidence contained in the record at the time of the offending rating was ignored or neglected by the rater and of course it has to meet "outcome determinative" test.

More CUE Trivia:1. The “Benefit of the Doubt” rule does not apply to a CUE claim. VA Gen Coun. Prec. 4-2002 (May 28, 2004).2. A change in the interpretation of a regulation after a decision is rendered cannot be CUE. 38 CFR 20.1403(e)(2006)3. Failure of the VA to fulfill the VCAA “Duty to Assist” cannot be grounds for CUE. 38 CFR 20.1403(d)(2)(2006).

Moreover, the “Duty to Assist” with claim development imposed by the VCAA does not apply to the veteran’s CUE claim itself. Livesay v. Principi, 15 Vet. App. 165, 179 (2001), Huston v. Principi 17 Vet. App. 195, 206 (2003) and Parker v. Principi, 15 Vet. App. 407, 412 (2002).

4. In order to make out a CUE claim the Veteran must raise the CUE claim with specificity; in other words, it is not enough for the veteran to merely state the VA was wrong in its prior decision; rather, the veteran must identify the error by articulating when and how the error occurred. McIntosh v. Brown, 4 Vet. App. 553, 561. Simmons v. Principi, 17 Vet. App. 104 (2003). If the veteran fails to adequately articulate the claim for CUE the claim may be dismissed without prejudice. Note however that although VA has no statutory “Duty to Assist” with developing the CUE claim, VA must “…give a sympathetic reading to the veteran’s filings…” in order to determine the scope or nature of the claim. Szemraj v. Principi, 357 F. 3d. 1370, 1373 (Fed. Cir. 2004).

5. Failure to schedule a VAE can never be grounds for CUE.6. A CUE must be based on the available evidence at that time of the prior Rating Decision.7. A CUE cannot be based on a subsequent change in the law; or, a recent change in how we applied the law at the

time of the prior Rating Decision.

General Discussion from VBMS-R:Clear and unmistakable errors are errors that are undebatable, so that it can be said that reasonable minds could only conclude that the previous decision was fatally flawed at the time it was made. A determination that there was a clear and unmistakable error must be based on the record and the law that existed at the time of the prior decision. Once a determination is made that there was a clear and unmistakable error in a prior decision that would change the outcome, then that decision must be revised to conform to what the decision should have been. In this case, the disability evaluation is reduced because the previous decision was a clear and unmistakable error.

TEMPLATE (CUEs, including EEDs, need Long Form Narrative, per III.iv.6.C.7.a):

Issue: Whether the {} was a clear and unmistakable error.

Decision: A clear and unmistakable error is found in {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

{state facts from rating that is in error} The Rating Decision dated {}… The service treatment records show {}. The DBQ dated {} shows {}.

W. Rees 33 updated 7/25/18

{state law} VA regulations say {}.

{state error & why} A clear and unmistakable error occurred when {}. Service connection is granted effective {}. / A higher evaluation of {} percent is granted from {}. / An earlier effective date is established from {}.

If relevant, add: The correction of this error does not reduce your combined evaluation.

If relevant, add this note on the codesheet: Please waive any potential overpayment due to administrative error on VA’s part.

Earlier Effective Date (EED):

For SC/Compensation: “Earlier Effective Date Granted” under Supplementary Decision, then choose "CUE Comp Earlier Effective Date Granted”

Issue: Whether the effective date of service connection for {} was a clear and unmistakable error.

Decision: A clear and unmistakable error is found in the effective date for service connection for {} and an earlier effective date of {} is established for the {} evaluation.

USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} assigned an effective date of {}, the day VA received the claim for service connection for {disability}. However, an Intent to File (ITF) was received on {}, within one year prior to the day VA received the claim.

VA policy says VA may grant entitlement to benefits from an effective date prior to the date of claim as long as the claimant submits a complete claim within one year of the date VA received the ITF. {III.ii.2.C.2.c}

As the previous decision was clearly and unmistakably erroneous, service connection is now granted effective {}.

CUE Description: RD dated {} assigned an effective date of {}, the day VA received the claim. The effective should have been based on the ITF received {} because a complete claim was received within one year of the ITF.

For Evaluation: “Earlier Effective Date Granted” under Supplementary Decision, then choose "Earlier Date – Evaluation Granted” (no option for CUE, so you need to modify the generated language); or use the above SC/Compensations selections & still modify the languge as below

Issue: Whether the effective date of the increased evaluation assigned for the service connected {disability} was a clear and unmistakable error.

Decision: A clear and unmistakable error is found in the effective date for the increased evaluation assigned for the service connected {disability} and an earlier effective date of {} is established for the {} evaluation.

USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} assigned an effective date of {}, the day VA received the claim, for the increased evaluation to {} percent for {disability}. However, an Intent to File (ITF) was received on {}, within one year prior to the day VA received the claim.

VA policy says VA may grant entitlement to benefits from an effective date prior to the date of claim as long as the claimant submits a complete claim within one year of the date VA received the ITF. {III.ii.2.C.2.c}

As the previous decision was clearly and unmistakably erroneous, the increased evaluation of {} percent is now effective {}.

CUE Description: RD dated {} assigned an effective date of {}, the day VA received the claim. The effective should have been based on the ITF received {} because a complete claim was received within one year of the ITF.

W. Rees 34 updated 7/25/18

Later Effective Date:

For Compensation/SC:

Issue: Whether the effective date of compensation/service connection for {} was a clear and unmistakable error.

Decision: A clear and unmistakable error is found in the effective date for service connection for {} and an effective date of {} is proposed for the {} percent evaluation.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} assigned an effective date of {} for the grant of service connection for {}, which is the day VA received the original claim for service connection for {}. However, service connection was denied by Rating Decision dated {} and a notification letter was sent on {}. An Intent to File (ITF) was received on {}, but a complete claim was not received until {}. Although the Intent to File was received within one year of the notification of the previous decision, the subsequent complete claim was not received within one year of the notification of the previous decision.

VA policy says an ITF may not be used to extend the period of non-finality for a recently decided claim, and if VA receives communication of a claimant’s ITF within one year of the non-final denial of a claim for service connection (SC), but the subsequent claim for SC for the same issue is not received within one year of the denial of the prior claim, the earliest potential effective date of entitlement to benefits is the date of receipt of the ITF.

As the previous decision was clearly and unmistakably erroneous, service connection is proposed to be granted effective {}.

CUE Description: RD dated {} assigned an effective date of {}, the day VA received the original claim for SC. The effective should have been based on the ITF received {} because the subsequent complete claim was not received within one year of the notification of the previous decision.

Add this note on the codesheet: Please include appropriate language in the notice of proposed adverse action, including language stating that the adjustment may result in an overpayment of benefits.

Incorrect denial:Issue: Whether the decision to deny service connection for {} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the denial of service connection for {}, and service connection is established with an evaluation of {} percent effective {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} denied service connection for {}. The service treatment records show {}. The DBQ dated {} shows {}. Service connection is warranted.

VA regulations say {}.*for denial when have non-PTSD dx & verified event: VA regulations say, “Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces…” VA policy says non-PTSD diagnoses require “actual documentation of the in-service event” and to grant the claim “if further development is possible and that development permits a finding that the in-service event(s) forming the basis for the diagnosis occurred.”

As the previous decision was clearly and unmistakably erroneous, service connection is established for {} with an evaluation of {} percent effective {}.

An evaluation of {} percent is assigned from {}…

Incorrect grant:W. Rees 35 updated 7/25/18

Issue: Whether the decision to grant service connection for {} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the grant of service connection for {}, and we are proposing to sever service connection.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} granted service connection for {}. The service treatment records do not show {}. The DBQ dated {} shows no diagnosis of {}. Service connection is not warranted.

VA regulations say {}.if have no dx: VA policy states "evidence of a current disability is required as one of the components of establishing SC. Generally, this criterion is satisfied when a current examination or other evidence demonstrates the presence of a chronic disability. However, the evidence must be reviewed to determine whether a disability was present at the time the claim was filed or during the pendency of the claim but has since resolved..." (can move last sentence, if not relevant)

As the previous decision was clearly and unmistakably erroneous, service connection is proposed to be severed.

Under-evaluation:Issue: Whether the evaluation assigned for {} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the evaluation of {} and a retroactive increased evaluation to {} percent disabling is established effective {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} granted {}. The service treatment records show {}. The DBQ dated {} shows {}.

VA regulations say {}.

A clear and unmistakable error occurred when {}. A higher evaluation of {} is granted from {}.

Two skin conditions each rated at 10% (if changes combined, must propose):Issue: Whether the assignment of separate 10 percent evaluations for {} and {} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the assignment of separate 10 percent evaluations for {} and {}, and the conditions are now evaluated together{ as 10 percent disabling from {}} OR {, and only as 0 percent disabling from {}.}

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} granted a 10 percent evaluation for {} and another 10 percent evaluation for {} effective {}. The 10 percent for {} was based on {}. The 10 percent for {} was based on {}. *ensure a 10% is warranted, may only be 0%

VA regulations do not allow the assignment of separate evaluations for {different} skin conditions, as the evaluation criteria is the same. Separate evaluations for each diagnosis are only permissible when the evaluation is based on disability due solely to the individual diagnosis. *if only 0% is warranted: Additionally, the evaluation criteria indicates that only a 0 percent evaluation is warranted for “no more than topical therapy required during the past 12-month period."

A clear and unmistakable error occurred when separate 10 percent evaluations were assigned for {} and {}. *if only 0% is warranted: Additionally, only a 0 percent evaluation is warranted based on the use of topical medication. A higher evaluation of 10 percent is not warranted unless the record shows 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The conditions are now evaluated together as {10 or 0} percent disabling from {}.

W. Rees 36 updated 7/25/18

The correction of this error does not reduce your combined evaluation.ORThe correction of this error will reduce your combined evaluation to {} percent effective {}.

Note for codesheet: Please consider waiving any potential overpayment due to administrative error on VA’s part.

Conds separate when should be together (can use for TBI & mental, respiratory, digestive):Issue: Whether the assignment of separate 10 percent evaluations for {} and {} was clearly and unmistakably erroneous.ORWhether the assignment of a 40 percent evaluation for traumatic brain injury (TBI) and a 70 percent evaluation for bipolar II disorder, major depressive disorder, and insomnia disorder was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the assignment of separate 10 percent evaluations for {} and {}, and the conditions are proposed to be evaluated together as 10 percent disabling from {}.ORA clear and unmistakable error is found in the assignment of a 40 percent evaluation for traumatic brain injury (TBI) and a 70 percent evaluation for bipolar II disorder, major depressive disorder, and insomnia disorder. Traumatic brain injury (TBI) is proposed to be evaluated together with bipolar II disorder, major depressive disorder, and insomnia disorder as 70 percent disabling from June 2, 2017.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} granted a 10 percent evaluation for {} and another 10 percent evaluation for {} effective {}. The 10 percent for {} was based on {}. The 10 percent for {} was based on {}.

VA policy says {}.

A clear and unmistakable error occurred when separate 10 percent evaluations were assigned for {} and {}. The conditions are proposed to be evaluated together as 10 percent disabling from {}.

If the proposed reduction takes effect, your combined evaluation will be {} percent.

scar(s) included with SC disability & wrong eff date: Issue: Whether evaluating {scar name} together with {disability name} was clearly and unmistakably erroneous. Whether the effective date of {} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the evaluation of {scar name} together with {disability name}, and a separate evaluation of 0 percent is granted. A clear and unmistakable error is found in the effective date, and the effective date is now {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

{state facts from rating that is in error} The Rating Decision dated {}… The DBQ dated {} shows {}.

{state law} VA policy says {}.

{state error & why} A clear and unmistakable error occurred when {}. A separate evaluation of 0 percent is granted for {} effective {}.

If relevant, add: The correction of this error does not reduce your combined evaluation.

surgical scar(s) not granted: Issue: Whether the failure to establish service connection for surgical scars, {} was clearly and unmistakably erroneous.

W. Rees 37 updated 7/25/18

Decision: A clear and unmistakable error is found in the failure to establish service connection for surgical scars, and service connection is established with an evaluation of {} percent effective {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} failed to establish service connection for surgical scars, {}. The DBQ dated {} shows {}. Service connection is warranted.

VA policy states that a scar from surgical intervention is an issue within the scope of the claim and a complication of the claimed issue.

As the previous decision was clearly and unmistakably erroneous, service connection is established for {} with an evaluation of {} percent effective {}.

Failure to address inferred issue:Issue: Whether the failure to establish service connection for {} was clearly and unmistakable erroneous.

Decision: A clear and unmistakable error is found in the failure to establish service connection for {}, and service connection is established with an evaluation of {} percent effective {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} failed to establish service connection for {}. The service treatment records show {}. The DBQ dated {} shows {}. Service connection is warranted.

VA policy states that {} is an issue within the scope of the claim for {} {and a complication of the claimed issue}.

As the previous decision was clearly and unmistakably erroneous, service connection is established for {} with an evaluation of {} percent effective {}.

Two knee evals under 5258 & 5260:Issue: Whether the assignment of a 20 percent evaluation for {}, and a separate 10 percent evaluation for {} was clearly and unmistakably erroneous. Evaluation of the current level of the {right/left} knee disability.

Decision: A clear and unmistakable error is found in the assignment of a 20 percent evaluation for {} and a separate 10 percent evaluation for {}. The disability is now called {}, and is evaluated as 20 percent disabling from {}. Additionally, the 20 percent evaluation is proposed to be decreased to 10 percent.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} granted a 20 percent evaluation for {} based on a meniscus disability with swelling and locking. The decision also granted a separate 10 percent evaluation for {} based on limitation of flexion. The service treatment records show a right ACL reconstruction and partial lateral meniscectomy. The {} examination/DBQ shows a diagnosis of {}. Based on the {} examination/DBQ results, only one 20 percent evaluation is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint, and x-ray evidence of traumatic arthritis along with any limitation of motion of the joint.

The Rating Decision dated {} continued the 20 percent evaluation for {} based on semilunar cartilage is dislocated with frequent episodes of "locking," pain, and effusion into the joint. The Rating Decision also continued the 10 percent evaluation for {} based on painful motion of the knee and x-ray evidence of traumatic arthritis. The {} DBQ diagnosed {}. Based on the DBQ results, only a 10 percent evaluation is warranted based on painful motion of the knee, symptomatic residuals of semilunar cartilage removal, and x-ray evidence of traumatic arthritis. However, sustained improvement was not demonstrated.

VA regulations do not allow the assignment of separate evaluations under the rating criteria for “Cartilage, semilunar, W. Rees 38 updated 7/25/18

dislocated, with frequent episodes of “locking,” pain, and effusion into the joint” and for “Leg, limitation of flexion of” as the evaluation criteria for “Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint” includes any limitation of motion from pain and effusion. VA regulations say “The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation… Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided.”

A clear and unmistakable error occurred when a 20 percent evaluation was assigned for {}, and a separate 10 percent evaluation was assigned for {}. The disability is now called {}, and is evaluated as 20 percent disabling from {}.

The correction of this error reduces your combined evaluation to {} percent from {}.

Additionally, the {} DBQ diagnosed {}. Based on the DBQ results, only a 10 percent evaluation is warranted based on painful motion of the knee, symptomatic residuals of semilunar cartilage removal, and x-ray evidence of traumatic arthritis. This is considered sustained improvement.

We are proposing to decrease the evaluation to 10 percent because the {} and {} DBQs show sustained improvement as described above. Although you have been evaluated at 20 percent for more than 5 years, sustained improvement is shown and there is no other evidence to support this 20 percent evaluation.

This proposal is based on the following:[add VEB/LEB/ Quick Reference Calculator: Evaluation Builder under Tools in VBMS-R info for proposed evaluation]

If the proposed reduction takes effect, your combined evaluation will be {} percent.

As this is a proposed action, you will have 60-days from the date of this notification letter to provide additional evidence to support why this action should not be taken or request a hearing.  If we do not receive a request for a hearing or additional evidence supporting the continued evaluation or entitlement to service connection for this condition, a new rating will be sent finalizing this proposed rating.  The effective date assigned will be the first of the month following 60-days from the date of that final notification letter to you.(changed 4/13/18, III.iv.4.A.6.f, per Lyles v. Shulkin (2017)NOT A CUE IF FOLLOWED PRIOR POLICY (before 4/13/18 changes)

Two limbs rated together:Issue: Whether the {evaluation assigned for amputation, all toes, both feet,} was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the {evaluation of amputation, all toes, both feet, as each foot should have been evaluated separately. Retroactive increased evaluations of 30 percent for each foot are established from March 21, 1946}.

SMC too low:Issue: Whether the assignment of the level of special monthly compensation was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the assignment of the level of special monthly compensation, as the next higher level should have been assigned based on an additional independent 100 percent evaluation, and a retroactive increase to this higher level is assigned effective {}.OR A clear and unmistakable error is found in the assignment of the basic rate for aid and attendance, as you have an additional independent 100 percent evaluation, which allows for entitlement to the next higher statutory rate, and a retroactive increase to this higher level is assigned effective {}.

SMC S not granted:

Temporary 100%:Issue: Whether the failure to establish entitlement to Special Monthly Compensation was a clear and unmistakable error.

W. Rees 39 updated 7/25/18

Decision: A clear and unmistakable error is found in the failure to establish entitlement to Special Monthly Compensation and entitlement is established based on the housebound criteria being met from {} to {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} failed to establish entitlement to Special Monthly Compensation based on housebound when a temporary evaluation of 100 percent was assigned from {} to {}, and there were separate and distinct service-connected disabilities, involving different anatomical segments/bodily systems, independently ratable at 60 percent.

VA regulations say "The special monthly compensation provided by 38 U.S.C. 1114(s) is payable where the veteran has a single service-connected disability rated as 100 percent and, has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems..."

A clear and unmistakable error occurred when entitlement to Special Monthly Compensation based on housebound was not established.

Entitlement to special monthly compensation is warranted in this case because criteria regarding housebound were met from {} to {}.

CUE Description: RD dated {} failed to establish entitlement to SMC S when granting a temporary 100% for {disability name} from {} to {}, and {disability name} and {disability name} combine to a separate 60%.

Bradley cases (effective 11/26/08):Issue: Whether the failure to establish entitlement to Special Monthly Compensation was a clear and unmistakable error.

Decision: A clear and unmistakable error is found in the failure to establish entitlement to Special Monthly Compensation and entitlement is established based on the housebound criteria being met from {} to {}.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} failed to establish entitlement to Special Monthly Compensation based on housebound when the grant of Individual Unemployability was based on a single disability (evaluated at 60 percent or more) from {}, and there were separate and distinct service-connected disabilities, involving different anatomical segments/bodily systems, independently ratable at 60 percent.

VA regulations say "The special monthly compensation provided by 38 U.S.C. 1114(s) is payable where the veteran has a single service-connected disability rated as 100 percent and, has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems..." In Bradley v. Peake, the United States Court of Appeals for Veterans Claims held that section 1114(s) does not limit the requirement for a “service-connected disability rated as total” to only a schedular rating of 100 percent, but may be satisfied by a Total Disability Individual Unemployability (TDIU) rating based on a single disability (if that single disability is evaluated at 60 percent or more).

A clear and unmistakable error occurred when entitlement to Special Monthly Compensation based on housebound was not established.

Entitlement to special monthly compensation is warranted in this case because criteria regarding housebound were met from {}.

CUE Description: RD dated {} failed to establish entitlement to SMC S when granting Individual Unemployability based on a single disability, {disability name} (evaluated at {}%) from {}, and there are separate evaluations combining to 60%.

Frostbite with two limbs rated together:Issue: Whether the single evaluation assigned for residuals, frostbite feet was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the single 10 percent evaluation of residuals, frostbite feet for both W. Rees 40 updated 7/25/18

lower extremities and a retroactive increased evaluation to 10 percent for each lower extremity for cold injury residuals is established effective January 12, 1998.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decisions dated May 6, 1998, September 12, 2002, February 23, 2005 and April 30, 2005 failed to separately evaluate each lower extremity for cold injury residuals based on the regulation change on January 12, 1998. VA cardiovascular regulations were changed effective January 12, 1998 to allow for separate evaluations for each extremity. A clear and unmistakable error occurred when you were not assigned separate evaluations for each lower extremity for your cold injury residuals on the four ratings that were done following the regulation change. Separate evaluations of 10 percent for each lower extremity are granted from January 12, 1998, since you had a claim pending from November 12, 1997 that was rated on May 6, 1998 and the change should have been made at that time.

Neuro with two limbs rated together:Issue: Whether the single evaluation assigned for bilateral lower radicular pain S/P hemilaminectomy and discectomy was clearly and unmistakably erroneous.

Decision: A clear and unmistakable error is found in the single 10 percent evaluation for bilateral lower radicular pain S/P hemilaminectomy and discectomy and retroactive increased evaluations to 10 percent for each lower extremity, as right lower extremity radiculopathy and left lower extremity radiculopathy, are established effective February 24, 2003.

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated May 12, 2004 granted a single 10 percent evaluation for bilateral lower radicular pain S/P hemilaminectomy and discectomy from February 24, 2003.

VA regulations state “The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor.”

A clear and unmistakable error occurred when you were not assigned separate evaluations for each lower extremity. Separate evaluations of 10 percent for each lower extremity, as right lower extremity radiculopathy and left lower extremity radiculopathy, are granted from February 24, 2003.

NO CUE & continuing evaluation:Add to decision line: “and the {} percent evaluation is continued.”

Reasons for Decision:USE VBMS-R System-Generated Text or CU1

The Rating Decision dated {} shows a 10 percent evaluation was assigned for {}.

If needed: The service treatment records show {}.

The DBQ of {} shows your reports of {}, and the examiner's findings of {}. These findings warrant a 10 percent evaluation. A higher evaluation of 20 percent is not warranted because the (service treatment records and) DBQ did not show {}.

We have continued the evaluation as 10 percent disabling as the current DBQ shows your reports of {}, and the examiner's findings of {}.

NO CUE on denial:

Whether the decision to deny compensation for {} was clearly and unmistakably erroneous.

No revision is warranted in the decision to deny compensation for {}.

USE VBMS-R System-Generated Text or CU1W. Rees 41 updated 7/25/18

CUE Denied (Evidence of Record/Rules in Effect At Time) – The decision to deny compensation for {} is not considered to have been clearly and unmistakably erroneous because the decision was properly based on the available evidence of record at the time and the rules then in effect.

CUE Denied (Not Undebateably Erroneous) – The decision to deny compensation for left knee degenerative joint disease claimed as bilateral knee condition is not considered to have been clearly and unmistakably erroneous because the alleged error involved an exercise of judgment which cannot be characterized as undebatably erroneous.

CUE Denied (Error Would Not have Changed Outcome) – The decision to deny compensation for left knee degenerative joint disease claimed as bilateral knee condition is not considered to have been clearly and unmistakably erroneous because the error is considered harmless since it would not have changed the outcome of the decision at the time.

Earlier Effective Date (EED)

I.1.B.1.k III.iv.5.C.8 – effective dates

October 2014 Rating Quality Call Notes – VA has no authority to adjudicate a freestanding claim for an earlier effective date (EED) in an attempt to overcome the finality of an unappealed RO decision. However, the claimant may request revision based on clear and unmistakable error (CUE) with respect to the assignment of the effective date in that prior final RO decision. I.1.B.1.k has text to include in letter if CUE not claimed

Per VA Pulse, https://www.vapulse.net/message/20799, a request for an earlier effective date (EED) does not need to be on a specific form

Claim for CUE, but none found, so NO earlier effective date (EED):

Choose “Earlier Effective Date Denied” under Supplementary Decision, then: “CUE Comp Earlier Effective Date Denied” &:or CUE Denied (Evidence of Record/Rules in Effect At Time) – “…because the decision was properly based on the available evidence of record at the time and the rules then in effect.”or CUE Denied (Error Would Not have Changed Outcome) – “… the error is considered harmless since it would not have changed the outcome of the decision at the time.”or CUE Denied (Not Undebateably Erroneous) – “… alleged error involved an exercise of judgment which cannot be characterized as undebatably erroneous.”

Issue: Whether the effective date of compensation for posttraumatic stress disorder was a clear and unmistakable error.Decision: Entitlement to an earlier effective date of service connection for posttraumatic stress disorder is not shown due to a clear and unmistakable error. The 50 percent evaluation is continued from December 18, 2008.

May need to modify to:Issue: Whether the effective date of the {increased} evaluation assigned to the service-connected posttraumatic stress disorder was a clear and unmistakable error.Decision: Entitlement to an earlier effective date for the {increased} evaluation of posttraumatic stress disorder is not warranted. The 50 percent evaluation is continued from December 18, 2008.________

A clear and unmistakable error will be held to exist when there is a finding in a prior decision that there were factual or legal errors which are more than a disagreement over matters of judgment. The finding must be limited to the factual record which was previously before the Department, the laws or regulations which existed at the time of the decision and the error must be material to the outcome of the claim. In this case, the previous disability evaluation is continued as no clear and unmistakable error is shown.

VA regulations say the "effective date of pension or compensation benefits, if otherwise in order, will be the date of receipt of a claim or the date when entitlement arose, whichever is the later."ORVA regulations state that, for disability compensation, for direct service connection, the effective date will be the "day following separation from active service or date entitlement arose if claim is received within 1 year after separation from W. Rees 42 updated 7/25/18

service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later."

{The Statement of the Case dated July 13, 2009 shows a 50 percent evaluation was assigned for post traumatic stress disorder effective December 18, 2008 because the December 18, 2008 VA examination was the first evidence of record showing worsening of the condition. All prior evidence showed that a continued 10 percent evaluation was warranted. There is no evidence of a clear and unmistakable error warranting entitlement to an earlier effective date for the increased evaluation of posttraumatic stress disorder.}

We have continued the evaluation as {} percent disabling. The treatment records show {}. The current DBQ shows your reports of {}. The examiner found {}.

These choices in VBMS-R do not discuss CUE & we do not address EED unless CUE claimed:Then: “SC Earlier Effective Date Denial” =Issue: Entitlement to an earlier effective date for service connection of {}.Decision: Entitlement to an earlier effective date for service connection of {} is denied.

Then: “Earlier Date - Evaluation Denied” =Issue: Entitlement to an earlier effective date for the evaluation assigned to the service connected {}.Decision: Entitlement to an earlier effective date for the evaluation of {} is denied.

Claims for Increase –

3.157 Report of examination or hospitalization as claim for increase or to reopen (eliminated 3/24/15) – I.1.C.3.j – from 8/26/15-9/21/17, this said exam only if an exam (or other med evid) within the last year is not

of record; changed 9/22/17, request exam unless (1) have veteran provided DBQ / private DBQ, (2) have surgical report for 4.29, 4.30 or joint replacement, (3) veteran has active cancer, (4) disability is at its maximum evaluation

I.1.C.3.k – need STRs before request audio exam

III.ii.2.C III.ii.2.C.5 – medical evidence of treatment before 3/24/15 (if after 3/24/15, need formal claim within one year

of date of treatment)

III.ii.2.E.3 III.iv.5.C.5 – effective dates

III.iv.5.C.5.e-h– need to determine if reconsideration or CFI, recommend explaining effective date even if it is the DOC; My Notes: Examples 1 (III.iv.5.C.5.f, prior FTR) & 2 (III.iv.5.C.5.g, submitted PTRs) show continuously prosecuted claims where 3.400(q) was applied. Example 3 (III.iv.5.C.5.h) shows application of 3.400(o).

III.iv.5.C.5.f & 3.400(q)Entitlement to an increased evaluation has been established from the day VA received the previous claim, as you continuously prosecuted your claim. OR Entitlement to an increased evaluation has been established from the day VA received your Intent to File (ITF) for the previous claim, as a complete claim was received within one year of the ITF, and you continuously prosecuted your claim.

III.iv.5.C.5.g & 3.400(q)Entitlement to an increased evaluation has been established from the earliest date the treatment records show evidence of increased disability, within one year prior to the day VA received the previous claim, as you continuously prosecuted your claim.For special notation: ITF 12/29/15 associated with 4/19/16 claim. 5/8/17 reconsideration filed within one year of 8/17/16 notification letter (of 8/15/16 decision).

*also see III.iv.5.C.6.d & III.iv.5.C.6.e for 3.156(b)(1)

Rating Note: Per III.iv.5.C.5.h, as there was no evidence relevant to the initially received claim, the 12/4/17 claim is considered a freestanding claim for increase independent of the prior claim even though it was received during the appeal period, and 3.400(o) governs the assignment of effective date.

W. Rees 43 updated 7/25/18

III.iii.1.C.9.a III.iv.3 III.iv.5.C.9 Bowers v. Derwinski (8/6/92) & Ardison v. Brown (4/4/94) – if veteran received treatment for a worsened

condition, they should be asked to submit evidence of the treatment (III.iv.3)

Crawford v. Brown (4/22/93) - a invoked when b criteria are met

Sears v. Principi (8/20/02) – 3.157 does not apply to N&M evidence (only to claims for increase); three classes of claims: original, reopened after previously denied, and claims for increase (Judge asked that this reg be re-written)

VAOPGCPREC 5-2003 (9/15/03)- 3.157(b)(1), which states that date of admission to a “uniformed services hospital will be accepted as the date of receipt of a claim” for increased benefits, is applicable to veterans hospitalized in private facilities at DoD expense under DoD's TRICARE program.

Gaston v. Shinseki (5/20/10) - Both the statute (38 USC § 5110(b)(2)) and the regulation (38 CFR 3.400(o)(2)) require “that an increase in a veteran’s service-connected disability must have occurred during the one year prior to the date of the veteran’s claim in order to receive the benefit of an earlier effective date.” Impact on VBA says “please note that VA or uniformed services medical records may provide a basis for an effective date earlier than one year prior to the date of claim for increased evaluation for a service-connected disability if these records adequately demonstrate that the disability was of such severity to warrant a higher evaluation at such date. See 38 C.F.R. § 3.157(b)(1). This case does not affect that established rule.”

October 2014 Compensation Service Bulletin (CSB) – As of 3/24/15, informal claims under current 38 CFR 3.155 will be eliminated. However, claimants will be able to preserve a potentially earlier effective date as currently provided by the informal claim process through a new “intent to file a claim for benefits” process whereby the date of receipt of the intent to file a claim that is submitted in a prescribed form will secure an earlier effective date if a complete claim is filed within one year. Otherwise, a complete claim on a prescribed form will be considered filed as of the date of its receipt. The final rule also will eliminate 38 CFR 3.157, “Report of examination or hospitalization as claim for increase or to reopen.” However, 38 CFR 3.400(o)(2) has been amended to provide potential retroactive effective date assignments for evaluations based on such medical records if a claimant files either a complete claim or an intent to file a claim within one year of such medical care or treatment. Finally, new sections, 38 CFR §§ 19.23 and 19.24, have been added to provide that if VA provides a form specifically for an appeal, claimant must express a notice of disagreement on such form to initiate an appeal. If VA does not provide a claimant a form to initiate an appeal, then claimant may submit an expression of disagreement in any format as current procedures allow.

March 2016 Quality Call Notes – Reminder to still apply 3.157 for informal claims rec’d prior to 3/24/15 (to include treatment records show worsening to next level, even if that condition is not specifically claimed), includes 6 scenarios

Reopened Claims –

3.156 New and material evidence

I.1.A.3.i III.ii.2.D.1 III.ii.2.D.2.c & III.ii.2.D.3.h & III.ii.2.D.3.i –

VSR: Please administratively deny {}, per III.ii.2.D.2.c, III.ii.2.D.3.h & III.ii.2.D.3.i, as {no evidence has been submitted / the evidence submitted is clearly and entirely duplicative}.

III.ii.2.E - N&M in CFI

III.iii.1.B.6 – effective dates

III.iv.2.B.3 – “Evidence is material if, by itself, or when considered with previous evidence of record, it relates to any unestablished fact necessary to substantiate the claim.” N&M evid “must raise a reasonable possibility of substantiating the claim.” “… low threshold for reopening claims.” Example 1 – if denied because treated in

W. Rees 44 updated 7/25/18

service (skin), but not diagnosed at VAE… then provides evidence of diagnosis = reopened [no need for nexus info]. Example 2 – if denied because not treated in service & not diagnosed at VAE (claimed asthma)… then provides evidence of treatment by private physician for acute issues (URIs) in service = not reopened as no evid if current disability [only one element addressed by new evidence]

III.iv.5.C.6 – effective dates

Manio v. Derwinski (2/15/91), Colvin v. Derwinski (3/8/91), Hayes v. Brown (1993) & Hodge v. West (1998) - defines N&M & 2-step analysis, Colvin also discusses limited weight of evidence & Hayes also discusses credibility

Masors v. Derwinski (2/7//92), Allday v. Brown (4/14/95) & Evans v. Brown (8/1/96) - defines what is not material

Gobber v. Derwinski (5/27/92) - well-grounded, outcome might change

Justus v. Principi (12/2/92) - credible when N&M

Guerrieri v. Brown (4/7/93) & White v. Principi (3/27/01) – N&M evidence; “treating physician rule" is not suitable for application to the issue of service connection of a veteran's disabilities. The Court has not adopted and will not today adopt, a rule that gives the opinions of treating physicians greater weight in evaluating claims made by veterans.

Cox v. Brown (5/12/93) - defines N&M

Moray v. Brown (6/11/93) - lay medical evidence not good, not N&M

Reonal v. Brown (9/8/93) – opinion based on inaccurate data is not credible opinion, thus not material evidence

Martinez v. Brown (5/27/94) – benefit of the doubt does not apply to reopening claims that are finally denied, as the evidence is not weighed

Barnett v. Brown (4/13/95 & 5/6/96) - defines what is not new

Curtis v. Brown (8/1/95) – must consider treating physician’s uncontradicted statements

Butler v. Brown (6/12/96) - if no N&M, no further analysis is required or permitted

Sears v. Principi (8/20/02) - “new claim” under 3.400(q)(1)(ii) refers to a claim to reopen a previous & finally denied claim; the earliest possible effective date for service connection benefits granted for a reopened claim as the date of receipt of the request to reopen

October 2010 Compensation Service Bulletin (CSB) Addendum

Shade v. Shinseki (11/2/10) – reopen if newly submitted evidence raises a reasonable possibility of substantiating the claim (low threshold)

March 2015 Compensation Service Bulletin (CSB), says to refer to VAOPGCPREC 12-98 (9/23/98)

W. Rees 45 updated 7/25/18

EVALUATION BUILDER, VBMS-R & VBMS INFO

RVSR SNL Trainee Handout –

“When there is a change in range of motion due to repetition, the additional limiting factors should be checked off in the boxes on the right side of the screen. The “Select from List” checkbox for pain is also for objective evidence of painful motion with or without further limitation due to repetitive motion.”

If granting individual unemployability (IU) you must list all the disabilities that contributed to the establishment in the Special Notation box.

Notes from January 2014 Evaluation Builder Refresher Training –

remember 4.7

successive builds upon itself, often uses “and” (diabetes is example; but in some cases can give the higher even if don’t have ALL, especially if have one from even higher eval, Camacho - thyroid)

non-successive doesn’t build upon itself (HIV is example)

PVD (7199-7114) is over-evaluated in EB (gives 100% for ischemic limb pain at rest), but Comp Service says that’s how it is to be applied

Migraines – “productive of severe economic inadaptability” doesn’t have to be shown in record, if affects work (lie down in dark room, occasionally miss work) it is 50%, take their word, don’t need objective evidence (& don’t have to be completely unable to work to qualify for 50%), Comp Service says very frequent completely prostrating and prolonged attacks = 50%; My Notes: 8100 says “very frequent completely prostrating and prolonged attacks,” DBQ says “very frequent prostrating and prolonged attacks”

IVDS – need evidence of prescribed bedrest under 5243, can’t accept just the checked box on the DBQ based on reported history, this is per Note 1. Don’t defer for clarification.

IBS is generally high.

Mental – Comp Service wants you to check all three for stressful circumstances, work & worklike setting; plus all three for circumstantial, circumlocutory, or stereotyped speech.

Peripheral Nerves – Sensory only can only be mild or moderate

Joints – 4.7 is not applied by VEB

Don’t use “more closely approximates” to give a lower eval than generated by EB unless have ample evidence to support lower eval

Evaluation Builder Refresher Student Handout dated September 2013 –

records showing “bedrest prescribed by a physician and treatment by a physician” are required to confirm incapacitating episodes, 5243

When frequent, completely prostrating attacks are indicated, assign the 50%, 8100

Use the generated evaluation for 7319, IBS

4.7 doesn’t apply to joint evaluations since they are based on ROM

ADL SOP March 2014 –

Add effective date explanation if it’s other that the date of claim or the day after discharge.

Most of the time, the extra information included in the rating decision is not required in the decision letter.

If the rating narrative includes free text, then the corresponding decision notice may also require free text to further explain the rating. Use free text in the decision notice infrequently…

Use language that is appropriate for the audience (e.g. reader focused writing).

Avoid legal terminology. If unavoidable, explain the terminology in layman’s terms.

Never include legal citations such as the CFR or case law. This is appropriate for the rating narrative but not in the notice to the Veteran.

Keep sentences direct, concise and clear.

W. Rees 46 updated 7/25/18

ADL SOP May 2014 –

Write the rating decision using second person active voice, III.iv.6.C.5.f.

Auto-populating a DBQ to the Evaluation Builder in VBMS-R

January 2015 Rating Quality Call Notes – Info on ADL.

To change claim status (to OPEN, RFD, RDC, etc) and re-assign, choose “Complete Work Item” (green check mark icon under Claim) [CANCELLED is for erroneous EPs, CLOSED gives the RO credit] My Notes: Do not change to RDC if you did not do the RD. If it is in RC/Rating Correction status, email your Coach to have it assigned to the correct RVSR.

III.v.2.B.4, III.iv.6.C.5 – Redesigned ADL (RADL), eff 12/11/17 (now sending copy of RD with notification letters AGAIN)

III.iv.6.C.5.f says avoid complex medical or legal terminology in the Reasons for Decision

Notification Letter Text & Notification Letter User Text no longer relevant as of 12/11/17 or 1/4/18, III.iv.6.C.5; BUT Do not use abbreviations.

In VBMS-R, type in the Abbreviation (if Abbreviation different in VBMS-R, it is in italics below) & do Ctrl-Shift-A

VBMS-R System-Generated Text

If Decision is Not Incurred/Caused by ServiceService connection may be granted for a disability which began in military service or was caused by some event or experience in service.

Then also have these FIVE choices for Decision Basis (should probably just pick one):No Actual Disability (should also use NODX) - Service connection is denied because {} is not considered an actually disabling condition.No Record of Condition (use when no evidence of treatment, should also use NODX) - Service connection for {} is denied since there is no evidence the claimed condition exists.No Relationship to Service (not very useful, maybe for when have a negative opinion OR maybe when have Element 1 & Element 2, but don’t have Element 3..., should also use NONEX) - There is no evidence to show a relationship between [required fill-in] which you had while in service, and your current [required fill-in] condition. Therefore, service connection is denied.Acute and Transitory (use for acute (AT) in STRs, then FTR; OR acute (AT) in STRs & no lay/medical evidence of association NONEX, should probably also use NOCONT or NODX) - A disability which began in service or was caused by some event in service must be considered "chronic" before service connection can be granted. Although there is a record of treatment in service for {}, no permanent residual or chronic disability subject to service connection is shown by the service medical records or demonstrated by evidence following service. Therefore, service connection for {} is denied. IV.ii.2.B.1.g - Do not arbitrarily determine in-service injuries to be acute and transitory without relying on competent medical evidence determining that chronic disability was not demonstrated.Not Incurred/Caused by Service - Service connection for {} is denied since this condition neither occurred in nor was caused by service.

If Decision Basis is No Diagnosis (not very useful; maybe use with treatment for pain or other symptom, or if no diagnosis on DBQ, most contentions are better addressed by No Actual Disability, No Record of Condition, or Acute and Transitory; if use this, obviously should also use NODX)

Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. Service connection for {} is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.

W. Rees 47 updated 7/25/18

If Decision Basis is Not Established by Presumption will also include Generated Text for Decision Basis of Not Incurred/Caused by Service & additional sentence for Not Incurred/Caused by Service - Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. Service connection for {} is denied since this condition neither occurred in nor was caused by service.

Then also have these FIVE choices (just pick one):Not Presumptive (Not a Condition In 3.309(a)) - Service connection may be granted on a presumptive basis for a chronic disease cited under 38 CFR 3.309(a) (also 38 CFR 3.309(c) for former POWs) if the disease is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge (specified under 38 CFR 3.307). As {} is not one of the cited diseases, service connection on a presumptive basis is denied.Not Presumptive (Not Compensable Within Time Limits) (if have evidence that currently compensable, but not diagnosed [does not specifically say that though] & compensable within a year; although below paragraph is better) - Service connection may be granted on a presumptive basis for {} if this condition is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge (specified under 38 CFR 3.307). While the medical evidence shows that {} is currently disabling to a compensable degree, the medical evidence fails to show that the disability became compensable within the time period specified under 38 CFR 3.307. Therefore, service connection on a presumptive basis must be denied.Not Presumptive (No Diagnosis Within Time Limits) - Service connection may be granted on a presumptive basis for {} if this condition is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge. As the medical evidence fails to show a diagnosis of {} within the time period specified under 38 CFR 3.307, service connection on a presumptive basis must be denied.Not Presumptive (Not Compensable) (if have diagnosis within a year, but not compensable) - Service connection may be granted on a presumptive basis for {} if this condition is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge (specified under 38 CFR 3.307). The medical evidence establishes the existence of {} within the specified period after military service; however, the severity of the disability is not shown to be at a compensable level within that specified period. Therefore, service connection on a presumptive basis is denied.

If Decision Basis is Constitutional/Developmental AbnormalityThe condition identified as {} is considered a congenital or developmental defect which is unrelated to military service and not subject to service connection.

If Decision Basis is Not Aggravated by ServiceThe evidence shows that {} existed prior to service. There must be objective evidence of worsening of a pre-existing condition in order to establish service connection by aggravation. There is no evidence that the condition permanently worsened as a result of service.

If Decision Basis is Not Secondary, also have these choices:NSC Secondary – Primary Condition is NSC - Service connection may be granted for a disease or injury which resulted from a service-connected disability or was aggravated thereby. The evidence does not show that {} is related to service. Therefore, service-connection for {} on a secondary basis to this condition cannot be established. There is also no evidence showing {} was incurred in or aggravated by military service.NSC Secondary – Primary Condition is SC - Service connection may be granted for a disease or injury which resulted from a service-connected disability or was aggravated thereby. The evidence does not show that {} is related to the service-connected condition of {}, nor is there any evidence of this disability during military service.

If the decision is Confirmed and Continued (under Supplementary Decision) because the Reopened Claim for SC Denied on Merits, generated text is:W. Rees 48 updated 7/25/18

The claim for service connection for {} is considered reopened. However, the evidence continues to show this condition was not incurred in or aggravated by military service.*need to add CCDENY**not for RECONSIDERATIONS, only for reopened claims with N&M evidence, but still denied; My Notes: I think it’s also for reopen claims without N&M evidence, as III.ii.2.D.4.b says we have to make a two part decision (1-whether N&M evidence has been submitted; 2-whether to grant or continue the denial) & III.iv.2.B.3.m says if evidence is new, but not material, we confirm the previous denial & say the claim is not reopened.

If the decision is Confirmed and Continued because the Evidence Not New/Material, also have these choices: Evidence Not Material (**Similar to Not Material Denial Reason, NM):A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.

The evidence from the {} submitted in connection with the current claim does not constitute new and material evidence because it does not relate to an unestablished fact necessary to substantiate the claim and does not raise a reasonable possibility of substantiating the claim.

Evidence Not New (**Similar to Cumulative Denial Reason, NM_CU) – not very useful, check for CAPRI records:A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.

The evidence from {} submitted in connection with the current claim does not constitute new and material evidence because it was previously submitted and considered in the rating decision of {}.

Issue: Service connection for {}.Decision: The claim for service connection for {} remains denied because the evidence submitted is not new and material.

If the decision is Individual Unemployability Denied, also have these FOUR choices (**first sentence in each of these choices is similar to IU Denial Reason):

IU Deny - Schedular:Entitlement to individual unemployability is denied because the claimant has not been found unable to secure or follow a substantially gainful occupation as a result of service connected disabilities. Service connected disabilities currently evaluated as {} percent do not meet the schedular requirements for entitlement to individual unemployability. 38 CFR 4.16 provides that individual unemployability may be granted where there is one disability evaluated as 60 percent disabling, or two or more disabilities, one of which is 40 percent with a combined evaluation of 70 percent or more. These percentage standards are set aside only when the evidence clearly and factually shows the veteran has been rendered unemployable solely due to service connected disabilities regardless of their individual and combined percentages. Such cases are submitted to the Director of the Compensation and Pension Service for extra-schedular consideration. This case has not been submitted for extra-schedular consideration because the evidence fails to show the veteran is unemployable due to service connected disabilities. (38 CFR 4.16)IU Deny - Capable of Employment:

W. Rees 49 updated 7/25/18

Entitlement to individual unemployability is denied because the claimant has not been found unable to secure or follow a substantially gainful occupation as a result of service connected disabilities. The veteran is considered capable of gainful employment. {38 CFR 4.16}IU Deny - NSC Caused:Entitlement to individual unemployability is denied because the claimant has not been found unable to secure or follow a substantially gainful occupation as a result of service connected disabilities. The veteran is considered unemployable due to nonservice-connected factors. The service connected disabilities, when considered apart from the nonservice-connected conditions, are not the cause of unemployability. {38 CFR 4.16}IU Deny - Employed:Entitlement to individual unemployability is denied because the claimant has not been found unable to secure or follow a substantially gainful occupation as a result of service connected disabilities. The Veteran is considered gainfully employed. {38 CFR 4.16}

If the Special Issue in VBMS-R is Environmental Hazard in Gulf War-Undiagnosed Illness (& Environmental Hazard in Gulf War-Other Unidentified; Environmental Hazard in Gulf War-Environmental; Environmental Hazard in Gulf War-Diagnosed-Biological),also have the FOUR choices below: The "Persian Gulf War Veterans' Benefits Act" authorizes VA to compensate any Gulf veteran suffering from a "qualifying chronic disability," resulting from an undiagnosed illness or combination of undiagnosed illnesses, appearing either during active duty in the Southwest Asia theater of operations during the Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the theater. Section 202 of the "Veterans Education and Benefits Expansion Act of 2001" expanded the definition of "qualifying chronic disability" to include (1) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; and (2) any diagnosed illness that the Secretary of the VA determines in regulations warrants a presumption of service-connection.

To fulfill the requirement for chronicity, the claimed illness must have persisted for a period of 6 months. The 6-month period of chronicity is measured from the earliest date on which all pertinent evidence establishes that the signs or symptoms of the disability first became manifest.**per IV.ii.2.D.5.b, the paragraphs are required in all denials of undiagnosed illness & MUCMIs, infectious diseases has additional paragraph

eff 8/1/17, IV.ii.2.D.5.c shows:NOT an option in VBMS-R - No Southwest Asia service:If evidence demonstrates service in the Southwest Asia theater of operations, service connection may be granted on a presumptive basis for certain qualifying chronic disabilities if the condition became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021. Service connection for [enter disability] is denied, because the required service is not shown.

Deny – Attributable to Other Etiology:Service connection under this provision is precluded if there is affirmative evidence that the disability was unrelated to service in the Gulf War. Service connection for {} is denied because evidence established that this disability resulted from {}.eff 8/1/17, IV.ii.2.D.5.c shows this, which is different from the above VBMS-R System-Generated Text: Service connection under this provision is precluded if there is affirmative evidence that the disability was unrelated to service in the Southwest Asia theater of operations. Service connection for [disability] is denied because evidence established that this disability resulted from [unrelated event, accident, injury, etc.].

Deny – Diagnosed Illness:Service connection for {} is denied because this disability is determined to result from a known clinical diagnosis of {}, which neither occurred in nor was caused or aggravated by service.eff 8/1/17, IV.ii.2.D.5.c shows this, which is different from the above VBMS-R System-Generated Text: Service connection for [claimed disability] is denied because this disability is determined to result from a known clinical diagnosis of [diagnosed disability], which, under current law, is not a qualifying disability associated with Gulf War service. Further, the condition was not incurred in or aggravated by service.

W. Rees 50 updated 7/25/18

Deny – Illness Not ChronicThe disability must have persisted for a period of at least 6 months. Service connection for {} is denied since this disability was first manifested on {} and lasted less than 6 months. eff 8/1/17, IV.ii.2.D.5.c shows “six” instead of “6”

Deny – Found Less Than 10 Percent Disabling:Service connection for {} is denied since this disability neither arose during service in the Gulf theater, nor was it manifested to a compensable degree after the last date of service in the Gulf theater during the Gulf War.eff 8/1/17, IV.ii.2.D.5.c shows this, which is different from the above VBMS-R System-Generated Text: Service connection for [disability] is denied since this disability neither arose during service in the Southwest Asia theater of operations, nor was it manifested to a compensable degree after the last date of service in the Southwest Asia theater during the Gulf War period.

From: VAVBAWAS/CO/21WEB Sent: Friday, January 12, 2018 10:06 AMSubject: Compensation Service Calendar Update - New fragment added to the VBMS-R National Glossary

Friday, January 12, 2018

Compensation Service has added a new fragment to the VBMS-R National Glossary.  Decision makers can use fragment, GW_NoSvc, in claims that are denied based on no Southwest Asia (Gulf War) service.  When selected, the following text will be added to the decision:  “If evidence demonstrates service in the Southwest Asia theater of operations, service connection may be granted on a presumptive basis for certain qualifying chronic disabilities if the condition became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021. Service connection for {enter disability} is denied, because the required service is not shown.

If doing a Proposal to Sever, have these FIVE choices:Change In Law:It is proposed to sever service connection for {} due to a change in law or interpretation of the law or VA issue.Character of Discharge:It is proposed to sever service connection for {} because the veteran does not have a character of discharge requisite for service connection.Fraud:It is proposed to sever service connection for {} due to fraud.No Requisite Service:It is proposed to sever service connection for {} because the veteran does not have requisite service.CUE: It is proposed to sever service connection for {} due to a clear and unmistakable error. Clear and unmistakable errors are errors that are undebatable, so that it can be said that reasonable minds could only conclude that the previous decision was fatally flawed at the time it was made. A determination that there was clear and unmistakable error must be based on the record and the law that existed at the time of the prior decision. Once a determination is made that there was a clear and unmistakable error in a prior decision that would change the outcome, then that decision must be revised to conform to what the decision should have been.

Proposals & Final severance decisions need Long Form Narrative, per III.iv.6.C.7.a

If the Special Issue in VBMS-R is Agent Orange – Vietnam – Other/Unknown-Agent Orange …, also have the SIX choices below:

Under the authority granted by the Agent Orange Act of 1991, VA has determined that presumption of service connection based on exposure to herbicides used in Vietnam is not warranted for any conditions other than those for which VA has found a positive association between the condition and

W. Rees 51 updated 7/25/18

such exposure. VA has determined that a positive association exists between exposure to herbicides and the subsequent development of the following conditions: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease including coronary artery disease, including coronary spasm, and coronary bypass surgery, and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; early-onset peripheral neuropathy; porphyria cutanea tarda (PCT); prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). PCT, chloracne, and early-onset peripheral neuropathy are required to become manifest to a compensable degree within one year from last exposure.

No Nexus:The available scientific and medical evidence does not support the conclusion that the condition is associated with herbicide exposure.

No Exposure:Service connection may be established based on a relationship to herbicide exposure only if evidence demonstrates either service in Vietnam during the Vietnam era or exposure to herbicides through some other military experience. The required service in Vietnam is not shown, nor is there evidence of exposure to herbicides during military service.

Not SC:There is no basis in the available evidence of record to establish service connection for {}. This condition did not happen in military service, nor was it aggravated or caused by service.

No Diagnosis:Service connection based on a relationship to herbicide exposure is denied because the evidence does not show a diagnosis of a condition for which VA has found a positive association to herbicide exposure.

Peripheral Neuropathy Not Within 1 YearService connection for peripheral neuropathy cannot be established since the neuropathy did not first become manifest to a compensable degree within one year after last exposure to herbicides.

Porphyria Cutanea Tardae Not within 1 Year:Service connection for porphyria cutanea tarda cannot be established since the porphyria cutanea tarda did not first become manifest to a compensable degree within one year after last exposure to herbicides.

Chloracne Not Within 1 Year:Service connection for chloracne cannot be established since the chloracne did not first become manifest to a compensable degree within one year after last exposure to herbicides.

If the Special Issue in VBMS-R is PTSD – Non-Combat – Stressful Event (don’t use “PTSD-Combat – Fear-Easing Standard” or “PTSD-Non-Combat – Other Stressor Verification”), also have THREE choices below:

No Link:Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred.

W. Rees 52 updated 7/25/18

If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, occurrence of the claimed in-service stressor may be established by the veteran's lay testimony alone. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of 38 CFR 3.1(y) and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, occurrence of the claimed in-service stressor may be established by the veteran's lay testimony alone. {38 CFR Sections 3.1(y), 3.304(f), 4.125(a)}

The available medical evidence is insufficient to confirm a link between current symptoms and an in-service stressor.

No Combat Stressor (PTSD):Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred.

If the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, the Veteran's lay statement alone may establish the occurrence of the stressor. The available evidence is not sufficient to confirm that the Veteran actually engaged in combat with the enemy. Receipt of an award or medal related to combat or other documentation of combat has not been established. When determining whether to grant service connection for PTSD, VA considers all potential in-service stressors reported by the Veteran or raised by the evidence. The stressors can include combat, non-combat, fear of hostile military or terrorist activity, or personal assault. VA was unable to corroborate combat or any other in-service stressor.

No Diagnosis (PTSD) (it seems you mayl also automatically get this language if you choose No Diagnosis as a Decision Basis on the DDI screen):Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred.

If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, occurrence of the claimed in-service stressor may be established by the veteran's lay testimony alone. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of 38 CFR 3.1(y) and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, occurrence of the claimed in-service stressor may be established by the veteran's lay testimony alone. {38 CFR Sections 3.1(y), 3.304(f), 4.125(a)}

A diagnosis of posttraumatic stress disorder must meet all diagnostic criteria as stated in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The evidence does not show a confirmed diagnosis of posttraumatic stress disorder which would permit a finding of service connection.

W. Rees 53 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial REASONS

Abbreviation Definition Language

Reasons That Require Additional Free Text

NODX No Diagnosed Condition The evidence does not show a current diagnosed disability. None

NIS

No Event, Disease or Injury in Service (Not-in-service)

The evidence does not show an event, disease or injury in service. None

NONEX No Nexus or LinkWe did not find a link between your medical condition and military service. Free Text

NM Not Material

The evidence you submitted is not new and material. Therefore, your claim is not reopened. It is not material because it does not relate to an unestablished fact necessary to substantiate the claim and/or does not raise a reasonable possibility of substantiating the claim. Free Text

NM_DUPNot New 1 (Duplicate evidence)

The evidence you submitted is not new and material. Therefore, your claim is not reopened. It is not new because it had already been submitted and considered. Free Text

NM_NONENot New 2 (No medical evidence submitted)

The evidence you submitted is not new and material. Therefore, your claim is not reopened. Although you raised the possibility that more evidence exists, you did not submit it. Free Text

NM_CUNot New and Material (Cumulative)

The evidence you submitted is not new and material. Therefore, your claim is not reopened. It is not new because it is cumulative or redundant of evidence we already considered. Free Text

P_NP

Not a presumptive condition – Chronic (Not Presumptive)

Your condition is not one of the chronic diseases that VA presumes is related to your military service. None

P_NC

Did not develop to compensable degree (Not Compensable)

The evidence does not show that your disease developed to a compensable degree within the specified time period after release from service to qualify for the presumption of service connection. Free Text

P_NENo qualifying exposure (No Exposure)

The evidence does not show the location(s) of your military service, or the events you experienced therein, qualify for the presumption of service connection for your disease. Free Text

P_NSNo service qualifying for presumption (No Service)

We did not find that you had active, continuous service for 90 days or more to qualify for the presumption of service connection. None

CCDENY

also see CC1 & CC2

*also need other Reasons (like an initial denial)

Confirm and Continue previous denial

The evidence does not support a change in our prior decision. Therefore, we are confirming the previous denial of this claim.

“Confirmed and Continued” under Supplementary Decision - then “Reopened Claim for SC Denied on Merits”VBMS-R System-Generated Text:Decision: The previous denial of service connection for {} is confirmed and continued.Reasons: The claim for service connection for {} is considered reopened. However, the evidence continues to show this condition was not incurred in or aggravated by military service.

**not for RECONSIDERATIONS, only for reopened claims with N&M evidence, but still denied; My Notes: I think it’s also for reopen claims without N&M evidence, as III.ii.2.D.4.b says we have to

None

W. Rees 54 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial REASONS

Abbreviation Definition Language

Reasons That Require Additional Free Text

make a two part decision (1-whether N&M evidence has been submitted; 2-whether to grant or continue the denial) & III.iv.2.B.3.m says if evidence is new, but not material, we confirm the previous denial & say the claim is not reopened.

NSC2Not a secondary condition

The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability. Free Text

NO_AGGNo evidence of aggravation

The evidence does not show that your condition, which existed prior to service, permanently worsened as a result of service.

*Do not also address direct SC in aggravation cases (i.e. do not use NIS or STRs or AT or NONEX or V_NONEX). Free Text

WMC Willful misconductThe evidence shows that this condition resulted from willful misconduct. Free Text

CDConstitutional and Developmental Condition

Your condition is considered a congenital or developmental defect, which is unrelated to military service and not aggravated by it.

**Similar to VBMS-R System-Generated Text None

R_NPRadiation (Not a presumptive condition)

Your condition is not one of the diseases that VA presumes is related to radiation exposure. None

R_NE Radiation (No exposure)

We did not find that you participated in a radiation risk activity while in service.*probably only for use by Jackson RO & only if have claim for disability linked to radiation None

CCEVAL Confirm and Continue current evaluation

We reviewed the evidence received and determined your service-connected condition(s) hasn’t/haven’t increased in severity sufficiently to warrant a higher evaluation.

*August 2014 EB training said do not use EB for C&Cs, go directly to the Disability Decision Information (DDI) – manual entry screen.

*as of 12/11/17the VBMS-R workaround, so that you don’t lose your Evaluation Builder verbiage on a confirmed & continued evaluation, is to add the original effective date to the new card, add "Confirmed and Continued Evaluation" under the Supplementary Decision drop-down, then delete old cardOR End-users should select the corresponding EB result by placing a check mark under the Save Changes button.

*non-CCEVAL notes:Rating Note: It seems that due to the recent coordinated install, VBMS-R is now duplicating verbiage. I've deleted the duplicate verbiage under Reasons for Decision.

Rating Note: It seems that due to the recent coordinated install, VBMS-R is now generating verbiage used on prior denials. I've deleted the duplicate verbiage under Reasons for Decision.sometimes only in the Reasons for Decision box, if so, just delete*might want to delete issue from Master Record & start from scratch, but need to retain “Original Date of Denial” on codesheet, per III.iv.6.E.8.b

Rating Note: It seems that due to the recent coordinated install,

None

W. Rees 55 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial REASONS

Abbreviation Definition Language

Reasons That Require Additional Free Text

VBMS-R is now generating evaluation verbiage with some denials. I've deleted the evaluation verbiage under Reasons for Decision {for the ? issue}.

IUIndividual Unemployability

Your claim for individual unemployability was denied because the evidence does not show you are unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Free Text

IU416

use if does not meet schedular criteria

Individual Unemployability - Does not meet the schedular requirements

We denied your claim for individual unemployability because you do not have one disability rated at 60%, or a combined rating of at least 70% with one disability rated at 40%, and the evidence does not demonstrate that you are unable to secure or follow substantially gainful occupation solely due to service-connected conditions.

We denied your claim for individual unemployability because you do not have one disability rated at 60 percent, or a combined rating of at least 70 percent with one disability rated at 40 percent, and the evidence does not demonstrate that you are unable to secure or follow substantially gainful occupation solely due to service-connected conditions. Free Text

P29_21Hospitalized less than 21 days

We denied your claim for a temporary total evaluation (100%). The evidence does not show that your service-connected condition required hospitalization for a period of more than 21 days. Free Text

P29_1

Private hospital summary received more than one year following discharge

We denied your claim for a temporary total evaluation (100%). The evidence shows VA received the summary of hospitalization more than one year following discharge from the hospital. Free Text

P30 Temp 100% for surgery

We denied your claim for a temporary total evaluation (100%). The evidence does not show that a service-connected disability required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. Free Text

3324 3.324 Denied

We denied a 10% combined evaluation based on your multiple 0% service-connected disabilities. The evidence does not show that your service-connected disabilities clearly interfere with normal employment.

OR USE VBMS-R System-Generated Text or BOTH None

SMC_KCOLoss of, or loss of use of Creative Organ

We have denied entitlement to special monthly compensation because the evidence shows you have not suffered the loss or loss of use of one or more creative organs due to your service-connected disability(ies). 

For generic anatomical loss/loss of use:We have denied entitlement to special monthly compensation because the evidence shows you have not suffered an anatomical loss or loss of use due to your service-connected disability(ies). None

W. Rees 56 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial REASONS

Abbreviation Definition Language

Reasons That Require Additional Free Text

SMC_AA

denyaa Denial of SMC A/A

We have denied entitlement to special monthly compensation because the evidence shows you do not need the regular aid and attendance of another person to perform routine activities of daily living, OR you are not permanently bedridden.

use:We have denied entitlement to special monthly compensation because the evidence shows you do not need the regular aid and attendance of another person to perform routine activities of daily living due to service-connected disabilities, and/or you are not permanently bedridden due to service connected disabilities. None

SMC_HB

denyhb Denial of SMC HB

We have denied entitlement to special monthly compensation because the evidence shows you are not substantially confined to your home or immediate premises due to your service-connected disability OR that you have a single service-connected disability rated 100 percent and a separate service-connected disability or disabilities independently rated 60 percent or more.

use:We have denied entitlement to special monthly compensation because the evidence shows you are not substantially confined to your home or immediate premises due to your service-connected disabilities and/or that you do not have a single service-connected disability rated 100 percent and a separate service-connected disability or disabilities independently rated 60 percent or more. None

CC3324(added 7/9/12)

Confirmed and continued (C&C) 3.324 entitlement 

We have continued your 10% combined evaluation for multiple 0% S/C disabilities. The evidence shows that your service-connected disabilities clearly interfere with normal employment.

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial RATIONALES

Abbreviation Definition Language

STRs* Not shown in STRsYour service treatment records do not contain complaints, treatment, or diagnosis for this condition.

AT

consider also using NOCONT, if pertinent

Shown in STRs, but not persistent (Acute-&-Transitory)

While your service treatment records reflect complaints, treatment, or a diagnosis similar to that claimed, the medical evidence supports the conclusion that a persistent disability was not present in service.

IV.ii.2.B.1.g - Do not arbitrarily determine in-service injuries to be acute and transitory without relying on competent medical evidence determining that chronic disability was not demonstrated.

NOCONT No Continuity of Symptoms There was no continuity of symptoms from service to the present.

W. Rees 57 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial RATIONALES

Abbreviation Definition Language

L_NODX Lay Evidence–No Diagnosis

You submitted a lay statement to support your claim. A credible lay statement may establish what was seen, heard, and directly experienced. The lay evidence was found not to be competent and sufficient in this case to establish a diagnosis of your condition or to show that a diagnosis had been made by a medical professional.

L_NONEX Lay Evidence– No Nexus

You submitted a lay statement to support your claim. A credible lay statement may establish what was seen, heard, and directly experienced. The lay evidence was found not to be competent and sufficient in this case to establish a link or nexus between your medical condition and military service or to establish that such a link has been found by a medical professional.

L_NOSYM*Lay Evidence – Current symptoms

You submitted a lay statement to support your claim. A credible lay statement may establish what was seen, heard, and directly experienced. The lay evidence was found not to be competent or credible evidence of the symptoms of your claimed condition.

NOCRED* No Credible event

You submitted lay evidence that your claimed disability is related to events or treatment in service. We have determined that the service treatment records and post service evidence contradict your statement(s) of a connection between your service and your claimed condition, and find the other evidence is more credible when considered in light of all the evidence. 

V_NONEX*Negative VAMC opinion (No nexus)

The VA medical opinion found no link between your diagnosed medical condition and military service.

V_ATNegative VAMC Opinion (Acute-&-Transitory) The VA medical opinion found no persistent disability.

PTSD_CConcede PTSD Stressor

We concede you experienced a stressful event in service or fear of hostile military or terrorist activity.

PTSD_NC No PTSD stressor concessionWe have not found that you experienced a stressful event in service, including fear of hostile military or terrorist activity.

PV_RAT*

III.iv.5.A.9.gRationale better supported (Probative Value Rationale)

While you submitted positive medical evidence to support your claim, we found other medical evidence more persuasive because it is better supported in its rationale and conclusions.

PV_S*

III.iv.5.A.9.gAuthored by specialist (Probative Value Specialist)

Some evidence supports your claim; however, we found other medical evidence more persuasive because a medical specialist in the appropriate field provided it.

PV_HX*

III.iv.5.A.9.g

Accurate account of medical history (Probative Value Medical History)

Although some evidence supports your claim, we found other medical evidence more persuasive because it is supported by an accurate account of the medical history and/or it is the most detailed and reliable depiction of your medical condition.

W. Rees 58 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial RATIONALES

Abbreviation Definition Language

PV_HX2*

III.iv.5.A.9.g

Includes relevant personal and/or military history (Probative Value Medical History2)

While some evidence supports your claim, we found other medical evidence more persuasive because it is supported by your relevant military and/or personal history.

May want to add:The opinion from {} is not credible or persuasive, as without any evidence of treatment or symptoms during service, an opinion connecting a current condition to military service, based on history, is not credible or persuasive. & also use NONEX

Without any evidence of treatment or symptoms during service, statements of symptoms in service, by history, are not credible or persuasive.& also use NOCRED

If get VA examiner’s opinion based on “overuse” or reported history of injury:Without any evidence of treatment or symptoms during service, statements of injury and overuse in service, by history, are not credible or persuasive.& also use NONEX & NOCREDRating Note: The VA examiner’s opinion links the diagnosed {} to "overuse" and “injury.” STRs are silent for treatment. VATRs show {} ({} years after separation). We have no regulation or policy that allows for SC based on "overuse" or reported injury without some treatment in service.

Without any evidence of treatment or symptoms during service, reports of wearing boots without support in service are not a credible or persuasive basis for service connection.& also use NONEX & NOCREDRating Note: The {} opinion links the diagnosed {} to wearing boots in service. STRs are silent for treatment. VATRs show {} ({} years after separation). We have no regulation or policy that allows for SC based on wearing boots without some treatment in service.

PV_MULTI*

III.iv.5.A.9.g

Multiple medical professionals (Probative Value supported by multiple medical professionals)

Even though some evidence supports your claim, we found other medical evidence more persuasive because it is supported by a consensus of medical expertise.

PV_CERT*

III.iv.5.A.9.g

Greater certainty (Probative Value supported by a greater medical certainty)

Some evidence supports your claim; however, we found other medical evidence more persuasive because it is supported by a greater degree of medical confidence.

PV_V_P*

III.iv.5.A.9.g

Private vs. VAMC medical opinion (Probative Value-VAX more convincing than private opinion)

The medical opinion we received from the VA Medical Center was more persuasive than your private physician’s opinion because it was based on a thorough review of your relevant military and/or personal history and contained a more convincing rationale.

ACK_NONEX*

Acknowledge receipt of Private Medical Opinion (PMO) Link (Acknowledgment of private medical evidence but insufficient to establish a nexus)

We acknowledge receipt of your private medical opinion intending to link your current disability to a disease, event, or injury from your military service.

ACK_NODXAcknowledge receipt of PMO diagnosis.

We acknowledge receipt of your private medical opinion, which diagnosed your current disability.

ACK_SX* Acknowledge receipt of symptom evidence

We received your medical evidence which discusses the symptoms of your medical condition.

W. Rees 59 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial RATIONALES

Abbreviation Definition LanguageFTR*

also see VE1

I.1.C.3.m - non-cooperation with exam

I.1.C.3.n – good cause; “any reason other than failure to receive notice of the examination,” proceed with decision after two FTRs

I.1.C.3.p – chart for if notice undeliverable / returned mail

I.1.C.3.q - we will consider evidence that rebuts the presumption of regularity, i.e. VA didn’t update the veteran’s address timely, or the exam notice was received after the date of the exam

IV.ii.3.B.1 – FTR for review exam, 3.655

IV.ii.3.B.2 – RSVP / FTRSVP

Failed to Report to VA Exam (Failure-to-report)

You did not attend the VA examination we scheduled in connection with your claim, and did not show good cause for your failure to do so. Therefore, medical evidence that could have been useful to support your claim was not available to us.

Changed to (date of change unknown, does not talk about good cause):We have been informed that you have missed the VA examination scheduled in support of your claim. There is no information presently indicating good cause for absence on the scheduled appointment date. As a result, medical evidence that could have been used to support your claim was not available to us. Please notify us when you are ready to report for an examination, or you may submit a disability benefits questionnaire (DBQ) which must be completed and signed by a physician.

*****Rating Note: The veteran has FTR twice. I.1.C.3.n says "Do not reschedule the examination if the claimant has previously been rescheduled for the same examination and did not report." FTR SNL code text has been modified.

Use this in the Reasons for Decision:

We have been informed that you have missed the VA examinations scheduled {and rescheduled} in support of your claim. As a result, medical evidence that could have been used to support your claim was not available to us. You may submit a disability benefits questionnaire (DBQ) which must be completed and signed by a physician.

*****

Rating Note: I.1.C.3.n&q say that allegations of failure to receive/non-receipt of a notice of a scheduled examination is not good cause & we should not reschedule the examination if the claimant indicates he/she did not receive notice of the examination.

*****

Hearing Loss Calculator Generated Text:This claim is considered based on the evidence of record as you failed to report for the scheduled VA examination. Evidence expected from this examination which might have been material to the outcome of this claim could not be considered. In order for your claim to be reconsidered, you must submit medical evidence of current treatment or show good cause for missing the examination, while indicating a willingness to report for another VA examination.*similar to VE1

*****

https://www.vapulse.net/message/24552, recommends this for RSVP: "You did not respond to attempts to schedule a VA examination in connection with your claim. Therefore, medical evidence that could have been useful to support your claim was not available to us."

W. Rees 60 updated 7/25/18

Glossary fragments (SNL/ADL codes, use CTRL-SHIFT-A) and VBMS-R Denial RATIONALES

Abbreviation Definition Language

OR, RSVP paragraph based on new FTR paragraph above (for Reasons for Decision):We have been informed that you did not respond to attempts to schedule a VA examination in support of your claim. As a result, medical evidence that could have been used to support your claim was not available to us. Please notify us when you are ready to report for an examination, or you may submit a DBQ which must be completed and signed by a physician.

for Evidence: Report of inability to contact you to schedule VA examination (RSVP), received {}

Rating Note: HL Calculator does not have a selection for failure to RSVP, so I modified/added the language.

If unavailable (modified from Hearing Loss Calculator Generated Text, similar to VE1):This claim is considered based on the evidence of record as you were unavailable for a VA examination. Evidence expected from this examination which might have been material to the outcome of this claim could not be considered. In order for your claim to be reconsidered, you must submit medical evidence of current treatment or indicate a willingness to report for a VA examination.

SUST (added 7/9/12)

III.iv.8.D.2.b

*see “Improvement” below For use with C&C Evaluations

Although current evidence demonstrates some improvement in your condition, the record as a whole does not show that sustained improvement has been demonstrated, or that the improvement will be maintained under the ordinary conditions of life.

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

ACE

Although we notified you of pending disability examinations, we determined that we could resolve your claim through a review of the evidence of record.

III.iv.3.A.4.b – ACE is only for VA, to include telehealth & telemental health exams, see III.iv.3.D.2.c below; which also says non-VA (veteran provided) DBQs / private DBQs cannot be done remotely

AG1

I.1.C.2.gIV.ii.2.B.5

In instances where a nonservice-connected disability is claimed to have been permanently aggravated by a service connected injury or disease, service connection may be granted. In order to warrant service connection on the basis of such aggravation, the medical evidence of record must show the baseline level of the nonservice-connected disability that existed prior to the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and receipt of medical evidence showing the current severity of the nonservice-connected disability. This baseline level, prior to aggravation, is deducted from the current level of impairment for compensation purposes.

W. Rees 61 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated TextIV.ii.2.B.5.d - The responsibility for submitting evidence to establish a baseline level of disability for a claim for secondary SC based on aggravation of a NSC disability by an SC disability rests with the claimant. Notes: Do not request an examination if the Veteran has failed to furnish medical evidence establishing a baseline level of the severity of the NSC disability. If no baseline can be established, no aggravation can be demonstrated and the claim should be denied.

AL1

Seasonal and other acute allergic manifestations, which subside in the absence of or removal of the allergen, are generally regarded as acute diseases, healing without residuals. In order for service connection to be granted by way of incurrence or aggravation, the determination must be made on the whole of the record which must indicate that a chronic, permanent disease or disability was either incurred in or aggravated beyond normal progression as a result of a veteran's military service.

ANALOGOUS

III.iv.6.E.2This disability is not specifically listed in the rating schedule; therefore, it is rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.

AO2

On June 10, 2008, the Secretary of Veterans Affairs announced that, based on the National Academies of Science (NAS) Institute of Medicine (IOM) report, there was no evidence to support the presumption of service connection for hypertension due to herbicide (Agent Orange) exposure. This information continues to be current. Therefore, under existent law, hypertension has not been added to the list of presumptive disabilities associated with herbicide exposure.

AO3

IV.ii.1.H.2.m

VA evaluates Agent Orange exposure claims on a case-by-case basis. In this case, the evidence is insufficient for VA to acknowledge Agent Orange exposure on either a presumptive or direct facts-found basis due to secondary or remote contact with aircraft or equipment previously used in Vietnam.

BD1

III.iv.5.A.1.j

When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.

CA1

VA General Counsel Precedent Opinion dated 5/2/97 noted that it is well established that a primary cancer of one organ may metastasize into other organs, causing secondary tumors in those other organs. "Metastasis" is the transfer of disease from one organ or part to another not directly connected with it. By definition, metastasis would represent the progress of the nonservice-connected primary cancer, and evidence that a secondary cancer resulted from metastasis of a primary cancer would be affirmative evidence that the secondary cancer was not the result of some other cause, such as herbicide exposure.

CC1 The medical records fail to provide any evidence which would warrant any change in the previous decision.

CC2

Service-connection for this condition remains denied as the evidence continues to show this condition was not incurred in or aggravated by military service.

**Similar to VBMS-R System-Generated Text when select “Reopened Claim for SC Denied on Merits”

CC5YR(added 12/2/13)

You will be scheduled for an examination at a future date to determine if your disability has shown sustained improvement.

CH1

hypercholesterolemia / high cholesterol7099-7000

High cholesterol is a symptom or abnormal finding and not recognized as a chronic disability under VA law for which compensation may be paid. Also, a chronic disability manifested by this symptom is not shown. Service connection for high cholesterol is denied.

CU1

A clear and unmistakable error (CUE) is an error that is undebatable, so that reasonable minds could not differ. A determination of CUE must be based on the record and the law that existed at the time of the prior decision. Such error must have been prejudicial to the claimant. Once a determination is made that there was a CUE in a prior decision that would change the outcome of that decision that decision must be corrected so as if the former error had not been made.

CV1 One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute.

DL1 The provisions of 38 CFR 4.40 and 4.45 concerning function loss due to pain, as cited in DeLuca v. Brown,

W. Rees 62 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text8 Vet. App. 202 (1995), have been considered and are not warranted because there was no additional loss of range of motion with repetitive movements as it relates to pain, weakness, excessive fatigability or incoordination.

DM1Because { BENEFIT } would be rated as a non-compensable disability by itself, it has been included in combination with your service-connected {S/C DISABILITY}. A higher and separate evaluation for { BENEFIT } is not warranted unless there is {FIRST COMPENSABLE CRITERIA}.

DM2

III.iv.4.M.1.e

Regulation of activities does not refer to the need for ordinary exercise, which is a standard prescription for diabetics. Regulation of activities refers to the avoidance of strenuous occupational and recreational activities in diabetics with poor blood sugar control. There is no indication that you have been advised by a physician to reduce your physical activities due to diabetic symptoms or complications.

DT1

Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment only. For compensation purposes, service connection may only be granted if there was service trauma or a chronic or systemic disease with loss of substance of the mandible and/or maxilla bone and there is clinical evidence that dentures or implants cannot replace the missing teeth. The term "service trauma" does not include the intended effects of treatment provided during military service. Thus, therapeutic tooth extractions are not considered dental trauma.

ED1The date of your claim for { BENEFIT CLAIMED }is { DATE }, which is within one year following the effective date from { DATE OF LAW CHANGE }, when the law changed for { NEW BENEFIT }.' Under 38 CFR '3.114, entitlement to { BENEFIT CLAIMED } can be established in your case from { DATE OF LAW CHANGE }, the date the law changed, since you were eligible for the { BENEFIT CLAIMED } on that date.

ED2

The date of your claim for { BENEFIT CLAIMED }is { DATE }, more than one year following the effective date from { DATE OF LAW CHANGE }, when the law changed for { BENEFIT CLAIMED }.' Under 38 CFR '3.114, entitlement to { BENEFIT CLAIMED } can be established in your case from { ONE YEAR PRIOR TO DATE OF CLAIM }, or one year prior to your date of claim, since you were eligible for the { BENEFIT CLAIMED } effective { DATE OF LAW CHANGE }.-OR- The date of your claim for { BENEFIT CLAIMED }is { DATE }, which is within one year following the effective date from { DATE OF LAW CHANGE }, when the law changed for { NEW BENEFIT }.' Under 38 CFR '3.114, entitlement to { BENEFIT CLAIMED } can be established in your case from { DATE OF LAW CHANGE }, the date the law changed, since you were eligible for the { BENEFIT CLAIMED } on that date.

ELCT(added ?)Changed to Elective procedure at some point, but have to use light bulb

Service connection is denied since there is no relationship between {disability}, which occurred in service, and a non-elective medical procedure, or no unexpected complications/subsequent aggravation was found. Service connection is denied because the evidence shows your {disability} is a result of your elective procedure and would not otherwise have occurred had your elective procedure not been performed.

EMPLO(added ?)

grant IU

Information that you provided on your application, as well as at your VA examination, indicates that you have been working as {}. You have a projected annual income of approximately {}. With a {} education and the nature and combination of your disabilities, it is considered that you are only able to maintain marginal employment and unable to maintain full-time gainful employment. Therefore, all reasonable doubt has been resolved in your favor.

ES1

III.iv.5.B.2.h

Consideration has been given to the extra-schedular provisions of 38 CFR 3.321(b)(1). This case does not present such an unusual disability picture to warrant referral to the Director, Compensation and Pension Service, because the evidence does not show a marked interference with employment or frequent periods of hospitalization due to the service connected condition as to render impractical the application of the regular schedular standards.

III.iv.6.B.4.d shows how to submit claims to Compensation Service for extra-schedular considerationES2

also see MAX_EVAL

This is the highest evaluation allowed under the law for this condition. An extra-schedular evaluation was considered. The evidence does not show that your case presents such an exceptional or unusual disability picture with such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards.

W. Rees 63 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

I.1.C.3.j - no automatic exams of disabilities at schedular maximum evaluationEXAMG

grant P&T / grantp&t

also see PT-65 & PT-EX & PT-MED

We scheduled an examination for you to evaluate your disabilities and your potential entitlement to non-service connected pension benefits. Specifically, we asked a VA examiner to provide all diagnoses found with associated objective findings. In addition, we asked the examiner to provide an opinion as to whether you are unable to secure or follow a substantially gainful occupation as the result of your disability(ies). You were examined at the {} VAMC on {}. The VA examiner noted that you are disabled due to {}, among other disabilities. Also, the examiner opined that your disabilities prevent you from maintaining substantial gainful employment.

FD1III.iv.4.J.3.c

Fibrocystic disease of the breast, more appropriately called fibrocystic condition of the breast, is not a pathological condition, but a physiologic (or normal and non-pathologic) finding occurring in two thirds of all women. As a physiologic finding it does not warrant service connection.

FED_REC &/or FRU*nostrs(added 4/8/14)

*can use CTL-SHIFT-A for FRU in Free Text Evidence in VBMS-R, but have to add FED_REC thru Glossary icon

**verbiage required in Evidence per ???

also see NO-STR

As we informed you in our previous letter, we have determined that {} cannot be located and therefore are unavailable for review. If VA subsequently obtains the records, it will reconsider your claim as though the records were in VA custody at the time VA originally decided the claim.

*your STRs*your complete STRs*the separation examination for your {} to {} period of service

FIRE1(added 11/20/13)

also see PMC-NPRC

Efforts to obtain your service treatment records from all potential sources were unsuccessful. The National Personnel Records Center (NPRC) reported that the records may have been destroyed in a fire at the Records Center in 1973. If these records are located at a later date, we will reconsider this decision.

GR1

direct & pres

Service connection may be granted for any disease or injury that is considered to have resulted in a period of war or service. To establish direct service connection for a claimed disorder, objective evidence must show a diagnosis of a current disability that is related to a disease or injury incurred in or aggravated during "active " service; or that manifested itself to a compensable degree within one year from the date of discharge.

GR2

aggravated

A preexisting injury or disease will be considered service-connected when it is shown to have been aggravated by active service or where there is an increase in disability during such service, which is beyond the natural progress of the disease. In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance

W. Rees 64 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textinto active service, whether the particular condition was noted at the time of entrance into active service, or whether it is determined upon the evidence of record to have existed at that time. It is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule except that if the disability is total (100 percent) no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule, no deduction will be made. Service treatment records show the condition pre-existed your active service and that there was an injury or disease that caused the condition to worsen beyond its normal progression.

GR3

tinnitus

The VA examiner indicates your tinnitus began many years after military service. However, you indicate that you did not fully understand the questions the examiner was asking and meant to indicate to the examiner that the ringing in your ears has been present since military service. We have assigned a 10 percent disability evaluation based on (in-service event/acoustic trauma/medical nexus to hearing loss) recurrent tinnitus. Reasonable doubt is found in your favor when, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.

GW1

Gulf War

MUCMI

Service connection may be established for a disability resulting from undiagnosed illness or a medically unexplained chronic multi-symptom illness that is defined by a cluster of symptoms, or a diagnosed illness that is determined by VA regulation to warrant a presumption of service connection which manifested itself either during active service in the Southwest Asia theater of operations during the Gulf War, or to a degree of ten percent or more after the date on which the veteran last performed service in the Southwest Asia theater of operations during the Gulf War.

HA1prostrating

A prostrating attack is defined as so debilitating that a person is unable to function within normal daily activity.

HC1hepatitis C

Medically recognized risk factors for hepatitis C consist of transfusion of blood or blood product before 1992, organ transplant before 1992, hemodialysis, tattoos, body piercing, intravenous drug use (due to shared instruments), high-risk sexual activity (risk is relatively low), intranasal cocaine (due to shared instruments), accidental exposure to blood products in health care workers or combat medic or corpsman by percutaneous (through the skin) exposure or on mucous membrane, and other direct percutaneous exposure to blood such as by acupuncture with non-sterile needles and sharing of toothbrushes or shaving razors.

HL1

hyperlipidemia7099-7000

Hyperlipidemia is a laboratory finding and is not considered an actual disabling condition for VA purposes. The evidence does not show a disability for which compensation may be established. Compensation is payable for a disease or injury which causes a disabling physical or mental limitation.

HT1

1151

You filed a claim for a disability which you indicated was caused by care, treatment, or other services in a VA facility. When a disability is caused by the administration of VA services and the disability is not due to the claimant's own willful misconduct, such disability may be compensated. In order to be considered for compensation, the claimed disability must be caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the care, treatment, or examination or by an event not reasonably foreseeable.

HT2

1151

(changed at some point)

Compensation is payable for any disability which is caused by VA hospitalization, medical or surgical treatment, vocational rehabilitation, compensated work therapy program (CWT), or as the result of having submitted to a VA medical examination. The evidence must show that the veteran's additional disability is actually the result of the VA care. Specifically, carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination must be shown; or the proximate cause of disability must be an event not reasonably foreseeable. For training and rehabilitation services or compensated work therapy program, it must be shown that the veteran's participation in an essential activity or function of the training, services, or CWT program provided or authorized by VA proximately caused the disability. Merely showing that a veteran has additional disability is not sufficient to establish causation.

IHD Ischemic heart disease, for the purposes of establishing a positive association between exposure to herbicides and the subsequent development of the condition, does not include hypertension or peripheral

W. Rees 65 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textmanifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease.

IN1The evidence of record does demonstrate that an increased evaluation for your service-connected disability is warranted. (Sufficient findings seem to imply that the record may not have been adequately developed).

IU1

gainful employment

Substantially gainful employment is defined as employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the veteran resides.

http://www.blogs.va.gov/VAntage/17608/individual-unemployability-understanding-basics/ - “Substantially gainful employment is simply full-time employment that provides a wage greater than the poverty level. (Note: In 2014, the U.S. Census Bureau considered a poverty-level, yearly wage for a person under the age of 65 to be $12,316.)”

IV.ii.2.F.9.b – confirms 2014 was $12,316, 2015 (added 4/20/16) as $12,331, nothing on 2016 as of 4/20/16

2013 Federal Poverty Guidelines – federal poverty level for 1 person - $11,888/$12,119/$11,173; 2014 - $12,316http://www.census.gov/hhes/www/poverty/data/threshld/index.html

IU2

use if does not meet schedular criteria

Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of 1) a single service-connected disability ratable at 60 percent or more, or 2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: disabilities of one or both upper extremities; or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from common etiology or a single accident; disabilities affecting a single body system (e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric); multiple injuries incurred in action; or multiple disabilities incurred as a prisoner of war. Prior employment or unemployment status is immaterial if your disabilities render you unemployable.**Similar to VBMS-R System-Generated Text

LAB

(added 10/8/14)

{Disability} is a laboratory finding. Laboratory findings alone are not considered disabling conditions for VA purposes. The evidence does not show a disability for which compensation may be established. Compensation is payable for a disease or injury which causes a disabling physical or mental limitation.

MAX_EVAL

also see ES2

I.1.C.3.j - no automatic exams of disabilities at schedular maximum evaluation

The assigned evaluation of {} percent for {} is the maximum evaluation provided in the Rating Schedule for this disability. The disability findings in this case do not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards or warrant a referral for an extra-schedular evaluation.

MD1

4.28

The law requires that, when a mental disorder that develops in service, as a result of a highly stressful event, is severe enough to bring about a veteran's release from active military service, an evaluation of not less than 50 percent will be assigned. An examination will be scheduled within the six-month period following your discharge to determine whether a change in evaluation is warranted.

MD3

PTSD

Service connection for post-traumatic distress disorder (PTSD) requires the presence of three elements: (1) credible supporting evidence that the claimed in-service stressor actually occurred; (2) a current diagnosis of PTSD; and (3) medical evidence of a causal connection between current symptoms and the claimed in-service stressor. For a stressor to be sufficient for PTSD, the stressor must meet two

W. Rees 66 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textrequirements: (1) you must have been exposed to a traumatic event in which you experienced, witnessed, or were confronted with an event or events that involved actual or threatened death or serious injury or threat to the physical integrity of yourself or others and (2) your response must have involved a psychological or physio-psychological state of fear, helplessness, or horror. Combat decorations will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed service stressor. Additionally, confirmed prisoner of war (POW) status is considered conclusive evidence of a stressor. In-service personal assault cases, may result in evidence from sources other than the veteran's service records to corroborate the veteran's account of the stressor incident.

NO-STR no_STR, nostrs

also see FED_REC & FRU

Efforts to obtain your service medical records from all potential sources were unsuccessful. If these records are located at a later date, this decision will be reconsidered.

P-HBD

deny SMP HB

also see PMC-SMPD

Housebound benefits are payable if the Veteran has a single disability ratable at 100 percent and additional disabilities independently ratable at 60 percent or more; or if the Veteran is substantially confined to his or her dwelling and immediate premises due to disability. Entitlement to special monthly pension on this basis is not established by the evidence of record. {38 CFR 3.351}. We sent you a letter dated {}, in which we asked you to submit medical evidence showing the need for the housebound benefit, as outlined above, and you were advised of the housebound benefit requirements. You had 30 days to submit the requested evidence to substantiate your claim. If applicable <><> <> The medical evidence reviewed shows that you are not substantially confined to your dwelling and immediate premises due to disability. Based on all evidence of record, entitlement to special monthly pension based on housebound status is denied.

P28G100

4.28A 100 percent prestabilization rating is assigned from {} for an unstabilized condition with severe disability and substantial gainful employment is not feasible or advisable.

P28G50

4.28

A 50 percent prestabilization rating is assigned from {} for unhealed or incompletely healed wounds or injuries, and it is likely there will be material impariment of employability. A 100 percent rating is not assigned since gainful employment is feasible and the veteran does not have an unstabilized condition with severe disability.

P29G

4.29An evaluation of 100 percent has been assigned because of hospitalization over 21 days from {}.

P30G

4.30

An evaluation of 100 percent has been assigned effective {} based on surgical or other treatment necessitating convalescence.

PA1 38 CFR 4.59 allows consideration of functional loss due to painful motion. Objective evidence reveals painful motion, therefore a 10 percent evaluation is assigned, effective { }.

PMC-HCD

deny helpless child

For purposes of establishing entitlement to VA benefits, a child over 18 years of age must be shown to be permanently incapable of self-support by reason of mental or physical defect by the age of 18. Our letter to you, dated {} requested that you submit evidence showing the extent to which {} is physically or mentally deficient, such as the ability to perform self-care functions, and ordinary tasks expected of a child that age; whether or not {}attended school and the maximum grade attended; evidence showing if any material improvement in {}condition has occurred; evidence showing if {}have ever been employed and, if so, the nature and dates of such employment, and amount of pay received; information as to whether or not {}have ever married; and a description of present condition. The letter also afforded you VA authorization forms for you to complete so that the agency can assist you in securing any additional medical evidence to help substantiate your claim. <> Currently, there is no medical evidence of record showing that {}, became permanently incapable of self-support prior to age 18 on {}. Based on these findings, permanent incapacity for self-support is not established.

PMC-HCG

grant helpless child

For purposes of establishing entitlement to VA benefits, a child over 18 years of age must be shown to be permanently incapable of self-support by reason of mental or physical disability by the age of 18. The evidence establishes that {} became permanently incapable of self-support prior to (his or her) 18th birthday due to a physical or mental disability diagnosed as {}. The cited evidence reports that {}?s

W. Rees 67 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textdiagnosis of {} severely limits (his or her) ability to care for their daily needs. The cited treatment report from Dr. {} indicates {}. The evidence shows {} became incapable of self- support prior to (his or her) 18th birthday. Therefore, entitlement as a helpless child for VA purposes is granted effective {} the date we received your claim. OR the date that {} reached the age of majority.

PMC-INCCC

propose incompetency

A mentally incompetent person is defined as one who, because of injury or disease, lacks the mental capacity to control or manage his or her own affairs, including disbursements of funds without limitation. Where there is a doubt as to whether the beneficiary is capable of administering his or her funds, such doubt will be resolved in favor of competency. The medical statement from {} notes that you have {}. The indicated level of severity of this mental disorder is such that you are unable to perform most basic tasks without assistance or reminders. Based on your diagnosis, the evidence of record is clear and convincing that you are unable to manage your affairs to include the disbursement of funds without limitation; therefore, we propose to rate you incompetent for VA purposes.

Proposals & Final incompetency decisions need Long Form Narrative, per III.iv.6.C.7.a

PMC-INCDEF

propose incompetency

A mentally incompetent person is defined as one who, because of injury or disease, lacks the mental capacity to control or manage his or her own affairs, including disbursements of funds without limitation. Where there is a doubt as to whether the beneficiary is capable of administering his or her funds, such doubt will be resolved in favor of competency. The medical statement from your physician notes that you have {} and are unable to manage your financial affairs. Since there is a definitive finding of incompetency by a physician in this case, and you are not shown to be able to manage personal affairs to include disbursement of funds, we propose to make a determination of incompetency for VA purposes. {38 CFR 3.353}

Proposals & Final incompetency decisions need Long Form Narrative, per III.iv.6.C.7.a

PMC-NPRC

also see FIRE1

No service treatment records were available for review. Efforts to obtain service medical records from all potential sources were unsuccessful. The National Personnel Records Center (NPRC), St. Louis Missouri, in response to VA requests, reported the records may have been destroyed in a fire at the Records Center in 1973. NPRC could not confirm the existence of such records; only the fact that if they had been stored at the Records Center, they would have been stored in an area damaged by the fire. If these records are located at a later date, this decision will be reconsidered. If a different decision results, that decision will be effective as of the date of this pending claim.

PR1

protected

Service connection for any disability or death granted or continued, which has been in effect for 10 or more years will not be severed except upon a showing that the original grant was based on fraud or it is clearly shown from military records that the person concerned did not have the requisite service or character of discharge. The 10-year period will be computed from the effective date of the finding of service connection to the effective date of the rating decision severing service connection.

PR2

protected

The evaluation of xxxx is continued as xx percent disabling. A disability that has been continuously rated at or above any evaluation for 20 or more years cannot be reduced except upon a showing that such rating was based on fraud.**Similar to VBMS-R System-Generated Text

Example text:The evaluation of {} is decreased to 10 percent from {}, the date of the DBQ showing improvement. You have been evaluated at 30 percent for fewer than 5 years, the DBQ shows improvement to the 10 percent level, and there is no other evidence to support a 30 percent evaluation. However, since you have been evaluated at 20 percent or above for more than 20 years, we are only reducing your evaluation to 20 percent.

PR3

protected

A readjustment to the schedule for rating disabilities shall not be grounds for reduction of a disability rating in effect on the date of the readjustment unless medical evidence establishes that the disability to be evaluated has actually improved. Your condition was previously rated as {} percent disabling under the condition that was changed on {}. A higher rating of HIGHER PERCENT is not warranted under the new schedule effective {}, unless there is medical evidence of HIGHER CRITERIA. Because there is no evidence that establishes that your condition has actually improved, your {} percent rating is continued.

VBMS-R now (as of at least April 2015) has PR3 as the below, but it’s not listed in W. Rees 68 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textthe Glossary:Since your last evaluation the rating criteria for {} disabilities have changed. Based on this change, we will evaluate your disability under the new criteria, as your claim was not pending at the time the criteria changed. Please note in order to obtain an increased evaluation you must meet the new criteria.

Under the old criteria you were rated 30 percent for {}, which is continued. The current evaluation takes into consideration the {}.

PT-65

grant P&T / grantp&t

also see EXAMG & PT-EX & PT-MED

We have determined that you are unable to secure and follow a substantially gainful occupation due to your age and disability. You are {} years old and you are not employed. You meet the basic eligibility requirements for nonservice connected pension as you are either age 65 or older, or have been deemed disabled by the commissioner of Social Security, and have the requisite wartime service for VA pension purposes. The cited medical evidence shows that you are disabled due to your disabilities of {}. Entitlement to nonservice connected disability pension is established effective {}, the date that we received your claim.

PT-D

deny P&T / denyp&t

You are {} years old, have a level of education reported as {} and last worked in {} as a {}. Entitlement to non-service-connected pension is granted to Veterans who are basically eligible and who are unable to secure and follow a substantially gainful occupation by reason of disability which is likely to be permanent. Permanent and total disability for pension purposes is held to exist when the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as the result of such disability (ies). The evidence of record fails to demonstrate that you are unable to secure or follow a substantially gainful occupation as the result of disability. Our letter to you dated {} asked you to provide us with additional information in support of your claim for VA pension benefits. If applicable <><> <> Based on the evidence of record, entitlement to nonservice-connected disability pension is not established.

PT-EX

grant P&T / grantp&t

also see EXAMG & PT-65 & PT-MED

We have granted entitlement to non-service-connected pension benefits because the evidence shows that you are unable to maintain substantially gainful employment due to your disability(ies). Entitlement to non-service-connected pension is granted to Veterans who are eligible and who are unable to secure and follow a substantially gainful occupation due to a disability(ies) which is likely to be permanent. Permanent and total disability for pension purposes is held to exist when there is a single disability ratable at 60 percent or more, or where there are two or more disabilities with a combined evaluation of 70 percent or more, with at least one of the disabilities rated at least 40 percent, and the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as the result of such disability(ies). Where the evidence fails to establish the basic disability percentage requirements, consideration is given to extraschedular entitlement to non-service-connected pension based on such factors as the degree and nature of the disability, your age, educational and occupational background or other factors pertinent to each individual case. You are {} years old, and the evidence shows that you are disabled due to {}, among other disabilities. You do not meet the schedular requirements of a single disability ratable at 60 percent or more, or two or more disabilities combining to 70 percent with at least one ratable at 40 percent. However, considering the level of your disability(ies) and other factors, such as your age, education and occupational background, extraschedular entitlement to non-service-connected pension is granted subject to approval by the Pension Center Manager. Therefore, entitlement to non-service connected disability benefits is warranted as allowed under 38 CFR 3.321(b)(2). The effective date for your entitlement to non-service-connected pension benefits is {}, the date that we received your claim.

PT-MED

grant P&T / grantp&t

also see EXAMG & PT-65 & PT-EX

We have granted entitlement to non-service-connected pension benefits because the evidence shows that you are unable to maintain substantially gainful employment due to your disability(ies). Entitlement to non-service-connected pension is granted to Veterans who are eligible and unable to secure and follow a substantially gainful occupation because of a disability that is likely to be permanent. Permanent and total disability for pension purposes is when a Veteran has a single disability ratable at 60 percent or more, or where there are two or more disabilities with a combined evaluation of 70 percent or more, with at least one of the disabilities rated at least 40 percent, and the Veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as the result of such disability(ies). You are {} years old, and the evidence shows that you are disabled due to {}. The effective date for your entitlement to non-service-connected pension benefits is {}, the date that we received your claim.

PTSD3304 We took your statement as evidence of the claimed stressful experience or stressor. The VA examiner

W. Rees 69 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

*may also want PTSD_C

related the stressor to fear of hostile military or terrorist activity, and the VA examiner linked your symptoms to the stressor.

PY1

4.14, pyramiding

The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Dyspnea, tachycardia, nervousness, fatigability, etc., may result from many causes; some may be service-connected, others, not. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service connected evaluation and the evaluation of the same manifestation under different diagnoses are to be avoided.

{} does not warrant a separate evaluation because it affects the same anatomical part and produces the same symptoms as {}.

RE1

proposed reduction including SMC HB

If the proposed reduction takes effect, your combined evaluation will be {} percent. Additionally, if this proposed reduction takes place you will no longer be entitled to special monthly compensation at the housebound rate, and will only be entitled to special monthly compensation based on the loss of use of a creative organ.

SA1Service connection may be established for a disability which was incurred in or caused by military service if such disability was not the result of alcohol or drug abuse. Disabilities caused by or incurred due to alcohol or drug abuse are not considered to have occurred in the line of duty.

SE1

INDUTRA & ACDUTRA

IADT & ADT

Active military service includes active duty or any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty. "Active duty" means full-time duty in the Armed Forces, other than active duty for training. "Active duty for training" means full-time duty in the Armed Forces performed by Reserves for training purposes. Disabilities caused by a disease process cannot be service connected if they are discovered during a period of inactive duty for training. Service connection may be warranted for an injury incurred or aggravated while performing inactive duty for training. Service connection may also be warranted for an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during inactive duty for training.

ORPlease note that we can only establish service connection for death or injury/disease (including myocardial infarction and stroke) that occur while performing, or in transit to or from, active duty for training. We can also grant service connection for death or injury that occur while performing, or in transit to or from, inactive duty for training. All other diseases are excluded from service connection based on reserve status or active/inactive duty for training.ORif injury (including myocardial infarction and stroke):ACK_SX The evidence does not show an event, disease or injury during active duty service. Your active duty service treatment records do not contain complaints, treatment, or diagnosis for this condition. Although the reserve treatment records show you were treated for {} in {}, this is not during your active duty period and there is no evidence of a {} injury while performing, or in transit to or from, active or inactive duty for training.ORif disease:ACK_SX The evidence does not show an event, disease or injury during active duty service. Your active duty service treatment records do not contain complaints, treatment, or diagnosis for this condition. Although the reserve treatment records show you were treated for {} in {}, this is not during your active duty period {and there is no evidence of {} while performing, or in transit to or from, active duty for training.}

III.ii.3.C.7.a - In some situations, service connection (SC) is awarded for a death, disease, or injury incurred or aggravated during a period of duty other than full-time active duty in the Armed Forces. In these situations, the period of duty during which the death, disease, or injury occurred is considered active

W. Rees 70 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textmilitary service for VA compensation purposes. Example: SC may be awarded for an injury incurred in the line of duty (LOD) during inactive duty for training (IADT). Once it is determined that SC is in order for that injury, the period of IADT is considered active military service for VA compensation purposes.

III.iv.4.D.1.c - Considering National Guard and Reserve Duty for Hearing Loss and/or Tinnitus claims – 1st basis to consider should be active duty or active duty for training (ADT / ACDUTRA), 2nd basis should be “decrease in auditory acuity d/t military duties as a member of the National Guard or Reserves,” 3rd basis should be “injury” during inactive duty for training shown by nature of service, MOS, lay evidence or other competent evidence

III.ii.3.C.7.d - Updating VA Systems for Active Service Based on a Single Day of ADT or IADT

III.ii.3.C.7.e – Updating VA Systems for Active Service Based on Multiple Periods of ADT or IADT

III.ii.3.C.7.f – Updating VA Systems for Claims When ADT or IADT Is the Only ServiceIn Participant Profile:

enter BRANCH (i.e. Army Reserve or Air National Guard) enter Sep reason or Unknown enter Character or Unknown enter Service Type

If VA grants SC, change to active service after RD complete, per III.ii.3.C.7.a & III.ii.3.C.7.dMy Notes: Also see III.ii.6.A.2.k.

III.ii.3.C.7.g - Updating VA Systems For Active Service Based on Multiple Title 10 Activations of Seven Days or Less

Active Service - III.ii.6.A.1.c"Active service" includes

active duty any period of active duty for training (ADT) during which a person is disabled or dies from a

disease or injury incurred or aggravated in the line of duty any period of inactive duty for training (IADT) during which a person is disabled or dies from an

injury incurred in or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during training

My Notes: Inactive duty does not include disease.

III.ii.6.A.2.b & III.ii.6.A.3.a – Inactive Duty for Training (IADT) [includes traditional drill weekends] & Active Duty Training (ADT) [incl initial basic training/specialized job skill training & 2 week annual training (AT)] are not considered full-time duty

Reserve AND National Guard (Army National Guard (ARNG) & Air National Guard (ANG)) Service (from III.ii.6.A.1.b, III.ii.6.A.2.c, III.ii.6.A.2.d, III.ii.6.A.2.f, III.ii.6.A.3.b, III.ii.6.A.4.b, III.ii.6.A.4.c) –

Federal Active Duty – full-time active duty under Title 10 / 10 USC / 10 U.S.C = veteran status & will get DD214, per III.ii.6.A.2.c

Dual Status Technician – Federal employee under Title 5 / 5 USC / 5 U.S.C for the Reserve – not qualifying service & not subject to VA benefits (unless during ADT or IADT not under Title 5 employment)

W. Rees 71 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text additional ADT – periods of training in addition to the two week period of ADT – might get DD214

RESERVE: Active Guard Reserve (AGR) – full-time duty for operational support of the Reserve under Title

10 / 10 USC / 10 U.S.C & will get DD214, per III.ii.6.A.2.c; BUT III.ii.6.A.3.b says Title 32 / 32 USC / 32 U.S.C 502(f), III.ii.6.A.3.b also says if full-time for operational support (not training) = considered active duty

Active Duty Support (ADS), previously known as Active Duty Special Work (ADSW) – full-time, temporary (generally fewer than 180 days) duty for operational support of the Reserve – usually no DD214, per III.ii.6.A.2.c (III.ii.6.A.2.d also says routinely no DD214); Title 32 / 32 USC / 32 U.S.C 502(f), if full-time for operational support (not training) = considered active duty, per III.ii.6.A.3.b & III.ii.6.A.2.d; if 180 days or more = active duty, per III.ii.6.A.2.d; if fewer than 180 days = type of ADT, per III.ii.6.A.2.d

NATIONAL GUARD: Active Guard Reserve (AGR) – full-time duty for operational support of the National Guard under

Title 32 / 32 U.S.C 502(f) & will get DD214, per III.ii.6.A.2.c; full-time operational/support service in ADT is NOT active duty, per III.ii.6.A.4.b UNLESS it’s “other than active service” (I think they mean “active service”) under III.ii.6.A.1.b (III.ii.6.A.1.b says “active service” is active duty, ADT with injury or disease, IADT with injury or MI or CVA); Title 32 / 32 USC / 32 U.S.C 502(f) OR 316, 502, 503, 504, 404 , if full-time for operational duty = ADT, per III.ii.6.A.4.c; only active duty if disabled or dies, also per III.ii.6.A.4.c & per III.ii.6.A.2.f. 

Active Duty Support (ADS), previously known as Active Duty Special Work (ADSW) – full-time, temporary (generally fewer than180 days) duty for operational support of the National Guard – usually no DD214, per III.ii.6.A.2.c (III.ii.6.A.2.d also says routinely no DD214); if 180 days or more = active duty, per III.ii.6.A.2.d; if fewer than 180 days = type of ADT, per III.ii.6.A.2.d; BUT III.ii.6.A.4.c says Title 32 / 32 USC / 32 U.S.C 502(f) OR 316, 502, 503, 504,404 , if full-time for operational duty = ADT, only AD if disabled or dies, also per III.ii.6.A.4.c (contradicts III.ii.6.A.2.d, which says it’s AD if 180 days or more)

III.ii.6.A.2.e says NGB Form 22, Report of Separation and Record of Service “does not verify individual periods of ADT or IADT.” III.ii.6.A.4.a & III.ii.6.A.4.e say will get 214 for period of initial ADT. BUT III.ii.6.B.3.a says NGB Form 22, National Guard Report of Separation and Record of Service, is acceptable/adequate evidence of service.III.ii.6.A.4.d – Title 10 service in National Guard / 10 USC / 10 U.S.C.if Federal active duty = qualifying serviceif ADT under 10 U.S.C. 12301(d) = NOT actually ADT

IADT – III.ii.6.A.2.g & IV.ii.2.B.1.m, “An individual who suffers from posttraumatic stress disorder (PTSD) as a result of military sexual trauma (MST) that occurred during a period of inactive duty for training may be considered disabled by an injury for purposes of 38 U.S.C. 101(2) and (24)”

III.ii.6.A.2.h – The presumption of soundness does not automatically apply to all periods of ADT & IADT.IV.ii.2.B.2.b – “In claims based on a period of active duty for training (ADT), there is no presumption of SC for chronic diseases under 3.309(a) or tropical diseases under 3.309(b).”III.ii.6.A.2.i “As ADT and IADT is not considered active service and Veteran status is not achieved on the basis of ADT or IADT, presumptive provisions under 38 CFR 3.307 cannot apply to periods of ADT or IADT.” (exception: if SC is established)

W. Rees 72 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated TextADT & presumption of soundness - IV.ii.2.B.1.lIADT & presumption of soundness - IV.ii.2.B.1.m

III.ii.6.A.2.j says ADT / IADT does not establish veteran status, the presumption of aggravation does not apply for preexisting conditions (the evidence must show worsening CAUSED by the ADT / IADT); this is different from normal aggravation, where VA has to prove there was no aggravationIV.ii.2.B.4.g – more on aggravation during ADT / IADT

updated 7/8/16III.ii.6.A.2.k. Adjudicating Claims Based on ADT and IADTWhen SC for disability or death has been established based on a period of ADT or IADT, the rating activity will identify this period as active service by preparing VA Form 21-6789, identifying

the dates of service, and an explanation of the reason for establishing this period as active service.  

Example:  Service in the Army National Guard from January 16-17, 2016, is now considered active service based on the grant of SC for right knee ACL injury that was incurred in the line of duty during this period of service. Note:  If the period of ADT or IADT upon which the grant of SC is based is a single day of ADT or IADT (the claimant was only called to a one-day period of ADT or IADT), utilize the day following as the end date of service but clearly annotate VA Form 21-6789 (created as directed in Step 7 above) to reflect that the service was actually only one single day of service.My Notes: Active service based on ADT or IADT will not be entered into the system until after the RD granting SC based on that service.

https://www.vapulse.net/message/145624 - There is no requirement to remove IADT/ADT that has been added (previously).

W. Rees 73 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

Per QRT/GiaBao Nguyen, 8/4/16 – points for Reserves are an indication that the veteran served during those dates & we need to develop for duty status (ADT or IADT)

W. Rees 74 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

From: VAVBASDC/RO/VSC Sent: Thursday, September 21, 2017 10:58 AMSubject: FW: Q-Tip: Updating Military Service in Systems

Good Morning VSC,

Q-Tip:  Updating Military Service in Systems

Target Audience:  VSRs, RVSRs, and DROs

This Quality Tip (Q-Tip) discusses updating systems for military service to include periods of active duty, ADT, and IADT.  This Q-Tip supersedes prior guidance provided by Q-Tip dated June 8, 2017 on a similar topic.

Please note that this Q-Tip relates to system updates only, and is not meant as a training item for National Guard/Reserve service or development for records relating ADT/IADT.

Background

A Veteran is a person who has service in the active military, naval or air service, and was discharged or released under conditions other than dishonorable.  Active service includes (but is not limited to):

active duty any period of active duty for training (ADT) during which the individual concerned was disabled or

died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during (IADT) which the individual concerned was disabled or

died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training.

Responsibilities

Each RO employee must check to ensure all periods of active service are updated and verified in the appropriate system(s) when undertaking any claim action.

All periods of active service must be updated and verified in the systems by the rating activity prior to completion of the rating decision.  Failure to do so will result in inaccurate or incomplete service displayed on the rating decision Codesheet. 

ADT/IADT is not considered active duty.  ADT/IADT is also not considered active service unless the Rating Activity deems it to be.

The completion and authorization of a rating decision granting SC based on a period of ADT or IADT is required before the service is considered active service.  Therefore, it is appropriate to enter the period of ADT or IADT into the systems after completion of the rating decision.

Areas of responsibility (development, rating, and authorization) are delineated in the attached Q-Tip document.  Also attached is a one-page “desk guide” summary.  Please note that the Q-Tip document should be reviewed in its entirety for detailed information and references. 

For any questions relating to this topic, please contact the QRT or your Coach.

Q-Tip for Updating Military Service in Systems AD ADT IADT & Desk Guide System Updates AD ADT IADT are saved at H:\VSC\Rating Reference

*If a veteran only has ADT/IADT, enter it in Participant Profile (see III.ii.3.C.7.f), NOT in BIRLS.

W. Rees 75 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

My Notes (early September 2017): If VBMS shows Satisfactory & Active Duty with only ADT service:

… you can update Separation Reason & Service Type in Participant Profile (but it does not update VBMS). You also need to remove the check for “Service Verified”:

9/21/17 Q-Tip says do not enter ADT/IADT in BIRLS, which resolves all of these problems!!SHARE only gives these options, so you can update Sep Reason, but not Service Type (SHARE also does not have Army Reserves):

:

W. Rees 76 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated TextIt will also give you this error (so you have to remove the “Y” from verified with NG or Unknown):

Then SPP no longer has “Active Duty for Training” (so you have to go back in & add it back):

Separation Reason will update in VBMS, but Service Type will still show Active Duty:

W. Rees 77 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated TextVBMS-R will give you this message (but you can still rate):

My Notes: As of June 2017, Post is deferring ratings if the Pre-VSR put in ADT in the system & listed it as verified:

And they’re changing the entries to:

Then, in VBMS-R, you will get this message:

W. Rees 78 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

You should follow III.ii.6.A.2.k.(which is actually insufficient, as it doesn’t discuss when you have other AD periods) & remove ADT from the system (if it is not the basis for SC) & add this note:

Note to File: The ADT period {} is not the period on which SC is based, so it is not listed in the system, as it is not considered active duty.

Note to File: 2/4/75-6/3/75 is ADT & there is no indication of any disability incurred during that period, so it is not active duty & has been removed from the Participant Profile (but could not be deleted from BIRLS). The Master Record shows these service event dates for the SC disabilities: {disability} {date}

SAH_GWOT

Section 202 of Public Law 112-154 provides that in addition to those Veterans currently eligible for Specially Adaptive Housing (SAH) (My Notes: It’s actually called Specially Adapted Housing.) under 38 U.S.C. § 2101(a), Veterans who served on or after September 11, 2001, and incurred a permanent disability that is ?due to the loss or loss of use of one or more lower extremities which so affects the functions of balance or propulsion as to preclude ambulating without the aid of braces, crutches, canes, or a wheelchair? are eligible for the SAH benefit. Originally, this provision, which is temporary, provided that SAH may be awarded for claims pending on or after October 1, 2012, as long as the application was approved on or before September 30, 2014. However, section 405 of Public Law 113-175 extended this provision for claims pending for the same period as long as the application is approved on or before September 30, 2015.

Then:Section 202 of Public Law 112-154 provides that in addition to those Veterans currently eligible for Specially Adaptive Housing (SAH) (My Notes: It’s actually called Specially Adapted Housing.) under 38 U.S.C. § 2101(a), Veterans who served on or after September 11, 2001, and incurred a permanent disability that is ?due to the loss or loss of use of one or more lower extremities which so affects the functions of balance or propulsion as to preclude ambulating without the aid of braces, crutches, canes, or a wheelchair? are eligible for the SAH benefit. Originally, this provision, which is temporary, provided that SAH may be awarded for claims pending on or after October 1, 2012, as long as the application was approved on or before September 30, 2013. However, section 405 of Public Law 113-175 extended this provision for claims pending for the same period as long as the application is approved on or before September 30, 2016. By law, VA may not approve more than 30 applications within a fiscal year. As of June 2016, VA has approved 30 applications. You will receive additional information regarding the status in a separate notification letter.*SEEMS YOU CAN GRANT & FINANCE WILL DECIDE IF CAN ACTUALLY PAY

IV.i.3.1.f – changed to 9/30/17

SC/DEN/RATIOn {} we received your submission of a VCAA Notice Response form indicating that you have no additional evidence to submit regarding your claim and that you wish to have a decision rendered as soon as possible.>> <><> <>

SE2 The records show the veteran served on periods of inactive duty for training and active duty for training during his military service. He had no periods of active service. Service connection may be granted for a disease which began during active military service or active duty for training, or for an injury incurred during any period of service, active or inactive. Active duty for training is defined as full-time duty in the

W. Rees 79 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Text

only INDUTRA & ACDUTRA

Armed Forces performed by Reserves for training purposes. Inactive duty for training is duty (other than full-time duty) in the Armed Forces prescribed for Reserves by the Secretary concerned. “Active duty" means full-time duty in the Armed Forces, other than active duty for training. “Active duty for training" means full-time duty in the Armed Forces performed by Reserves for training purposes. “Inactive duty training" means duty (other than full-time duty) prescribed for Reserves. Active duty for training and inactive duty training also include other types of service, but none of these are relevant to the issue raised by the facts in this case.

SHA_GWOT

Section 203 of P.L. 112-154 amends section 2101(b)(2) to provide special home adaptations to Veterans who have central acuity of 20/200 or less in the better eye with the use of a standard correcting lens. An eye with a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having a central visual acuity of 20/200 or less.

STGD

staged ratings

The Court of Appeals for Veterans Claims (CAVC) has ruled that notice requirements concerning the reduction of compensation evaluations are not applicable to separate (staged) ratings that are assigned as part of the initial disability rating decision.

http://vbaw.vba.va.gov/vbms/multimedia.aspsearch "staged rating"

With VBMS-R change in December 2016, no longer the same as above.

Decision & first line in Reasons for Decision:Evaluation of {}, which is {} percent disabling, is increased to {} percent effective {}. A {} percent evaluation is assigned effective {}.

SUPP

supplemental STRs

IV.ii.2.A.3.dIII.iv.5.C.6.f (3.156(c))

VA has received additional service treatment records that were previously unavailable. The following decision is based on the additional medical evidence.

Can add:At any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, we will reconsider the claim. 

TR1

grant of 1702

*use “psychosis” or “mental illness” as diagnosis

issue line will say “psychosis” so need to change to “mental illness” if appropriate

Decision line is also missing “for mental illness” or “for psychosis”

VBMS-R System-Generated Text shows “psychosis/mental illness,” so need to change

A determination of entitlement to service connection under 38 USC 1702 is inferred for the purpose of establishing eligibility for hospital and medical treatment for certain wartime veterans. Service connection for treatment purposes only may be granted for veterans of World War II, Korean Conflict or Vietnam era who develop an active psychosis and veterans of Gulf War service who develop an active psychosis or other mental illness within two years after discharge or release from the active military, naval, or air service, and before July 26, 1949, in the case of a veteran of World War II, before February 1, 1957, in the case of a veteran of the Korean conflict, before May 8, 1977, in the case of a Vietnam era veteran, or before the end of the two-year period beginning on the last day of the Persian Gulf War, in the case of a veteran of the Persian Gulf War. A review of the evidence shows that you were discharged on XXXX. The medical evidence shows that your XXXX was first diagnosed on XXXX, which was within the required period of time. Therefore, entitlement to service connection for treatment purposes only under 38 USC 1702 is established.

**Similar to VBMS-R System-Generated Text

Issue: Service connection for mental illness for the purpose of establishing eligibility to treatment.

Decision: Service connection for the purpose of establishing eligibility to treatment {for mental illness} is established.

last line of Reasons for Decision: Entitlement to treatment is established because a mental illness was diagnosed within the required period of time.

W. Rees 80 updated 7/25/18

ADDITIONAL GLOSSARIES FROM VBMS-R (use CTRL-SHIFT-A)[excluding Nehmer, death decisions & final incompetency;

see Rating References Archive for SMP, HL & more ]

Glossary KeyAssociated Textthat too, if appropriateVA_COMPETENT There is no evidence of record that shows that you are unable to manage your financial affairs.

VE1

We received notification from {} that you did not report for your scheduled examination. Evidence expected from this examination that might have been material to the outcome of this claim could not be considered. When a claimant does not report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. -OR- We received notification from {} that you did not report for your scheduled examination. Evidence expected from this examination that might have been material to the outcome of this claim could not be considered. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit, which was previously disallowed, or a claim for increase, the claim shall be denied.

VE2 Since there is a likelihood of improvement, the assigned evaluation is not considered permanent and is subject to a future review examination.

VBMS-R FREE TEXTDefinition LanguageNODX Free Text(not required)

The DBQ indicates that you do not now have, nor have you ever been diagnosed with, a {} condition.The DBQ indicates that you do not now have, nor have you ever had, a {} condition.The DBQ indicates that you do not have a current diagnosis associated with the claimed {}, as there is no pathology to render a diagnosis.

borderline hypertension / pre-hypertension, III.iv.4.G.3.d & IV.ii.2.A.2.a – use No Diagnosis if claims hypertension or high blood pressure, but only has borderline hypertension / pre-hypertensionSince the STRs do not show a diagnosis of hypertension in service and the DBQ, blood pressure checks, and addendum only show a diagnosis of borderline hypertension, asymptomatic, with readings that do not allow for a full diagnosis of hypertension, we cannot establish service connection for borderline hypertension.

carious teeth / cavities / replaceable missing teeth / abscesses / periodontal disease / wisdom teeth extraction / cracked/chipped/broken/fractured teeth (9999-9900 or another 99##, choose “No Actual Disability,” IX.ii.2.2.a) DT1Then add: {Treatable carious teeth, replaceable missing teeth not resulting from bone loss due to trauma or disease (such as osteomyelitis), dental or alveolar abscesses, periodontal disease, calculus, acute periodontal disease, third molars, impacted or malposed teeth, or other developmental defects, …cracked/chipped/broken/fractured teeth, other gum/pulp issues, whatever claimed, can use “The claimed {}”} is/are not a disability for compensation purposes. {OR The record shows your missing teeth and restorations are not due to service trauma with loss of substance of the mandible and/or maxilla bone or a chronic or systemic disease with loss of substance of the mandible and/or maxilla bone, or that dentures or implants cannot replace the missing teeth/The record shows your missing teeth are replaced with dentures/implants. You do not have a disability for compensation purposes.)}

This is also under the Dental section:IX.ii.2.2.a says to clarify claims if they only say “dental” or "dental condition" & refers us to III.iii.1.B.1.c, which says "If the claim is substantially complete per Step 1, but attempts to clarify the claim with the claimant and representative are unsuccessful, continue the required claims development, and when complete, refer the claim for a decision.” But, it’s unclear if it is “substantially complete” if we don’t know if the veteran is claiming compensation or treatment…

W. Rees 81 updated 7/25/18

VBMS-R FREE TEXTDefinition LanguageNON-DISABILITIES:

(probably NIS, STRs or AT, NODX, plus maybe V_AT, ACK_SX)

**choose No Actual Disability, if applicable**

Non-disabilities (scan of local 2004 document) is saved at H:\VSC\Rating Reference

unconfirmed diagnosesIn the absence of clinical findings of asthma on examination, a verified history of asthmatic attacks must be of record.Gastritis must be identified by gastroscope.Sleep apnea must be confirmed by a sleep study.

pain only, IV.ii.2.A.2.cService connection cannot be granted for pain without a diagnosis of an associated chronic disability.ORfinding/symptom only (choose No Actual Disability), plus: {} is {a finding/symptom and} not considered a disabling condition for VA purposes. The evidence does not show a disability for which compensation may be established. Compensation is payable for a disease or injury which causes a disabling physical or mental limitation.ORchoose No Actual Disability, plus: {} is not an actually disabling condition for which service connection can be granted.

INCLUDES:

abdominal / stomach pain (7399-7319), pain only, see above

acute bronchitis / flu / influenza [usually acute] (6699-6600), choose No Actual Disability & see above, plus AT

acute gonorrhea (7599-7512), AT acute infections with no disease diagnosed (6399-6300) , AT acute non-specific urethritis (NSU) (7599-7518), AT acute sinusitis, AT adult situational reaction (9499-9400), AT allergies / hayfever (6599-6522), AL1 arthralgia / pain of joints (5099-5003), pain only, see above

breast surgeries / reduction mammoplasty / cosmetic breast reduction [elective, per III.iv.4.J.3.d & IV.ii.2.A.2.b, can only do reduction mammoplasty on basis of aggravation if recommended to alleviate physical discomfort (also consider SMC K)] - (7626), Elective procedure, plus: We can only establish service connection for an elective surgery if there were unexpected, disabling residuals.

bruise [acute per IV.ii.2.B.1.g], AT bruxism (9999-9905) - March 2014 Compensation Service Bulletin (CSB) –

Bruxism may not be rated as a stand-alone service-connected disability. However, it may be considered on a secondary basis as a symptom of a service-connected disability, such as an anxiety disorder, TMJ dysfunction, etc. for rating purposes. If an examination report diagnoses bruxism, the examination must be returned to the examiner to provide the etiology of bruxism. III.iv.3.D.4.a Per QRT/Erin Walsh, 3/14, grant as “anxiety disorder with bruxism.”

Can use:Bruxism, alone, is a symptom and not an actually disabling condition for which service connection can be granted. The VA examiner indicated that you do not now have, nor have you ever had, a temporomandibular joint condition. There is no evidence that your bruxism is a symptom of a service-connected disability.

bundle branch block, right or left (RBBB, LBBB) (7099-7000), EKG finding only, unless it’s disabling (i.e. causes syncope) or can rate the underlying heart disease

W. Rees 82 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

(usually RBBBs are caused by MIs & LBBBs are caused by CAD, valvular heart disease or other heart disease, can lead to very slow heart rate causing dizzy spells/passing out) (do “also claimed as …”), choose No Actual Disability & see above, plus: The DBQ shows a diagnosis of right bundle branch block with no clinical significance. Bundle branch block without symptoms or heart disease is a finding and not an actually disabling condition for which service connection can be granted.

calluses (7899-7819), choose No Actual Disability & see above

cardiomegaly / left ventricular hypertrophy (LVH) [finding only if no heart disease] (7099-7005 or 7007), finding only, choose No Actual Disability & see above

cervical dysplasia / cervical intraepithelial neoplasia / CIN / abnormal pap smear [lab finding & usually acute, per III.iv.4.J.2.e not a disability unless requires treatment and there are residuals post-treatment, or if linked to subsequent development of cervical cancer] (7699-7612), LAB

cervicalgia (5299-5237), pain only, see above

chest pain (cardio 7099-7000, muscle strain 5399-5321, pleuritic 6799-6732), pain only, see above

circumcision (7899-7805) - Elective procedure, plus: We can only establish service connection for an elective procedure if there were unexpected, disabling residuals.

color blindness (6099-6066), or CD

constipation (7399-7319), symptom only, choose No Actual Disability & see above, 7/11/14 DBQ Call – Chronic diarrhea and chronic constipation are only listed as diagnoses so that the examiner can enter a diagnosis and complete the DBQ, otherwise if there is no diagnosis most of the DBQ is disabled and can’t be answered.

contusion with no residuals (7899-7805), AT cough / shortness of breath / dyspnea (6699-6600), symptom only, choose No

Actual Disability & see above

dehydration (7099-7000), choose No Actual Disability & see above, plus AT dyslipidemia / hyperlipidemia / hypercholesterolemia / high cholesterol / elevated

cholesterol / hypertriglyceridemia / elevated triglycerides / hyperlipoproteinemia [lab finding, per IV.ii.2.A.2.h] (7099-7000), choose No Actual Disability, plus: HL1 or CH1

dyspepsia (7399-7346), symptom only, choose No Actual Disability & see above

diarrhea (7399-7319), symptom only, choose No Actual Disability & see above, 7/11/14 DBQ Call – Chronic diarrhea and chronic constipation are only listed as diagnoses so that the examiner can enter a diagnosis and complete the DBQ, otherwise if there is no diagnosis most of the DBQ is disabled and can’t be answered.

elective tattoo removal (7899-7805), Elective procedure, plus: We can only establish service connection for an elective procedure if there were unexpected, disabling residuals.

elective tubal ligation (7699-7614), Elective procedure, plus: We can only establish service connection for an elective procedure if there were unexpected, disabling residuals.

epitaxis / nose bleeds (6599-6522), choose No Actual Disability & see above

fatty liver / fatty liver disease [lab finding per III.iv.4.H.3.e] (7399-7345), finding only,

W. Rees 83 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

fibrocystic breast disease [not a disability per III.iv.4.J.3.c unless nexus to subsequent excision of persistent lumps/thickening or associated atypical hyperplasia and the development of breast cancer] (7699-7628), choose No Actual Disability, plus: FD1

floaters in eyes (6099-6066), choose No Actual Disability & see above

G6PD deficiency, asymptomatic (7799-7700), finding only, choose No Actual Disability & see above

gastroenteritis / food poisoning / enterovirus [usually acute] (7399-7307), AT glaucoma suspect / preglaucoma / pre-glaucoma / borderline glaucoma (6099-

6013), choose No Actual Disability & see above; OR if claims glaucoma, but only has ucoma suspect / preglaucoma / pre-glaucoma / borderline glaucoma, use No Diagnosis, plus: The STRs only show borderline glaucoma/pre-glaucoma, which is not considered an actually disabling condition. The STRs do not show a diagnosis of glaucoma. The DBQ also does not show a diagnosis of glaucoma.

heat rash (7899-7806), choose No Actual Disability & see above, plus AT heat stroke / heat exhaustion, with no residuals (7099-7000) , choose No Actual

Disability & see above, plus AT hematuria [symptom/lab finding] (7599-7500), if symptom, choose No Actual

Disability & see above, if found on labs, use LAB hirsutism – maybe not a disability

hoarseness (6599-6516), symptom only, choose No Actual Disability & see above, can grant if diagnosis is dysphonia

human papilloma virus (HPV) [lab finding, per III.iv.4.J.2.f not a disability unless there are associated genital warts, or development of persistent infection that progresses to cervical dysplasia and then cervical cancer] (7899-7819), finding only, choose No Actual Disability & see above, OR use LAB, plus: Human papilloma virus, in the absence of genital warts, is a laboratory finding and not an actually disabling condition for which service connection can be granted.

hypoglycemia / hyperglycemia / elevated blood glucose / elevated blood sugar / pre-diabetes / prediabetes [lab finding, per IV.ii.2.A.2.h & IV.ii.2.A.2.a] (7999-7913), LAB

hypotension (7199-7101), choose No Actual Disability & see above

infertility (7599-7523) – https://www.gpo.gov/fdsys/pkg/FR-2018-04-09/pdf/2018-07081.pdf says “…infertility is not in itself a disability for VA rating purposes. It does not result in the loss of average earning capacity.”

Per QRT/Carlos Rosario, 9/16:

This is one of those issues we do not and should not be generalizing.  This must be handled on a case by case basis.

Infertility may or may not be a congenital, developmental or hereditary disorder. Infertility is definitely not a laboratory finding.

Infertility is secondary to something. Sometimes the pathology is known and sometimes it is not.

Consider the following when reviewing evidence:

Infertility causes in women may include: ovulation disorders, polycystic ovary syndrome, hypothalamic dysfunction, premature ovarian insufficiency, damage to the fallopian tubes, endometriosis, polyps or fibromas of the cervix or uterus, and there is unexplained infertility.

Laboratory and physical testing are used to confirm or rule out possible pathologies

W. Rees 84 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

such as ovulation testing, hysterosalpingography, ovarian reserve testing, other hormone testing, laparoscopy, ultrasounds and genetic testing.

Infertility causes in men may include: varicoceles, infection, ejaculation issues, autoimmune antibodies that attack the sperm, tumors, undescended testicles, hormone imbalances, defects of the tubules, chromosome defects, problems with sexual intercourse, celiac disease, certain medications, and prior surgeries. There are environmental exposure to chemicals and pollutants. Occupational causes like prolonged sitting such as truck driving. Other contributing causes are health and lifestyle causes like stress, alcohol, drugs, and obesity.

Laboratory and physical testing are used to confirm or rule out possible pathologies such as hormone testing, semen analysis, scrotal or transrectal ultrasound, genetic testing, testicular biopsy, specialized sperm function tests,

The M21-1 III.iv.3.D.2.n guides us to use the table to determine what is required for a sufficient diagnosis.  It says, if a definite disability exists but a definitive diagnosis cannot be given, the examiner should describe the disability and indicate that it is of unknown etiology. This is will be a sufficient diagnosis for VA purpose.

The regulation and the M21-1 makes a distinction between defects and diseases or disorders of congenital, developmental or hereditary origins. {M21-1 IV.ii.2.B.6.a and b}.

The M21-1 IV.ii.2.B.6.b – Establish service connection for congenital developmental or hereditary disorders

       that first manifested themselves during service

       or pre-existed and progressed at an abnormally high rate during service

       or manifested to a compensable degree within the presumptive period.

Bottom line, it is a case by case scenario. We need to analyze the evidence to find out if testing has been done. Is there a cause? Is it a defect? Is it a disease or disorder? Is it of unknown etiology?  If we don’t know, ask the examiner to help.

Other references:

Mayo Clinic - Female Infertility

Mayo Clinic - Male Infertility

insomnia without an Axis I diagnosis [can only grant if given as Axis I diagnosis, per STAR quality call - FEB 2010 Q&A's, otherwise not a disability] (9499-9400) NODX & We can only establish service connection for an Axis I psychiatric diagnosis of primary insomnia / insomnia disorder / sleep disorder. My Notes: It is unclear, but it seems it can be “insomnia” or “insomnia disorder” or “primary insomnia” or “sleep disorder,” per https://mhreference.org/dsm-codes/dsm-category/

jaundice (7399-7345), symptom only, choose No Actual Disability & see above

Klinefelter’s syndrome (7599-7523)

labile hypertension (7199-7101), choose No Actual Disability & see above

lactose intolerance (7399-7319) , choose No Actual Disability & see above

Lasik / PRK [without unexpected, disabling residuals, it’s ameliorative surgery, per III.iv.4.C.3.d & IV.ii.2.A.2] (6099-6066), Not Incurred/Caused by Service, plus NODX, plus: We can only establish service connection for an ameliorative surgery if there were disabling, unexpected residuals.

low testosterone (7599-7523),finding only, choose No Actual Disability & see above

lumbago or mechanical low back pain (5299-5237), pain only, see above – per STAR error, if diagnosed by examiner but exam shows symptoms of a

W. Rees 85 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

thoracolumbar spine disability, send back for clarification and new diagnosis, if any

measles with no residuals (6399-6300), AT mitral valve prolapse, if alone [finding only] (7099-7000), finding only, choose No

Actual Disability & see above, plus: Your STRs show mitral valve prolapse, which is a finding when alone (without a diagnosis of a specific disease process), and not an actually disabling condition for which service connection can be granted.

moles (7899-7819) – MEPSS says moles, dysplastic nevi & skin tags are benign skin neoplasms under 7819; Per QRT/Larry Townsend, 6/29/16 - grant SC.

mononucleosis [usually acute] (7799-7709), choose No Actual Disability & see above

mumps with no residuals (6399-6300), AT muscle cramps (5399-5301), symptom only, choose No Actual Disability & see

above

nasopharyngitis (6599-6521) or catarrhal fever (common cold) [acute per IV.ii.2.B.1.g] also upper respiratory infection / URI / cold / head cold / common cold, AT

natural menopause (7699-7617), choose No Actual Disability & see above

obesity / weight gain / weight loss [obesity not a disease/injury per IV.ii.2.A.2.e], but if obesity results from SC disability & produces impairment beyond rating criteria, consider extra-schedular rating under 3.321(b)(1) per IV.ii.2.A.2.f & if caused a potential secondary disability, consider secondary SC under 3.310(a) per IV.ii.2.A.2.f] (7399-7310, or 7999-7903); December 2017 Compensation Service Bulletin (CSB) – reiterates the above

ocular hypertension [finding only] (6099-6013), finding only, choose No Actual Disability & see above

osteopenia , if alone and no osteoporosis [finding only] (5099-5013), confirmed by December 2013 Compensation Service Bulletin (CSB), finding only, choose No Actual Disability & see above

pelvic pain (7699-7613), pain only, see above

penicillin / drug allergy (7099-7000),choose No Actual Disability & see above, plus AL1

pressure ulcers (7199-7121), choose No Actual Disability & see above; https://www.gpo.gov/fdsys/pkg/FR-2018-07-13/pdf/2018-14957.pdf says “pressure ulcers normally are not considered a skin condition warranting compensation.”

primary drug / substance abuse (9399-9326), choose No Actual Disability & see above

primary enuresis (bed-wetting) (7599-7512), choose No Actual Disability & see above

PPD converter [lab finding] (6799-6731), finding only, choose No Actual Disability & see above, plus LAB

pneumonia (6699-6600) [acute per IV.ii.2.B.1.g], AT pregnancy / child birth / miscarriage / abortion (7699-7613), choose No Actual

Disability & see above; https://www.gpo.gov/fdsys/pkg/FR-2018-04-09/pdf/2018-07081.pdf says “Miscarriages themselves are not disabilities for VA rating purposes, as they do not result in impairment of earning capacity.”

proteinuria [lab finding] (6799-6731), finding only, choose No Actual Disability & see above, plus LAB

seasickness / motion sickness (6299-6204), choose No Actual Disability & see

W. Rees 86 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

above

short term memory loss (9399-9310), symptom only, choose No Actual Disability & see above

sickle cell trait, asymptomatic (7799-7714), finding only, choose No Actual Disability & see above, plus LAB

sinus bradycardia / decreased heart rate / slow heart rate [finding only, if alone] (7099-7010), finding only, choose No Actual Disability & see above, plus: Your STRs show bradycardia, which is a finding when alone (without a diagnosis of a specific disease process), and not an actually disabling condition for which service connection can be granted.

skin tags (7899-7819), choose No Actual Disability & see above – MEPSS says moles, dysplastic nevi & skin tags are benign skin neoplasms under 7819

sleep walking (8199-8108), choose No Actual Disability & see above

splenomegaly [finding only, if alone] (7799-7706), finding only, choose No Actual Disability & see above

sterilization (7599-7523), Elective procedure, plus: We can only establish service connection for an elective surgery if there were unexpected, disabling residuals.

stretch marks (7899-7805), choose No Actual Disability & see above

sun sensitivity (7899-7806), choose No Actual Disability & see above

temperature intolerance / cold intolerance / heat intolerance (7099-7000), choose No Actual Disability & see above

tobacco dependence [not a disease or injury for compensation purposes] (6699-6600), choose No Actual Disability & see above

tonsillitis / tonsillectomy (6599-6516) – seems you can grant if chronic in service, III.iv.4.F.6, or choose Acute and Transitory & use AT, NOCONT & NODX

undescended, or congenitally undeveloped testis [not a ratable disability, per note under 7524] (7599-7523), choose No Actual Disability & see above

upper airway resistance syndrome (UARS) [not a ratable disability, per III.iv.3.D.4.m & III.iv.4.F.5.f], I think No Actual Disability (& sentences above) is more appropriate, but III.iv.4.F.5.f says use No Diagnosis

urinary frequency [symptom only, if alone] (7599-7512), symptom only, choose No Actual Disability & see above

urinary tract infection (UTI) [usually acute] (7599-7516), choose No Actual Disability & see above

uvulopalatopharyngoplasty / UPPP (6599-6515), if no residuals, then choose No Actual Disability, plus: A uvulopalatopharyngoplasty is a surgical procedure and not an actual disability. The DBQ shows no residuals.

vasectomy [without unexpected, disabling residuals, it’s elective surgery, per IV.ii.2.A.2.b] (7599-7525), Elective procedure plus: We can only establish service connection for an elective procedure if there were unexpected, disabling residuals. *will be added to manual per VA Pulse, https://www.vapulse.net/thread/10077

vitamin deficiency (6399-6313), choose No Actual Disability & see above

yeast infection / vaginal candidiasis), choose No Actual Disability & see above

W. Rees 87 updated 7/25/18

VBMS-R FREE TEXTDefinition LanguageNIS Free Text(not required)

For hepatitis C –HC1There is no evidence any medically recognized risk factors in service.

Jet injectors are not a medically recognized risk factor.

For septum deviation without in-service trauma (6502) -There is no evidence of trauma causing nasal septum deviation in service. We can only establish service connection for traumatic deviation of the nasal septum.

NONEX Free Text

I.1.C.3.b

I.1.C.3.d – Element 1 (current disability/sx; certain conditions require evid of dx, like cancer)

I.1.C.3.e – Element 2 (in-service event/injury/dz)

I.1.C.3.f – Element 3 (indication of association)

NEGATIVE OPINION (also use V_NONEX):The VA examiner opined that your claimed {} (diagnosed as {}) is less likely than not incurred in or caused by the claimed in-service injury, event or illness because {}.

The VA examiner opined that your tinnitus is less likely than not caused by or a result of military noise exposure because {}.

HAVE ELEMENTS 1 & 2, BUT MISSING ELEMENT 3 , PER 3.159(c)(4)(i)) & Waters v. Shinseki (probably AT, NONEX, maybe ACK_SX, plus one of these): While you report persistent/recurrent symptoms, you have not submitted or identified

any lay or medical indication of an association with service.

While the treatment records show {persistent/recurrent symptoms OR a current diagnosed disability}, you have not submitted or identified any lay or medical indication of an association with service.

You have not submitted or identified any lay or medical indication of an association with service.

HAVE CLAIM only (NO stmt of persistent/recurrent sx or medical evid of dx) & ELEMENT 2, BUT MISSING ELEMENTS 1 & 3 , PER 3.159(c)(4)(i)) & Waters v. Shinseki (probably AT, NOCONT, NONEX, plus this):You have not submitted or identified any lay evidence of persistent/recurrent symptoms, or any medical evidence of persistent/recurrent symptoms or a current diagnosed disability, nor have you submitted or identified any lay or medical indication of an association with service.

if also L_NODX:The evidence shows you have symptoms, but there is no competent medical evidence of a diagnosis or of a lay or medical indication of an association with service.

OTHER NONEX:{} is not a disease associated with asbestos/herbicide exposure.

{} is a condition that has been determined to have no positive association with herbicide exposure. - see IV.ii.2.C.3.k, for hypertension AO2

AO:There is no evidence of early-onset peripheral neuropathy manifest to a degree of 10 percent or more within a year after the last date on which you were exposed to an herbicide agent during active service.

Chloracne (or other acneform disease consistent with chloracne) and porphyria cutanea tarda associated with herbicide exposure both have a one year presumptive period from the date of exposure.

Chloracne (or other acneform disease consistent with chloracne) associated with herbicide exposure has a one year presumptive period from the date of exposure.

W. Rees 88 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

Porphyria cutanea tarda associated with herbicide exposure has a one year presumptive period from the date of exposure.

Gulf War:If No Record of Condition, use Environmental Hazard in Gulf War – Other Unidentified Special Issue in VBMS-R & choose “Deny – Found Less Than 10 Percent Disabling”NIS STRs NODX GW1

There is no evidence that your claimed {} is a manifestation of undiagnosed illnesses or medically unexplained chronic multi-symptom illnesses (MUCMI).

The evidence does not show treatment for the disability claimed, nor is there lay testimony describing the disability pattern. ORThere is no evidence of that the claimed illness persisted for 6 months, nor is there evidence of a current disability.

Service connection for {} is denied since there is no evidence the claimed condition exists.

The Gulf War General Medical Examination DBQ indicates no diagnosed illnesses for which no etiology was established; shows you did not report any additional signs and/or symptoms that may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multisymptom illness” (MUCMI); and indicates you do not have additional signs and/or symptoms that may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multisymptom illness” (MUCMI).

The Gulf War General Medical Examination DBQ indicates {} is a disease with a clear and specific etiology and is not caused by exposure to environmental hazards while stationed in Southwest Asia.

The Gulf War General Medical Examination DBQ indicates {} is a disease with a partially explained etiology and is not caused by exposure to environmental hazards while stationed in Southwest Asia.

{Inflammatory bowel disease / ulcerative colitis / Crohn's disease / gastroesophageal reflux disease (GERD)} is a structural gastrointestinal disease and does not fall under the medically unexplained chronic multi-symptom illness (MUCMI) of functional gastrointestinal disorders (FGIDs).

*See Gulf War General Medical DBQ, if needed.

Bader opinion:The VA examiner opined that your claimed {} (diagnosed as {}) is less likely than not incurred in or caused by the claimed in-service injury, event or illness because the service record does not document objective findings consistent with a high energy injury to the soft tissue or osseous structures of your {}, such as fracture, internal derangement/herniated disc or dislocation, and in the absence of such findings a post traumatic or chronic inflammatory process is less likey than not; nor does the service record document repetitive microtrauma which would be required to initiate and sustain a posttraumatic or chronic inflammatory process; and you were on active duty for less than 10 years so any microtrauma you sustained during active duty, even in aggregate, would be insufficient to initiate and sustain a posttraumatic or chronic inflammatory process since the literature suggest a 10 year exposure as the threshold value; furthermore your radiographs do not reveal advanced degenerative changes and therefore are inconsistent with a post traumatic process.

W. Rees 89 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

Magnusson opinions:The VA examiner opined that it is less likely than not that your hearing loss is due to military noise exposure. Your examiner provided the following rationale:  The separation audiogram demonstrates excellent hearing, so the current hearing loss is more likely from other sources/factors, as a 2010 study shows hearing loss increases with age but is not significantly different for veterans and non-veterans, so it is difficult to attribute your recent hearing impairment functioning solely to the trauma suffered during military service and not to consider other factors such as aging, and noise exposure from occupational activities after military service.

The VA examiner opined that your tinnitus is less likely than not incurred in or caused by the claimed in-service injury, event or illness because tinnitus is more likely from other sources, as a 2006 Institute of Medicine study stated there is no scientific basis on which to conclude that a hearing loss that appeared many years after noise exposure could be casually related to that noise exposure if hearing was normal immediately after the exposure. The VA examiner linked your tinnitus to your hearing loss, which is not service-connected.

NM Free Text

(see C&C DENY Free Text if receive N&M evid sufficient to reopen the claim, but denial is continued)

For reopens, you only need one of the NM codes, plus Free Text.

Just address the evidence received for this claim. You need to know why it was previously denied, as that’s the only way you will know if the evidence is N&M. But if the evidence is not N&M, you don’t need to explain why the issue was previously denied, you just need to explain why the evidence isn’t N&M.

The statement you submitted from your spouse addressed the symptoms you currently experience, and that information is not material to the question of whether there is an association with service. While the evidence from {} provided a diagnosis, he reported that your disability is due to an automobile accident that occurred after your discharge from the military, so it does not provide an association with service. You have not submitted or identified any lay or medical indication of an association with service.

While the evidence from the treatment records provides a diagnosis, it also shows your disability is due to injuries that occurred after your discharge from the military. You have not submitted or identified any lay or medical indication of an association with service.

While the evidence from the treatment records provides a diagnosis, you have not submitted or identified any lay or medical indication of an association with service{, nor is there evidence that your condition manifested itself to a compensable degree within a year of your release from service}.

You have not submitted or identified any lay evidence of persistent/recurrent symptoms{, or any medical evidence of persistent/recurrent symptoms or a current diagnosed disability}, nor have you submitted or identified any lay or medical indication of an association with service.

While the evidence from treatment records shows your reports of {} pain, there is no evidence that establishes a chronic disability, nor have you submitted or identified any lay or medical indication of an association with service.

The treatment records do not show any evidence of a chronic {} disability with an indication of an association with service.

While the evidence from the DBQ shows left ear hearing loss, there is no indication of an association with service.

The treatment records do not show any evidence of {}. You have not submitted or identified any lay evidence of persistent/recurrent symptoms{, or any medical evidence of persistent/recurrent symptoms or a current diagnosed disability}, nor have you submitted or identified any lay or medical indication of an association with service.*Or could do an admin denial.

The evidence from the treatment records shows you have this condition, but not that it is related to your military service, or diagnosed within one year of discharge (to a compensable level).

W. Rees 90 updated 7/25/18

VBMS-R FREE TEXTDefinition Language

The evidence from the treatment records continues to show you have {this condition / complaints}, but not that {it is / they are} related to your military service, or diagnosed within one year of discharge (to a compensable level).

The evidence from the treatment records continues to show you have {this condition / complaints}, but not that {it is / they are} related to your military service, or diagnosed within one year of discharge (to a compensable level), or that {it / they} resulted from, or was aggravated by, a service-connected disability.

NM_DUP Free Text The evidence from {} was previously considered on Rating Decision dated {}.*Normally this is an admin denial, but you can use “claim form” in generated verbiage if an exam was ordered in error & the veteran FTR, so you really only have the claim form, but you have to rate the case due to the FTR.

OR don’t rate / admin denial:VSR: Please administratively deny {}, per III.ii.2.D.2.c, III.ii.2.D.3.h & III.ii.2.D.3.i, as these claims have previously been denied and the evidence submitted is clearly and entirely duplicative.

NM_NONE Free Text You did not submit any evidence with regard to {}.*Normally this is an admin denial, but you can use “your claim form” in generated verbiage if an exam was ordered in error & the veteran FTR, so you really only have the claim form, but you have to rate the case due to the FTR.

OR don’t rate / admin denial:VSR: Please administratively deny {}, per III.ii.2.D.2.c, III.ii.2.D.3.h & III.ii.2.D.3.i, as these claims have previously been denied and no evidence has been submitted.

NM_CU Free Text The evidence from the {treatment records and DBQ} essentially duplicates evidence that was previously considered which showed that you {were diagnosed with {} after service, but not that it is related to your military service, or was diagnosed within one year of discharge (to a compensable level).ORThe evidence from the treatment records continues to show you have this condition, but not that it is related to your military service, or diagnosed within one year of discharge (to a compensable level), or that it resulted from, or was aggravated by, a service-connected disability.

P_NC Free Text (NIS should also be included as a reason code)

There is no evidence that your condition was diagnosed, and manifested itself to a compensable degree, within a year of your release from service.

Your condition was diagnosed more than one year after your release from service.

The treatment records show that you have {}, but not that it was diagnosed in service or within one year of your release from service.

If presumptive disability, but no medical evidence of diagnosis:Use NIS STRs P_NC NODX

high blood pressure / HBP claimed:if not in service & no medical evidence of diagnosis of hypertension/HTN: NIS STRs P_NC NODX There is no evidence that hypertension was diagnosed, and manifested itself to a compensable degree, within a year of your release from service. There is no evidence the claimed condition exists.if not in service, but have diagnosis of hypertension/HTN: NIS STRs ACK_DX P_NC There is no evidence that hypertension was diagnosed, and manifested itself to a compensable degree, within a year of your release from service.for both, change VBMS-R System-Generated Text to: Service connection may be granted on a presumptive basis for hypertension if this condition is manifested to a compensable degree (severe enough to be evaluated at least 10 percent disabling) within a certain period after military discharge. As the medical evidence fails to show a diagnosis of hypertension within the time period specified under 38 CFR 3.307, service connection on a presumptive basis must be denied.

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VBMS-R FREE TEXTDefinition LanguageP_NE Free Text Choose Not In Country for the Decision Basis, use Agent Orange – outside Vietnam or

unknown OR Other/Unknown-Agent Orange OR other appropriate Special Issue in VBMS-R; then if not Diabetes/IHD/etc, choose “NSC – Agent Orange General,” then choose “Not SC” and “No Exposure”

The STRs, SPRs and DD214(s) do not show that you served in-country in Vietnam during the Vietnam Era. AND/OR Although you may have served aboard a vessel which was in the official waters of Vietnam, there is no proof of in-country service. OR The JSRRC response shows that the USS {} did not dock in the Republic of Vietnam in {September} or {October} 196{4}. OR You reported that you did not serve in Vietnam during the Vietnam Era.

NSC2 Free Text(NODX should also be included as a reason code if there is no medical evidence of a disability)

I.1.C.3.g - 3 elements for secondary & aggravation of NSC disability by SC disability - “A generalized statement merely asserting a conclusion that a condition is secondary to an SC disability is not sufficient to satisfy the Element 3 standard for requesting an examination.”

Deferral: No exam is in order for {} at this point, as we do not have Element 3 (an indication that the claimed secondary condition may be associated with the primary disability, including medical evidence, a lay statement or a medical treatise), per I.1.C.3.g.

The VA examiner opined that your diagnosed {} (claimed as {}) is less likely than not proximately due to or the result of your service-connected {} because {}.ORAlthough you are claiming your {} is due to your service-connected disability of {}, there is no objective medical evidence to support your claim, nor have you submitted any indication of an association with the service-connected disability (besides a generalized statement, which is insufficient).Rating Note: I.1.C.3.g says “A generalized statement merely asserting a conclusion that a condition is secondary to an SC disability is not sufficient to satisfy the Element 3 standard for requesting an examination.”ORAlthough you are claiming {} is due to your service-connected disability of {}, there is no objective medical evidence to support your claim, to include a clinical diagnosis of {}.*add “There is no evidence the claimed condition exists.”

diabetic complications:The VA examiner indicated that you do not have {erectile dysfunction/cardiac condition(s)/hypertension (in the presence of diabetic renal disease)/peripheral vascular disease/stroke/skin conditions/eye conditions other than diabetic retinopathy} that is at least as likely as not (at least a 50% probability) due to diabetes mellitus.

NSC AGG:Although you are claiming your {} is due to your service-connected disability of {}, the medical evidence is inadequate to establish the baseline level of disability, so no aggravation can be demonstrated.

If claimed as secondary to NSC condition:{} is not related to service, so service connection on a secondary basis cannot be established. **Similar to VBMS-R System-Generated Text

You do not have a {} disability that is related to service, so service connection on a secondary basis cannot be established.

NO_AGG Free Text

I.1.C.3.h – Element 1 (current disability/sx)

Element 2 (evid the disability worsened – Davis v. Principi, Maxson v. Gober, Verdon v. Brown, Jensen v. Brown, Paulson v. Brown)

Element 3 (satisfied by

The VA examiner opined that your {}, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service injury, event or illness because {}.ORThe evidence clearly indicates that there was no change in the condition during service. Your {date} {entrance / enlistment} examination shows {}. There is no evidence of any subsequent treatment during service. No {} disability was mentioned on your {date} separation examination.ORAlthough your {date} {entrance / enlistment} examination does not show any mention of {}, the records show {x-ray evidence of an old fracture seven days after your enlistment, which clearly did not occur during service, and was attributed to an injury while playing football in High School}. You were separated from service for a condition existing prior to service. The evidence clearly indicates that there was no change in the condition during service.

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VBMS-R FREE TEXTDefinition LanguageElement 2)

WMC Free Text

III.v.1.D

SA1

The DBQ shows a diagnosis of alcohol abuse. We will establish service connection for a chronic disabling condition which is not the result of the veteran's own willful misconduct. We will also evaluate the residuals of alcohol dependence under a service-connected psychiatric condition if it is determined that the alcohol dependence results from the psychiatric condition. Alcoholism is defined, by law, as willful misconduct, and you do not have a service-connected psychiatric condition that is shown to be causing your alcohol dependence. / The Mental DBQ does not show alcohol dependence/abuse is caused by your service-connected psychiatric condition.

Organic diseases that are secondary to chronic use of alcohol cannot be considered to have been incurred in the line of duty and cannot qualify for compensation. Although it was first diagnosed in service, the VA examiner reviewed your service treatment records and indicated that your {} is at least as likely as not related to alcohol consumption.

IU Free Textdenyiu

Entitlement to individual unemployability.

Entitlement to individual unemployability is denied.

use IU2 and IU416 if does not meet schedular criteria

The VA Form 21-8940 shows your report that your {} prevent(s) you from securing or following any substantially gainful occupation and that you left your last job because of your disability, but you also reported that you have not tried to obtain employment since you became too disabled to work. OR The VA Form 21-8940 shows your report that your {} prevent(s) you from securing or following any substantially gainful occupation, but you also reported that you did not leave your last job because of your disability and you have not tried to obtain employment since you became too disabled to work. {You reported working for {} from {} to {}. You reported becoming too disabled to work on {} and you last worked full-time on {}. You reported not receiving or expecting to receive disability retirement benefits or workers compensation benefits.}

The treatment records do not show definitive evidence that you are unemployable because of your service-connected disabilities. {ADD details from TRs}

The DBQ(s) do(es) not show definitive evidence that you are unemployable because of your service-connected disabilities. {ADD details from DBQ(s)}

The employment information from {} [shows that you retired on {date} and indicates that no concessions were made to you by reason of disability / does not indicate that any concessions were made to you by reason of disability; or shows you were employed from {date} to {date} and you last worked on {date}. The type of work performed was {}. There was no time loss during the 12 months preceding your last date of employment due to a disability. You are receiving retirement benefits which began on {date}. The evidence shows your employment ended due to retirement and not for any service connected disability, and that no concessions were made to you by reason of disability.]

The Social Security records show {}.

OR {} stated that you would be unable to obtain and maintain substantial gainful employment. The VA Form 21-8940 and your statements show your reports that you {retired with no mention of disability/did not leave your last job because of your disability} and have not tried to obtain employment since you became too disabled to work. OR The {} shows that you are able to work/can work in another capacity/ are currently working {full-time at ?}, so you are considered gainfully employed /are currently gainfully employed/are unemployable due {}, which is not a service-connected disability. There is no evidence that your service-connected disabilities (when considered apart from the nonservice-connected conditions) are the cause of your unemployability. OR The {} shows that you are only partially disabled by your service-connected {} and that you can work in another capacity. You are in the VA Vocational Rehabilitation and Employment program being trained as a {}, as they have determined that you are capable of gainful employment. OR for Evidence: VA Form 21-4192, Request For Employment Information in Connection

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VBMS-R FREE TEXTDefinition Language

With Claim For Disability Benefits, requested from XXXX, but not received

Vocational Rehabilitation & Employment has found you entitled and you are in the evaluation and planning stage. / The information from Vocational Rehabilitation and Employment shows you are in training at {} to complete a Bachelor’s degree in {}, starting around {date}.

The record shows that you are attending school full-time instead of working, indicating an ability for employment/you are attending school part-time and working part-time because you are in school, indicating an ability for employment.

PV_HX2 Despite …, your attending school, your service in the Reserves, your recent working and your participation in Vocational Rehabilitation & Employment all indicate an ability for employment.

Faust v. West (2000) -You are considered capable of engaging in a substantially gainful occupation since you are working and making an annual income that exceeds the poverty threshold for one person (irrespective of the number of hours or days that you work). IU1IV.ii.2.f.9.b – poverty thresholds

IV.ii.2.F.1.b – Please note that being unemployed and being unemployable are not the same. Your service-connected disabilities are not shown to be of such severity as to render you {unemployable/unable to secure or follow a substantially gainful occupation}.OR Please note that being unemployed and being unemployable are not the same. Although your service-connected disabilities may {impair/impact} your work ability, this is the reason you are being compensated for those disabilities by VA, and there is no evidence that they render you {unemployable/unable to secure or follow a substantially gainful occupation}.

IV.ii.2.F.1.b – Although you are unemployed from {list job} due to {list SC disability}, the VA examiner has indicated that you are capable of securing/following another substantially gainful occupation, specifically {}.

PV_RAT

PV_HX

Since the evidence does not show that you are unemployable due to service-connected disabilities, we cannot establish entitlement to individual unemployability.

**********If granting 100% (My Notes: It says “a single SC disability rated 100-percent disabling,” but it’s also moot with a combined 100% & below says “your service-connected disabilities.”) IV.ii.2.F.4.h says need to deny separately as free text issue:

Issue: Entitlement to individual unemployability.

Decision: Entitlement to individual unemployability is moot.

Reasons for Decision: Entitlement to individual unemployability is moot because your service-connected disabilities are evaluated as 100 percent disabling and no potential entitlement to an earlier effective date for a total disability evaluation based on a grant of individual unemployability is warranted by the evidence of record.

*There will be no record of an IU decision on the rating codesheet since no decision has

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VBMS-R FREE TEXTDefinition Language

been made.

**********

IU inferred (if IU was inferred):Juris: Same as pending claim with IU inferred & deferredEvidence: Rating Decision and all evidence contained therein, dated {}, and award notification letter dated {}

**********

ADL SOP March 2014 – IU When There Is No Complete VA Form 21-8940

if does not return completed 8940, in VBMS-R, select “IU Deny – Failure to Return Form 21-8940” *Use VBMS-R generated text (same text as listed at IV.ii.2.F.4.m), which is:Entitlement to individual unemployability is denied because you have not been found unable to secure or follow a substantially gainful occupation as a result of service connected disabilities.  On [insert the date of the development letter that initially requested completion of the VA Form 21-8940 as Month DD, YYYY], we wrote and asked you to send us a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability.  As of this date, we have not received a complete VA Form 21-8940.  This form is required to further consider your claim.

P29_21Free Text

Issue: Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days for {}.

Decision: Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days is denied.

IV.ii.2.J.2.f

Treatment as a resident in a State Veterans’ home does not qualify for a temporary total evaluation.

Residence at a VA domiciliary program (ASPIRE, then 5A-PRRTP / PRRP / RRTP / DRRTP, name is unclear, see my notes below) does not qualify for a temporary total evaluation unless it is required as part of a day hospital program of treatment consistent with hospital care.February 2018 Compensation Service Bulletin (CSB) - The ASPIRE program is a Residential Rehabilitation Treatment Program (RRTP) that promotes recovery in Veterans, particularly those who returned from the wars in Iraq and Afghanistan.  Since the level of care at ASPIRE does not equate to “hospitalization” under 38 CFR 4.29, Veterans would not be eligible for a temporary 100% evaluation.VHA Handbook 1162.02 shows many Programs:

Psychosocial Residential Rehabilitation Treatment Program (PRRTP) Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program

(PTSD-RRTP) Domiciliary Residential Rehabilitation Treatment Program (DRRTP) Domiciliary Care for Homeless Veterans (DCHV) Mental Health Residential Rehabilitation Treatment Program (MH-RRTP) Compensated Work Therapy-Transitional Residence (CWT-TR)

My Notes: 4.30 definitely not in order for domiciliary programs. It seems 5A-PRRTP is an addiction program. To determine if there is treatment consistent with hospital care, look for an admission, plus treatment notes every day.

Participation in a live-in/work out program to facilitate transition to community living does not qualify for a temporary total evaluation.

STARR is not inpatient treatment and does not qualify for a temporary total evaluation.

?Voluntary hospitalization does not qualify as “required hospital treatment” and a temporary total evaluation is not warranted.

P29_1 Free Text You were discharged from the hospital on {date} and we received your claim on {date}.

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VBMS-R FREE TEXTDefinition Language

Issue: Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days for {}.

Decision: Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days is denied.

P30 Free Text

Issue: Evaluation of {} currently evaluated as {} percent disabling. Entitlement to a temporary total evaluation because of surgical treatment requiring convalescence for {}.

Decision: Evaluation of {}, which is currently {} percent disabling, is continued. Entitlement to a temporary total evaluation because of surgical treatment requiring convalescence for {} is denied.

The treatment records show you were on convalescence for {} days following your surgery.ORThe treatment records do not show at least one month convalescence following your surgery, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more.ORA temporary total evaluation cannot be granted for nonservice-connected disabilities.ORThe private medical records show your surgery was more than one year prior to your date of claim. Entitlement to a temporary 100 percent evaluation can only be granted if the claim is filed within one year of the date of the surgery.

SMC_AA Free Text(not required)

Although the {examination and treatment records} show that you need aid and attendance, the need is not based on your service-connected disabilities{, but rather on nonservice-connected disabilities}. You also do not have a single service-connected disability rated as totally disabling.ORWe have denied entitlement to special monthly compensation because the evidence does not show you need the regular aid and attendance of another person to perform routine activities of daily living, nor are you permanently bedridden, as a result of service-connected disabilities.

SMC_HB Free Text(not required)

BRADLEY:Additionally, the {examination and treatment records} do not show you are housebound {due to the service-connected disability on which Individual Unemployability is based}, nor do you have a separate service-connected disability or disabilities independently rated 60 percent or more.

Or:Rating Note: SMC S is not being granted, as IU was based on multiple conditions, and for a Bradley grant of SMC S the IU has to be based on a single disability and 4.16 does not apply, per FL 09-33.

My Notes: Review: SMC for Statutory Housebound - VBMS-R forces reviews of SMC S when there is one disability at 100% (or 70%+IU), but there are no separate disabilities that combine to 60% & there is no option for that specific “reason” for not granting SMC S, so I select the first reason in the list.

Glossary fragments (SNL/ADL codes) and VBMS-R NOTESIssue Notes/Language

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For Rating Introduction Text (*not required)

with EBN ITFs, eff 3/24/15 - You initiated your electronic application on {}, which is considered an Intent to File (ITF), and a complete claim was received on {}.

You filed an Intent to File (ITF) that was received on {} and a complete claim was received on {}.

You filed an original disability claim that was received prior to your separation from active duty.

Effective Date

(a great effective date resource is RVSR Assistant)

*see DMII grant (for 3.114) and IU grant

Rating Note: Per III.iv.6.C.5.a, explanation of the effective date in the Reasons for Decision is not required since it is the date of the claim’s receipt / the day following discharge.

For codesheet:ITF {date}. / No associated ITF.

III.ii.2.C.2 - Service connection has been established from the day VA received your Intent to File (ITF) because a complete claim was received within one year of the ITF.

Service connection has been established from the day VA received your incomplete claim because a complete claim was received within one year of the incomplete claim. Your Intent to File (ITF) was received more than one year prior to the complete claim, and cannot be used as a basis for the effective date.

CLAIMS FOR INCREASE:III.ii.2.C.2 - Entitlement to an increased evaluation has been established from the day VA received your Intent to File (ITF) because a complete claim was received within one year of the ITF. *see below if have TRs

3.400(o)(2), w/TRs (III.iv.5.C.5) –

based on DOC even though have TRs:Entitlement to an increased evaluation has been established from the day VA received your claim. The treatment records do not show evidence of an increase in disability (increase actually manifested itself) within one year prior to the date of claim.

, the day VA received your claim, since the treatment records do not show evidence of an increase in disability (increase actually manifested itself) within one year prior to the date of claim, or prior to March 24, 2015. (prior to 3/24/15 in VATRs only, 3.157 for CFIs or complications of diabetes, residuals of cancer, scars from surgery, neurological disabilities related to the spine, complications of progressive disorders (ALS, MS), constitutional symptoms of systemic disorders (RA, ankylosing spondylitis)).

, the day VA received your claim, since the treatment records do not show that this disability was diagnosed within one year prior to the date of claim, or prior to March 24, 2015. (prior to 3/24/15 in VATRs only, 3.157 for CFIs or complications of diabetes, residuals of cancer, scars from surgery, neurological disabilities related to the spine, complications of progressive disorders (ALS, MS), constitutional symptoms of systemic disorders (RA, ankylosing spondylitis))

*with ITF - The treatment records do not show evidence of increased disability that manifested within one year prior to the ITF.

based on veteran provided DBQ / private DBQ w/i year of claim, 3.400(o)(2):Entitlement to an increased evaluation has been established from the date of the veteran provided DBQ showing evidence of increased disability, within one year prior to the date of claim.OR, the date of the veteran provided DBQ received within one year prior to the date of claim.

based on TRs w/i year of claim (*all three are the same, verbiage just slightly different):Entitlement to an increased evaluation has been established from the earliest date the treatment records show evidence of increased disability, within one year prior to the date of claim.OREntitlement to an increased evaluation has been established from the date of the medical evidence showing an increase in disability. When an increased evaluation is granted based on medical evidence showing an

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increase in disability within one year prior to the date the claim was received, the effective date of the increase is the date of the medical evidence.OREntitlement to an increased evaluation has been established from the date of the medical evidence showing an increase in disability. When medical evidence showing an increase in disability is received within one year of the date of the evidence, the effective date of the increase is the date of the evidence.

*with ITF - Entitlement to an increased evaluation has been established from the date of the medical evidence showing an increase in disability, as you filed an Intent to File (ITF) within one year of the date of the evidence, and a complete claim was received within one year of the ITF. - III.iv.5.C.5.b & 3.400(o)(2) The DBQ associated with your prior claim for increase did not show evidence of increase in severity sufficient to warrant a higher evaluation, but the DBQ associated with the current claim for increase does show evidence of increase to the {} percent level.

TRs under historic 3.157 prior to 3/24/15 (also applies to seconday SC for common complications; also see III.ii.2.C.1.a & III.ii.2.C.1.c, plus VA Pulse, https://www.vapulse.net/message/9403, https://www.vapulse.net/message/11293 & https://www.vapulse.net/message/51221)– Entitlement to an increased evaluation has been established from the date of the VA medical evidence showing an increase in disability which is considered an informal claim based on our regulations prior to March 24, 2015.

, the date of the VA medical evidence showing an increase in disability which is considered an informal claim based on our regulations prior to March 24, 2015.

PRESUMPTIVE:Service connection has been established from the date the treatment records show {}, because the claim was filed within one year of discharge.*only if no evidence of the condition in the STRsOR date of claim if diagnosed within one year of discharge, but no claim until more than one year following discharge

SECONDARY:

3.400(o)(2), w/TRs (III.iv.5.C.5) –

based on DOC even though have TRs:Service connection has been established from the day VA received your claim. The treatment records do not show evidence of {}, which is a medically-known complication of {}, within one year prior to the date of claim.ORService connection has been established from the day VA received your claim. [The DBQ requested for your claim is the first date we have a medical opinion of its relationship to your service-connected ().]

3.155(d)(2) says “VA will also consider all lay and medical evidence of record in order to adjudicate entitlement to benefits for the claimed condition as well as entitlement to any additional benefits for complications of the claimed condition, including those identified by the rating criteria for that condition in 38 CFR Part 4, VA Schedule for Rating Disabilities.”

Rating Note: III.iv.6.B.2.c says complications* of an expressly claimed condition are issues within the scope of the claim (formerly “reasonably raised,” formerly “sympathetic”).*including (but not limited to) complications of diabetes, residuals of cancer, scars from surgery,

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neurological disabilities related to the spine, complications of progressive disorders (ALS, MS), constitutional symptoms of systemic disorders (RA, ankylosing spondylitis)*also see III.iv.5.C.5.i for effective date for complications

March 2016 Quality Call Notes – Distinguishes arteriosclerotic manifestations secondary to hypertension (& depression secondary to hearing loss) from diabetic neuropathy as a natural progression of the complicated metabolic disorder of diabetes. 3.157 does not apply to secondary disabilities.

based on TRs w/i year of claim (*all three are the same, verbiage just slightly different):Service connection has been established from the earliest date the treatment records show…--neuropathy/radiculopathy, which is a medically-known common complication of {spine disability}--common/recognized complication*, which is a medically-known common complication of diabetes mellitus--{condition due to diabetes**} which the VA examiner indicated is due to diabetes mellitus, within one year prior to the date of claim.

*common/recognized complications: neuropathy/radiculopathy related to the spine; diabetic peripheral neuropathy, diabetic nephropathy/renal dysfunction caused by diabetes mellitus and diabetic retinopathy [per RVSR Assistant, PVD should be up here]**possible conditions due to diabetes mellitus: ED, cardiac, hypertension (in the presence of diabetic renal disease), PVD, stroke, skin, other eye, other complications indicated by examiner as due to diabetes.

SMC K:Service connection has been established from the date service connection was established for erectile dysfunction from diabetes mellitus type II.

increasing tinnitus from 0% to 10%, per 6/10/99 change allowing for disease process as well, apply 3.114:Service connection has been established from one year prior to the day VA received your claim. The disability existed at the time of the change in the law that allowed a 10 percent evaluation for all persistent/recurrent tinnitus (including from a disease process and not just from acoustic trauma), but the claim was filed more than a year after the change in the law.

Misc:Service connection has been established from the date you met the criteria for this benefit.

Service connection has been established from the day VA received your previous claim. Additional evidence has been received, and a review of that evidence and prior evidence reveals a higher evaluation is warranted.

III.iv.5.C.6.d, III.iv.5.C.6.e, 3.156(b) & 3.400(q)Service connection has been established from the day VA received the previous claim, as you continuously prosecuted your claim. OR Service connection has been established from the day VA received your Intent to File (ITF) for the previous claim, as a complete claim was received within one year of the ITF, and you continuously prosecuted your claim.

Cannot use ITF to establish continuous prosecution:III.ii.2.C.2.i - An ITF may not be used to extend the period of non-finality for a recently decided claim.  Any evidence submitted in connection with a non-final claim will be assessed for a new and material determination in accordance with 38 CFR 3.156(b).  Accept an ITF submitted during the period of non-finality as an active ITF, if an active ITF is not already of record, and associate it with a claim if received within one year of the ITF.

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III.iv.5.C.2.b -

Service connection has been established from the day VA received your Intent to File (ITF) because a complete claim was received within one year of the ITF. Please note that an ITF may not be used to extend the one year period of non-finality following notification of a decision, and your complete claim was not received within one year of notification of the previous decision.Rating Note: Although the {date} ITF was received within one year of the {date} denial notification, the complete claim was received {date}, more than one year after the notification, so the earliest effective date is the ITF, per III.ii.2.C.2.i.

Service connection has been established from the date of the sleep study showing a confirmed diagnosis of obstructive sleep apnea, based on facts found, as that is the date entitlement arose.

III.iv.4.D.2.a – sympathetic reading of hearing loss claims The claim for hearing loss is sympathetically read to include a claim for service connection for tinnitus because tinnitus was reported and associated with service.Rating Note: Although the Veteran did not claim tinnitus until {}, the hearing loss claim is sympathetically read to include a claim for service connection for tinnitus.

III.iv.4.D.3.a - a claim for tinnitus is not a claim for hearing loss; if could grant, solicit claim

VSR, solicitation is needed, so please include this in the notification letter to the Veteran: “We have reviewed your records and they suggest you may be entitled to an additional benefit. If you want to file a claim for bilateral hearing loss, 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.” **We already have a DBQ on file for bilateral hearing loss with a positive opinion.

From Hearing Loss & Tinnitus training PowerPoint:Although you did not claim this disability, service connection for tinnitus is granted as the VA examiner opined that your tinnitus is related to the noise exposure you experienced in the field artillery…

CD includes

Manual says “congenital, developmental or hereditary disorders” and VBMS-R says“Constitutional/Developmental” but then the paragraph says “congenital or developmental defect”

absent parts, III.iv.4.A.8.h accessory or supernumerary parts, III.iv.4.A.8.h

atrial septal defect, IV.ii.2.B.6.a congenital deviated nasal septum without trauma in service or abnormal

progression during service (6502)

congenital diastasis of the rectus abdominus, III.iv.4.A.8.h congenital heart defects (i.e. patent foramen ovale, patent ductus arteriosus,

coarctation of the aorta, intraventricular septal defect) (7099-7000) III.iv.4.G.1.h congenital pes planus (5276) (only SC for “acquired” pes planus, which is indicated

by depression of the longitudinal arch, associated anatomical changes (such as the inward rotation of the superior portion of the os calcis, medial deviation of the

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insertion of the Achilles tendon, or a medial tilting of the upper border of the astragalus), painful plantar surface with demonstrable tenderness, spasm of the Achilles tendon with manipulation of the foot, peroneal spasm due to adhesion about the peroneal sheaths, and other evidence of pain and limitation of motion. Simple flattening of the arches without evidence of abnormal callosities, areas of pressure, strain or demonstrable tenderness, is a congenital abnormality.)

deformity or exostosis (bony overgrowth) of parts, III.iv.4.A.8.h displaced parts, IV.ii.2.B.6.a heart murmur, if alone (without a diagnosis of a specific disease process) (7099-

7000) Your STRs show a heart murmur, which is a finding when alone (without a diagnosis of a specific disease process), and not an actually disabling condition for which service connection can be granted.

hernia of the diaphragm, III.iv.4.A.8.h incomplete sacralization, III.iv.4.A.8.h kyphosis, scoliosis, lordosis or hyperlordosis, if alone & did not first manifest in

service or permanently worsen in service (5299-5237)

lazy eye/amblyopia (III.iv.4.C.2.d – need etiology, as may be developmental or acquired)/strabismus/estropia/exotropia/exophoria/hyperphoria (6099-6066)

male pattern baldness/androgenetic alopecia/hair loss without alopecia areata or scarring alopecia (7899-7831), confirmed by September 2013 Compensation Service Bulletin (CSB), October 2014 Rating Quality Call Notes, III.iv.4.L.4.b, eff 10/5/15

mental retardation/deficiency (9399-9327), IV.ii.2.B.6.a myotonias, III.iv.4.A.8.h

pectus excavatum, IV.ii.2.B.6.a personality disorder (9499-9400), IV.ii.2.B.6.a Scheuermann’s disease (5299-5237)

spina bifida, III.iv.4.A.8.h spondylolysis, III.iv.4.A.8.h says congenital defect (*it appears this is not spondylosis),

but spondylolisthesis is not automatically a congential condition although is commonly associated with a congenital defect

subluxation (partial dislocation of a joint), III.iv.4.A.8.h was modified 2/9/17 to say “Do not automatically classify joint subluxation as a developmental or congenital condition.”

supernumerary parts, IV.ii.2.B.6.a uncomplicated refractive error (regular astigmatism, myopia,

hyperopia/hypermetropia & presbyopia) [blurry vision, blurred vision, eyesight, glasses, contacts, etc.] (6099-6066) *exceptions are malignant myopia and pernicious myopia per III.iv.4.C.2.a

undescended testicles, IV.ii.2.B.6.a unstable or exaggerated lumbosacral joints or angles, III.iv.4.A.8.h vertebral anomalies (i.e. block (fused) vertebrae), IV.ii.2.B.6.a

Name change , and is now called {}.Close-outs

My Notes: If a prior RD gave two 0% evaluations incorrectly (like two evals for plantar warts, or

Decision: Evaluations of pes planus left foot with posterior tibial tendonitis, currently evaluated as 20 percent disabling, and pes planus, right foot, current evaluated as 0 percent disabling, are closed-out and now evaluated as bilateral pes planus with posterior tibialis at 50 percent effective June 20, 2017.

Reasons for Decision: The evaluations of pes planus left foot with posterior tibial W. Rees 101 updated 7/25/18

separate evals for shin splints & knees; since 0% it doesn’t affect the combined), might not want to do a close-out, but just correct it in the Master Record, evaluate the new, corrected issue & make a note on the codesheet about correcting it

tendonitis, currently evaluated as 20 percent disabling, and pes planus, right foot, current evaluated as 0 percent disabling, are closed-out and now evaluated as bilateral pes planus with posterior tibialis at 50 percent effective June 20, 2017, the day VA received your claim.

Add a note to the codesheet:Rating Note: A CUE is not being called, as the two separate evaluations for the feet is not outcome determinative (i.e. the decision does not change). SC is still warranted and the combined evaluation doesn’t change.

shin splints now separated:Issue: Entitlement to separate evaluations for each lower extremity for left shin splints and right shin splints (previously rated as bilateral shin splints).

Decision: Separate evaluations for each lower extremity for left shin splints and right shin splints (previously rated as bilateral shin splints) are granted at {} percent effective {}. [use DOC]

Reasons for Decision: Separate noncompensable evaluations for each lower extremity for left shin splints and right shin splints (previously rated as bilateral shin splints) are granted from {}, the day VA received your claim.

Add a note to the codesheet:Rating Note: A CUE is not being called, as the one evaluation is not outcome determinative (i.e. the decision does not change). SC is still warranted and the combined evaluation doesn’t change.

*adding 2nd ear to HL, probably best to do this decision under the previously denied ear & change to “bilateral hearing loss” in the Master Record, then backfill the prior SC condIssue: Evaluation of hearing loss, left ear currently evaluated as 0 percent disabling. Service connection for hearing loss, right ear.

Decision: Evaluation of hearing loss, left ear, which is currently 0 percent disabling, is continued and is now called bilateral hearing loss.

Reasons for Decision: Use HL Calculator verbiage

Reopened claim granted

Keep issue as is.

Decision: New and material evidence has been submitted that is sufficient to reopen a claim for {} (previously denied as {}, now claimed as {}). The claim is reopened and service connection is granted with an evaluation of {} percent effective {}.

Service connection has been established from the day VA received your claim where subsequent new and material evidence allowed for a grant of service connection.

Service connection has been established from the day VA received your Intent to File (ITF) because a complete claim was received within one year of the ITF, and subsequent new and material evidence allowed for a grant of service connection.

Need to retain Original Date of Denial on codesheet, per III.iv.6.E.8.bTemporary evaluations

IV.ii.2.F.4.i – no need to stop/discontinue & re-start IU when grant temporary total eval

P29 -*also see P29G & P29<21 & P29_1 -Issue: Entitlement to a temporary total evaluation because of hospital treatment in excess of 21 days for {}.

Grant Decision: A temporary evaluation of 100 percent has been assigned effective {}

W. Rees 102 updated 7/25/18

(temp 100%) based on hospital treatment in excess of 21 days. An evaluation of {} percent is assigned from {}.

January 2017 Quality Call Notes –

Question: If we are to continue the IU entitlement, even while we are granting temporary 100 percent, how will this impact IU decisions that are based solely on a single issue that is assigned the temporary 100 percent? This could potentially lead to confusion on the codesheet and erroneous entitlements to housebound.

Answer: Payment cannot be made for a period of temporary 100 percent evaluation under 38 CFR 4.29 or 4.30 and IU for the same disability. The IU is continued for the purposes of facilitating effective authorization of associated payments and does not bestow additional entitlement, including entitlement to SMC. If the potential for confusion exists, then add a note to the codesheet explaining that the continuation of the IU coding is for records purposes only during the period of the temporary 100 percent evaluation, and no SMC entitlement is warranted.

S plus K Issue: Entitlement to special monthly compensation based on housebound and loss of use.

Decision: Entitlement to special monthly compensation based on housebound criteria being met and based on loss of use of a creative organ is granted from {}.

Reasons: Entitlement to special monthly compensation is warranted in this case because criteria regarding housebound and criteria regarding loss of use of a creative organ were met from {}.

VBMS Tips & Tricks 9.0 –To produce two SMC decisions for the Rating Decision and ADL, end-users should follow the following steps: Enter in the decision for the first SMC grant. Enter in the SMC code for the first SMC grant. Create the narrative and hit accept. Go back to the SMC code screen in the Master Record and delete the SMC code entered for the first decision. Enter the decision for the second SMC grant. Enter in the correct SMC code for the first and second grant and complete the narrative for the second issue.

W. Rees 103 updated 7/25/18

100% Mental Eval (or 70% + IU)

III.iv.8.A.2.a

April 2014 Compensation Service Bulletin (CSB) – If the veteran is competent, delete the Competency issue and add this to the mental issue: There is no evidence of record that shows that you are unable to manage your financial affairs.

May 2014 Rating Quality Call Notes – Competency needs to be considered if mental at 70% & grant IU based on that mental disability.

Rating Note: Per May 2014 Rating Quality Call, Competency was addressed because the mental disability is at 70% and IU is granted based on the mental disability. Per April 2014 and October 2014 CSB, Competency is addressed within the mental issue (there is no separate issue, so it is not on the codesheet).

October 2014 Compensation Service Bulletin (CSB) – When a 100 percent evaluation for a mental condition is found warranted, the issue of competency must be addressed. In situations where the Veteran is found competent, address the fact that the Veteran has not been deemed incompetent under the mental condition which relates to the issue of competency. VA_COMPETENT “There is no evidence of record that shows that you are unable to manage your financial affairs.”

Per QRT/Carlos Rosario, don’t need to put it on the codesheet.per VA Pulse, https://www.vapulse.net/message/21285, no procedural requirement to backfill

December 2015 Compensation Service Bulletin (CSB) – The issue statement on the rating decision could be worded as follows: “1. Evaluation of psychotic disorder currently evaluated as 30 percent disabling; Competency to handle disbursement of funds.”

VBMS-R System-Generated Text Issue: Competency to handle disbursement of funds.Decision: The claimant is considered competent.Generated Text: Since the claimant in this case is not shown as unable to manage personal affairs, we have determined that the claimant is competent for VA purposes.

Improvement, but at that % more than five years, so need routine future exam / RFE in 18/24/30 months

OR

Improvement, but no future because over 55 or combined won’t change

*August 2014 EB training said do not use EB for C&Cs, go directly to the Disability Decision Information (DDI) – manual entry screen.

*Unclear if you have to change the language or if you can just leave it as generated by the system.

Decision: Evaluation of {}, which is currently {} percent disabling, is continued.

Reasons for Decision: The evaluation of {}, which is currently {} percent disabling, is continued.VBMS-R System-Generated Text: Although recent evidence shows some improvement in the condition, sustained improvement has not been definitively established. SUSTCCEVAL

The current evidence shows only a {noncompensable/10/20 percent} evaluation is warranted based on: (add VEB/LEB info)

An evaluation of {the current eval} percent is assigned if the evidence shows: (add VEB/LEB info; or text from “Alternative Text Builder” if needed)

USE VBMS-R System-Generated Text or A higher evaluation of {} percent is not warranted unless there is…

CC5YR [do exam in 18, 24 or 30 months from the date of the rating]

Other useful routine future exam / RFE language:Rating Note: Future exam in three years due to watchful waiting status.

OR

Rating Note: {} is continued with improvement but no future review examination since (1) the Veteran is over 55 years of age (and there are no unusual circumstances involved in

W. Rees 104 updated 7/25/18

the case), and/OR (2) the combined evaluation would not change even if the reexamination resulted in a reduced evaluation, and/OR (3) the evaluation is 10 percent or less, per III.iv.3.B.2.d.

Protected evaluation, 20+ years

PR2 **Similar to VBMS-R System-Generated Text CCEVAL The current evidence shows only a {noncompensable/10/20 percent} evaluation is

warranted based on: (add EB info) An evaluation of {the current eval} percent is assigned if there is: A higher evaluation of {} percent is not warranted unless there is:

Protected evaluation, old criteria

PR3 & change “under the condition” to “under rating criteria,” plus “under the new schedule” to “under the new criteria,” as below:

A readjustment to the schedule for rating disabilities shall not be grounds for reduction of a disability rating in effect on the date of the readjustment unless medical evidence establishes that the disability to be evaluated has actually improved. Your condition was previously rated as {} percent disabling under the rating criteria that was changed on {}. A higher rating of {HIGHER PERCENT} is not warranted under the new criteria unless there is medical evidence of {HIGHER CRITERIA}. Because there is no evidence that establishes that your condition has actually improved, your {} percent rating is continued.

Then add:

You do not currently meet the {CURRENT EVALUATION} percent evaluation requirements under the current rating criteria, but your evaluation is being continued under the old criteria because it is most advantageous to you.

CCEVAL The current evidence shows only a {noncompensable/10/20 percent} evaluation is

warranted under the current rating criteria based on: (add EB info) An evaluation of {the current eval} percent under the current rating criteria is

assigned if there is: A higher evaluation of {} percent under the current rating criteria is not warranted

unless there is:DMII grant(consider 3.114)

3.114 effective date:Service connection has been established from one year prior to the date VA received your claim. When a claim of service connection is received more than one year after a change in law, and all the requirements were met for a grant on the date of the change in law, the effective date is one year prior to the date VA received your claim.

also see ED1 & ED2applying 3.114 to ITF:Service connection has been established from one year prior to the date VA received your Intent to File (ITF) because a complete claim was received within one year of the ITF; and the ITF was received more than one year after a change in law, and all the requirements were met for a grant on the date of the change in law. *3/18 ITF Consistency Study seems to imply this is incorrect, but it’s supported by III.ii.2.C.2.c

Please note that we cannot assign an effective date prior to the date of claim, as although you reported/the VA treatment records show your diagnosis was made in {}, we do not have any medical records confirming the date of your diagnosis.

Service connection has been established from date of the change in the law, as you filed your claim within one year of the change in the law and your disability existed at the time of the change in the law.

W. Rees 105 updated 7/25/18

Reasonable Doubt

III.iv.5.A.1.j

BD1

The evidence is in equipoise and reasonable doubt is resolved in your favor.

When evidence is in proximate balance, reasonable doubt will be resolved in your favor.

When reasonable doubt arises regarding service origin, such doubt will be resolved in favor of the claimant.

Reasonable doubt is to be resolved in the veteran's favor when the favorable and unfavorable evidence is in approximate balance.

Reasonable doubt is resolved in your favor that these findings more closely approximate the level of functional impairment contemplated by the {} percent evaluation based on objective evidence of {} with subjective complaints of {} impacting functional activities.

If not in equipoise:The preponderance of the evidence is in favor of service connection.

Higher of two evaluations / 4.7

Rating Note: The higher evaluation was assigned because the disability picture more nearly approximates the criteria required for that rating.ORThe higher evaluation is assigned because the disability picture more nearly approximates the criteria required for that rating.

Grant 0% (or higher) and request At Once exam or clarification (might just go straight to the Disability Decision Information (DDI) – manual entryscreen rather than using VEB)(QRT/GiaBao Nguyen says for clarifications, we should go into the Master Record backfill & add “Deferred Evaluation” under Supplementary Decision of the “Diagnosis Information” card so it will show on the codesheet as both SC & as deferred.)

(put under EB text )We are requesting a Disability Benefits Questionnaire to determine your current level of disability.ORWe are requesting clarification of your Disability Benefits Questionnaire results to determine/confirm your current level of disability.

If rate on TRs We have evaluated your disability based on treatment records. Please let us know if you believe your disability meets the next higher evaluation.

If have deferred issues Issue: Compensation for {}.Decision: A decision on entitlement to compensation for {} is deferred.Reasons: The issue of compensation for {} is deferred for the following information: further development

Exam missing info, but not insufficient

Rating Note: Although the VA examiner did not provide the degree where objective evidence of painful motion begins for {extension, lateral flexion or rotation}, other findings allow for a 10% and this missing information would not affect the veteran's evaluation.

Arthritis on x-ray, but not in diagnosis

Rating Note: The x-ray shows {}, but the examiner did not include arthritis in the diagnosis, so only {} was used.

Or use something like: {} strain (with x-ray evidence of arthritis)Rating Note: The x-ray shows {}, but the examiner did not include it in the diagnosis, so it was put in parentheses.

W. Rees 106 updated 7/25/18

Exposure only

I.1.B.1.f – special issue notif

I.1.B.1.h – incomplete application based on exposure

IV.ii.1.I.6.cIV.ii.2.A.1.c

VSR: The Veteran claimed exposure to {Agent Orange/other herbicide, asbestos, mustard gas, ionizing radiation, Gulf War environmental hazard}. However, we didn't receive a response to our {} 5103 Notice, which asked for a specific disability. No further action is needed for this substantially incomplete claim, per IV.ii.2.A.1.c & I.1.B.1.h.ORVSR: The Veteran claimed exposure to {Agent Orange/other herbicide, asbestos, mustard gas, ionizing radiation, Gulf War environmental hazard}. However, the {} 5103 Notice failed to ask the veteran for a specific disability. Please address this substantially incomplete exposure claim in the notification letter, per I.1.b.1.g & I.1.B.1.h.

Tinnitus already at 10%

I.1.C.3.j - no automatic exams of disabilities at schedular maximum evaluation

ES2 & MAX_EVAL

Rating Note: CCEVAL not used for tinnitus / perforated tympanic membrane / hallux valgus because increased severity is not relevant with a maximum schedular evaluation.

From VEB:A single evaluation for recurrent tinnitus is assigned whether the sound is perceived in one ear, both ears, or in the head.

This is the highest schedular evaluation allowed under the law for tinnitus.Tinnitus not reported

(if also NIS & STRs choose “No Record of Condition”)

The evidence does not show a current disability. The DBQ shows you did not report recurrent tinnitus.

Pension

grant P&T / grantp&t

Administrative grants:VSR: Pension can be administratively granted based on the veteran’s age, if the income and net worth requirements are met.ORVSR: Pension can be administratively granted, if the income and net worth requirements are met, as the veteran is presumed to be totally and permanently disabled for pension purposes because he/she is (1) a patient in a nursing home for long-term care because of disability (SMP based on A&A can also be granted without a rating, per V.ii.3); or (2) disabled, as determined by the Commissioner of Social Security (SS) for purposes of any benefits administered by the Commissioner, such as SS disability insurance or supplemental security income.

Administrative denials:VSR: Please administratively deny pension for no wartime service, per III.ii.7.2.b.ORVSR: Please administratively deny pension, as the veteran did not have 24 months of active duty, did not serve the full period for which he was called/ordered to active duty and is not excluded from these requirements. Per 3.12(a). (A veteran can be excluded from the minimum active duty requirement if they (1) had a hardship discharge or early out, or (2) were discharged for a disability, or (3) have a compensable service-connected disability.)

Note to File: The veteran completed the income and net worth information, but put "N/A" or selected "No" on all other answers in the Pension section and indicated that he is only applying for Compensation.

W. Rees 107 updated 7/25/18

IU No 8940 – no8940Note to File: The Veteran meets the minimum schedular criteria under 38 CFR 4.16(a), however there is no evidence the Veteran is unemployable due to S/C conditions at this time. Therefore, IU is not being put at issue.

OR if infer IU, defer &:VSR: Please send 21-8940, as the veteran meets the schedular requirements for IU, and the available evidence on file indicates the veteran is unemployable due to SC conditions, per IV.ii.2.F.2.k & IV.ii.2.F.2.l.*add a deferral under the Deferrals tab in VBMS (Issue – Inferred Issue)**if you are not granting a benefit, do not infer & defer IU, per III.iv.6.A.1.e, you first need to develop for IU info per IV.ii.2.F.2.m (Issue – Inferred Issue)

Per VA Pulse, https://www.vapulse.net/message/138355, IU should then be added as a contention in VBMS.

Note: IV.ii.2.F.2.m says if claim that prompted the reasonably raised inference of IU was on a non-EZ or rec’d more than one year ago, need to send 5103 notice with 8940.

III.iv.6.B – interpretation of Example 2 under III.iv.6.B.1.c - IU is a “reasonably raised” claim if exam shows symptoms of SC disability cause veteran to be fired from their job

IV.ii.1.F.2.b – need new 8940 if prior one was part of finally adjudicated claimIU grant

Grant IU

grantIU

IV.ii.2.F.4.m - we have to explain how impairment from SC disability supports the decision and specify which disability(ies) render the veteran unemployable.

Entitlement to individual unemployability is granted because you are unable to secure or follow a substantially gainful occupation as a result of your service-connected disability(ies) of {} because {}.

*consider SMC S based on other conditions not rendering them unemployable, if grant IU due to just one disability

*consider Ch. 35

EMPLO

May 2014 Rating Quality Call Notes – Competency needs to be considered if mental at 70% & grant IU based on that mental disability.

IU effective date:Individual Unemployability is granted from {}, the day following the date you last worked, as you filed the claim within one year of the date you last worked.ORIndividual Unemployability is granted from {}, the earliest date you met all of the criteria for entitlement to individual unemployability. OR , the day VA received your previous claim as that is the earliest date you met all of the criteria for entitlement to individual unemployability. (use this with date of CFI if solicit IU claim & get 8940 w/i 1 year)ORIndividual Unemployability is granted from {}, the day VA received your claim.

W. Rees 108 updated 7/25/18

Ch35 grant

Grant Ch35

grantch35

Ch. 35

DEA

USE VBMS-R System-Generated Text

IX.ii.2.1.k - The RO does not actually determine the effective date of  the DEA benefit.  It makes a determination on the date of commencement of a P&T disability.  38 CFR 21.3021(r) defines effective date of the P&T rating as the date from which VA considers that P&T disability commenced for the purpose of VA benefits as determined in the initial rating decision.

III.ii.2.B.1.i – P&T requests (veteran needs to specify SC issue(s) associated with claimed P&T status, if not it’s an incomplete application; change 8/12/16 – exception is if only one SC disability exists); addressing Ch. 35 addresses request for P&T

III.iv.5.B.3.a – conceding permanence

November 2017 Quality Call Notes - FAQ regarding EP 310s for P&T determinations: Effective date is generally the date of review. Only a P&T decision is needed (no C&C’s for RFE condition). If Veteran is already P&T, no other action is required for RFE condition – submit EP

310 to be cancelled. If Veteran is 100% due to 1151 grant ensure that the 1151 flash is of record to avoid

this coming up on our next review. If a regulatory DC exists (e.g. cancers), that was not the DC we cancelled. Review

the last codesheet. Document, document, document. Write VBMS notes that others can understand.

My Notes: If P&T based on review exam, use that exam date for effective date.

VSR at Houston RO (in Nov 2016) says effective date explanation is required, per III.iv.6.C.5.a, but to me it’s unclear, no one else seemed to be doing it & I stopped several months prior without anyone saying anything until now. As of Dec 2016, Trainee RVSRs are adding explanation date (trained to do so at Challenge?).Eligibility has been established from {}, the date of the DBQ showing permanency.

W. Rees 109 updated 7/25/18

EB Notes

OverrideTraining PowerPoint is saved at H:\VSC\Development & Rating Resources

In July 2014, a VBMS PMO Program Analyst said higher evals (specifically hemorrhoids at 20% for persistent bleeding) are correct per 4.7, per Tatum (& noted that it is supported & approved by Comp Service and Policy Staff) VBA Issue Tracker Response – Issue 591 says do not check anemia (for hemorrhoids) if the hemoglobin level is normal, regardless of what the examiner checked.

Tips & Tricks, as of 8/7/14 –3.324 (2 separate issues)1151 & Ch. 35BUNHearing loss reductions/proposals to reduceScars of head/face/neck with one characteristic of disfigurementTemporary Total musculoskeletal ratingsTemporary Total ratingsAmputation ruleEffective date builderDuplicate special issuesFL 13-17Female Sexual Arousal Disorder (FSAD)Rheumatoid arthritis of the elbowAnalogous codesTwo evals of same body part (knees, etc)

August 2014, Jeff Henderson (Comp Service Quality Review & ConsistencyTeam):EB does not automatically apply Tatum/4.7 to musculoskeletal, eyes or hearing loss.successive/cumulative rating criteria – builds on self – 7913 is the only onerest are non-successive – does not repeat self – good example is 7903and, with, or, semi-colons, commas – mean nothing Judgment is not an error, just explain why you made that decision (one or two

sentences is plenty)For 7913, more than 1 episode of ketoacidosis is considered the same as regulation of activities, per policy staff, and EB will reflect as much

Not using % from EB for Mental

Add after this sentence: “The overall evidentiary record shows that the severity of your disability most closely approximates the criteria for a {} percent disability evaluation.”

A 10 percent is assigned because the DBQ shows a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and A 10 percent is assigned because the DBQ shows mild or transient symptoms, which generally indicates a 10 percent evaluation is warranted. Your functioning is not severely A 30 percent is assigned because the DBQ shows mild or transient symptoms, which generally indicates a 10 percent evaluation is warranted, but there are symptoms sufficient to warrant a 30 percent evaluation. Your functioning is not severely impaired enough to assign a 50 percent evaluation.

A 30 percent is assigned because the DBQ shows occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which generally indicates a 30 percent evaluation is warranted. Your functioning is not severely impaired enough to assign a 50 percent evaluation.

A 50 percent is assigned because the DBQ shows occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which generally indicates a 30 percent evaluation is warranted, but there are symptoms sufficient to warrant a 50 percent evaluation. Your functioning is not severely impaired enough to assign a 70 percent evaluation.

A 50 percent is assigned because the DBQ shows occupational and social impairment with reduced reliability and productivity, which generally indicates a 50 percent evaluation is warranted. Your functioning is not severely impaired enough to assign a 70 percent evaluation.

A 70 percent is assigned because the DBQ shows occupational and social impairment with reduced reliability and productivity, which generally indicates a 50 percent evaluation is warranted, but there are symptoms sufficient to warrant a 70 percent evaluation. Your

W. Rees 110 updated 7/25/18

functioning is not severely impaired enough to assign a 100 percent evaluation.Hypertension at 0% with previously established diagnosis(EB gives verbiage about unconfirmed diagnosis)

o A previously established diagnosis of hypertension with a requirement for continuous medication with currently controlled blood pressure readings (with no history of diastolic pressure predominantly 100 or more).

Evaluating DM even though not specifically claimed

Although you did not specifically claim an increase in your diabetes mellitus type II, you claimed a complication(s)/secondary condition(s) that we are required to evaluate together with diabetes mellitus type II.

“(claimed as…)” III.iv.6.E.6.b – changed 9/15/15, include “(claimed as …)” in the issue so its on the codesheet too [under section #6, which is called “Listing Compensation Rating Codes”]*maximum is 254 characters

Per VA Pulse, https://www.vapulse.net/message/33297, keep claimed as on the codesheet, so it will be in the ADL letter, but with subsequent claims, can remove it from Master Record before addressing issue - Redesigned ADL (RADL), eff 12/11/17 (now sending copy of RD with notification letters AGAIN)

My Notes: If granting, use the diagnosis from the DBQ/TRs & add “(claimed as…)” to the decision line. III.iv.6.E.6.bIf denying, deny as claimed.

The Issue The Issue should always be clean. Do not include “secondary to the service-connected disability of …” or “associated with herbicide exposure.” The issue is service connection, including ALL relevant types of service connection - direct, presumptive, and secondary, not just the ONE type being granted/claimed/denied.

EP 960s

(per AVSCM 7/23/12)

VSR: PCLR the EP 960, as this RD addresses all issues that need to be addressed under the 960.ORVSR: PCAN the EP 960, as all issues are addressed under the 960 but we cannot take the 960 credit because we already have a running EP. ORVSR: This RD does not address the EP 960, and it will be addressed separately.

POA Change

I.3.A – info on POAs

M21-1 I.3.B.2.g. 38 U.S.C. 7332 Authorization – Relationship to the Representatives System Access

To prevent inadvertent disclosure of records protected by 38 U.S.C. 7332, a claimant’s representative may only access VA electronic systems pertaining to the claimant when there is a valid claimant authorization in effect permitting disclosure of all protected records.  

Upon review of a claimant’s VA file, prior completion of a 38 U.S.C. 7332 authorization (already of record) in connection with the representative’s appointment using VA Form 21-22 or VA Form 21-22a remains in effect and is sufficient for purposes of establishing VA electronic system access by a specific representative if:

the form was valid at the time it was received the claimant has explicitly authorized the representative to access records

protected by 38 U.S.C. 7332, and there are no restrictions described by the Veteran. 

The representative may not access VA electronic systems if: the claimant did not provided specific authorization to release all records

protected by 38 U.S.C. 7332 (including cases where the claimant has provided a limited authorization), or

the claimant has revoked the 38 U.S.C. 7332 authorization in writing

M21-1 III.ii.3.C.4.c . Acceptable Versions of VA Form 21-22

VA can accept older versions of VA Form 21-22 until depletion of existing stock in accordance with M21-1 III.ii1.C.8.b.   Follow the guidance in M21-1 III.ii.3.C.4.g., for establishment of representation when an outdated version of the VA Form 21-22 is

W. Rees 111 updated 7/25/18

received.

M21-1 III.ii.3.C.5.d. Updating Electronic Systems to Reflect POA Access to the eFolder

As a reminder, POA electronic access must be granted if a claimant has authorized disclosure to an appointed representative for records protected under 38 U.S.C. 7332 (relating to drug abuse, alcoholism or alcohol abuse, infection with human immunodeficiency virus (HIV), or sickle cell anemia) without limitation.  SHARE must be updated to ensure POA access to the eFolder and then POA access must be also verified in VBMS.

Important:  Authorization to sensitive records is granted by the claimant by checking either Box 12 on VA Form 21-22 or Box 9 on VA Form 21-22a. Use the table below to determine how to update electronic systems to reflect POA access to sensitive information. If the claimant … And … Then …

authorizes a representative’s access with no limitations to records protected by 38 U.S.C. 7332

Share will be used to update VA’s computer systems

select Yes from the drop-down box in the AUTH’D POA ACCESS field on the 101 PENDING ISSUE/CORPORATE CONTROL ESTABLISHMENT screen.

VBMS will be used to update VA’s computer systems

click on the VETERAN down arrow on the VETERAN PROFILE screen

select POA, and place a check mark in the

ALLOW POA ACCESS TO DOCUMENTS box.

indicates any limitation to or does not authorize a representative’s access to records protected by 38 U.S.C. 7332

Share will be used to update VA’s computer systems

select No from the drop-down box in the AUTH’D POA ACCESS field on the 101 PENDING ISSUE/CORPORATE CONTROL ESTABLISHMENT screen.

VBMS will be used to update VA’s computer systems

click on the VETERAN down arrow on the VETERAN PROFILE screen

select POA, and ensure the ALLOW POA

ACCESS TO DOCUMENTS box is blank.

 Important:  A PIF CHANGE is necessary to update disclosure of records when: there is a pending claim, and representation is changed via the BIRLS system *Note:  Details regarding POA access are viewable in Share via: the All Relationship screen using Corporate Inquiry, and the General Information screen under Awards/Ratings

References:For more information on:

executing a PIF CHANGE to update POA, see Step 4 of M21-1 III. ii.3.C.5.b. using Share to allow POA access to the eFolder when no EP is pending, see

M21-1 III.ii. 3.C.5.e.

W. Rees 112 updated 7/25/18

claims establishment, see M21-1 III.ii.3.D.2, andrecords protected by 38 U.S.C. 7332, see M21-1 I. 3.B.2

Service incomplete

III.ii.1.A.2.a

III.ii.3.C.7

Update service information in SPP/Participant Profile, then in SHARE with BIRLS Update, then do “Refresh Profile” in VBMS-R.

June 2015 Quality Call Notes – the above is still correct.

If you are a WAH & do not have access to Participant Profile through the START menu, you likely have access through the Terminal Server/Citrix, https://citrixaccess.va.gov 

Click on Log OnClick on DESKTOPSClick on R05 - VBApp DesktopClick OKIt may take a few minutes, will say “Welcome” then “Please wait for the Citrix Profile Management,” then several other messages while it’s preparing the desktopWithin the desktop, click on START, type in “Participant” & it will pull up “Participant Profile T11,” click on that, click OKEnter 377, then click on PIV Card Only, click on your name, enter your PIN [or log-in with username & password]

End Product (EP) or Claim Label incorrect(formerly PIF / PIF Change)

*Pencil icon / “Update Claim Details” in VBMS

Then, in VBMS-R, do “Claim Association”

Note to File: I did "Update Claim Details" in VBMS & changed the EP & Claim Label from "020NEW - New" to "020CLMINC - Claim for Increase.”

*Don’t need to change 110 to 010 or vice versa, eff 10/30/17 (see M21-4, Appendix B, November 2017 Quality Call Notes & December 2017 Quality Call Notes)

110 options:

010 options:

W. Rees 113 updated 7/25/18

020 options:

I’ve also seen this (which doesn’t come up as an option for me, so must be just a system option for electronic claims):020 - eBenefits 526EZ-Supplemental (020)

W. Rees 114 updated 7/25/18

EFFECTIVE DATES – a great effective date resource is RVSR Assistant

3.400 General (2/6/97, 3/24/15)

III.iv.5.C – added 9/22/17, Wright v. Gober (1997) says “date entitlement arose” similar to “facts found”; III.iv.5.C.2 – ITFs; III.iv.5.C.3 – direct & secondary (incl non-continous service & DVA period); III.iv.5.C.4 – presumptive; III.iv.5.C.5 – CFIs (incl IU & complications); III.iv.5.C.6 – reopened claims; III.iv.5.C.7 – 3.114;

III.iv.6.E 3.151 3.156 3.400(g) – Correction of military records (i.e. discharge upgrade)

USB Letter 20-98-2 (2/27/98)

GC 88-90, 19-92, 9-94, 10-94, 26-97, 11-97, 11-99 & 3-2000 VAOPGCPREC 12-98 (9/23/98) – “the effective date for increased disability compensation is the date on

which the evidence establishes that a veteran’s disability increased, if the claim is received within one year from such date. The effective date of an increased rating would be the date of claim only if the claim is not received within the year following the increase in disability, as explained in Harper.” AND “the effective date of an increased rating based upon new and material evidence received within the appeal period or prior to an appellate decision is the date on which the facts establish the increase occurred or the date of the original claim for increase, whichever is later.”

Lalonde v. West (5/11/99) - TRs not informal claim for secondary condition, but if an informal claim is filed, we will treat it like a claim for increase (and the date of treatment can be used for the effective date)

Sears v. Principi (8/20/02) - “new claim” under (q)(1)(ii) refers to a claim to reopen a previous & finally denied claim

RULE: effective date for pension, compensation, and DIC, for original, reopened after final disallowance, or increase is “the date of receipt of the claim, or the date entitlement arose, whichever is the later.”EXCEPTIONS: pension may not be prior to date entitlement arose, and effective date is date of receipt of claim, unless the veteran became P&T w/i 1 year prior to the date of claim for retroactive benefits, and could not file a claim for the first 30 days immediately following the date he/she became P&T, then we can pay from date became P&T (unless that is to the veteran’s disadvantage); III.iv.6.B, V.ii.1.B

direct SC can also be day following separation from active service, or date entitlement arose (if rec’d w/i 1 year after separation)pres SC can also be date entitlement arose (if rec’d w/i 1 year after separation)increases can be the earliest date it is factually ascertainable that an increase occurred if the claim is rec’d w/i 1 yearreopens can be “as though the former decision had not been rendered” if N&M evid is rec’d w/i the appeal period or prior to the appellate decision; or the date of receipt of the new claim (claim to reopen a previously & finally denied claim, per Sears case) or date entitlement arose if N&M rec’d after final disallowance

USB Letter dated 2/27/98:“reopen” does not refer to increase for an SC cond, 3.400(q)(1)(i) only refers to a previously denied claim for SC, N&M only refers to a previously denied claim for SC & we will only go back to prior claim “as though the former decision had not been rendered” for previously denied claims.

If an increase is correctly denied, then TRs/new claim comes in which shows increase, we will use trs/new claim as effective date, we will NOT go back to the prior claim just because the claim was continuously prosecuted, as that only refers to previously denied claims & increases are under 3.400(o)(2) - III.ii.2.E.3.c shows we can apply 3.400(q)

However, if new evid comes in which shows an increase, we will use that evidence for effective date (which can be before DOC), based on the facts.

Notes from March 2012 Effective Date Training:

W. Rees 115 updated 7/25/18

(http://cptraining.vba.va.gov/C&P_Training/RVSR/rvsr_man.htm)-

1. Issue (What is the issue: Service connection, entitlement to pension, or claim for increased evaluation?)2. DOC (What is the date of receipt of the claim?)3. Entitlement (What is the date basic entitlement arose?)4. 3.114 (Do any liberalizing laws apply?)

M21-4 Appendix B – guidance on EP 930s, updated per October 2015 Quality Call NotesIII.ii.4.G.2.m – need permanent, claim-associated note explaining why establishing a 930 & if it’s a correction (include specific correction action taken, date of action taken & station # that took the action) [also says need rationale for changing DOC of an EP]

November 2017 Quality Call Notes - 110/010 is based on original application (do not need to change if # of issues changes during lifetime of claim)

Notes from August 2013 Training Provided by Central Office by RQRS Challenge Instructors on SD’s “other” category has the highest error rate

Informal claims – 3.155 – formal claim has to be received within 1 year of our letter to them; must identify benefit sought (i.e. describe nature of disability); if no disability described, need to send letter asking what claiming (do not send the informal claim letter, if informal claim letter sent need to tell veteran the letter was sent erroneously)

Even if treatment is paid for by DoD or VA, records are not considered Federal because they are not in Federal custody.

The increased manifestation (i.e. addition of Metformin) has to be shown within one year in PMEs. 3.400(o)(2) says “factually ascertainable that an increase in disability had occurred if claim is received within 1 year from such date.” Continuation on Metformin within one year of the claim is not sufficient to go back to the date within on year of the claim.

Notes from January 2014 Effective Dates Training (John Trunick):

General rule is fall back, if no other rule is provided.

1. What is issue? (SC? CFI? “original” or “non-original”)2. What is the date of receipt of the claim?3. What is the date entitlement arose?4. Do any liberalizing laws apply? (3.114)

New nomenclature for types of claims. “Disability” claim is TU or Temp 100%, then “SC,” “Death,” “Subsequent” (N&M or CUE) claims. Also have “Other” (1151 [can pay from date of injury if claimed within one year], CFI, 3.114 [can pay one year prior to date of Admin review], additional records received [Fed or Svc Dept], reductions.

3.155, Informal claims must “identify benefit sought” – need nature of disability (identify the body system or part or symptoms; or attach records, to include DBQ). If benefit not identified, but VSRs accept as informal claim, may be able to use that date…

N&M cases – Leonard v. Principi (2004), Sears v. Principi (2002), Flash v. Brown (1995)

Secondary issues are conditions, not disease process – have to be claimed, effective date is date of claim or date entitlement arose, use 3.400(b). Cannot apply 3.157 (it’s not a worsening). Worsening is part of the disease process like radiculopathy/neuropathy related to the spine or diabetes common complications: cataracts (My Notes: I think he means retinopathy, per the DBQ), peripheral neuropathy & nephropathy). Use 3.400(o) & potentially 3.157. – Carlos Rosario says radiculopathy related to the spine is not a disease process, not worsening, but RVSR Assistant says it’s a common complication & the 2/9/17 change to III.iv.4.A.5.a confirms “spinal disease can cause objective neurological abnormalities, onset of a neurological complication represents medical progression or worsening of the spinal disease.  For that reason and because neurological complications of spinal disease are contemplated in the evaluation criteria for spinal conditions under 38 CFR 4.71a, a claim asserting new complications of spinal disease is a claim for increase rather than a claim for secondary SC”; we can do the date of factual entitlement (if the claim is received within one year) or with VA / military hospital / Military Treatment Facility / MTF TRs, we can use the date of admission/exam as the date of claim [examples are stroke as medically-known common complication of hypertension and PVD as medically-known common complication of DM] *Note that November 2013 Compensation Service Bulletin (CSB) says effective date for stroke/CVA & nephrosclerosis & myocardial damage/coronary occlusion (conds listed at III.iv.4.G.3.g) is date of claim or date entitlement arose, cannot

W. Rees 116 updated 7/25/18

apply 3.157 or 3.400 (it’s not a worsening of hypertension)

3.400 – can go back 1 year if increase is “factually accertainable.” 3.157 – VA or Military Hospital / Military Treatment Facility / MTF records – can go back more than 1 year; Private limited to 1 year by 3.400. 3.157 – can infer CFI or reopen with VA or Military Hospital / Military Treatment Facility / MTF records (if don’t have actual claim from veteran) & date of claim is the date of receipt of the VA or Military Hospital / Military Treatment Facility / MTF records [i.e. have a claim for something else, but receive records for SC cond or previously denied condition, can use those records to grant increase, or reopen claim if they are N&M]. A claim for diabetes includes a claim for all complications. Ellington v. Nicholson, December 2008 Compensation Service Bulletin (CSB), March 2009 Compensation Service Bulletin (CSB), January 2011 QA Times

FDC claims – for original claims rec’d 8/6/13-8/5/15, can pay up to 1 year prior to receipt of claim

DIC effective date is first day of month of death

Symptoms of a potential secondary condition at VAE (veteran says L hip hurts secondary to SC L knee & examiner gives positive secondary opinion – can be considered informal claim

Fully Developed Claims (FDC) Refresher Training

38 CFR 3.114 Effective Date CriteriaIf the claim does not meet the FDC program requirements, you should assign an effective date under the 38 CFR 3.114 Liberalizing Law guidelines, when applicable. Specifically, if the claimant met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue, then apply 38 CFR 3.114 as follows:

If claim is reviewed... Effective date

On the initiative of the VA within one year from the effective date of the law or VA issue

Date that the law or issue was authorized

On the initiative of the VA more than one year after the effective date of the law or VA issue

One year prior to the date of administrative determination of entitlement

At the request of the claimant more than 1 year after the effective date of the law or VA issue

One year prior to the date of the receipt of the request

Notes from October/November 2014 Effective Dates & FDC Refresher Training (Erin Walsh):

If files informal FDC (III.i.3.A.2.j says should be “incomplete FDC” instead of “informal FDC”) prior to 8/6/13, but files formal FDC claim after 8/6/13, can give 1 year prior to receipt of the FORMAL claim

Brokowski v. Shinseki (2009) - [March 2014 Compensation Service Bulletin (CSB) & January 2015 Rating Quality Call Notes say Brokowski applies to all 020s, including informal FDCs (III.i.3.A.2.j says should be “incomplete FDC” instead of “informal FDC”)]

W. Rees 117 updated 7/25/18

FDC Effective Dates ANSWERS1. EOD: 7/13/2003, RAD: 7/17/2012; 110(p), 526 received on 9/1/2013Vet claimed service connection for right shoulder condition. STRs are silent for treatment for right shoulder condition or injury. Vet submitted Kaiser private treatment records containing X-ray report, dated 1/14/2013 showing right shoulder osteoarthritis. Vet’s private physician prepared a statement indicating Vet has weakness and pain with movement. Shoulder DBQ shows full range of motion with pain on movement. What is the effective date for the right shoulder OA?9/1/13 (if claimed 6/1/13, eff 1/14/13)

2. Air Force Vet, RVN service confirmed by DD Form 214; EOD: 7/13/1962, RAD: 9/17/1967; 020(p), 4138 received on 3/1/2014Vet submitted a VAF 4138 on which Vet claims diabetes. Vet submitted private treatment records showing diagnosis of DMII, dated 7/13/1990. Veteran was prescribed Metformin on 4/1/1997. Vet failed to report for VAE.What is the effective date for DMII?3/1/13

3. EOD: 7/13/2003, RAD: 7/17/2013; 110(p), 526 received on 1/5/2014Vet claimed service connection for GERD. STRs show treatment for acid reflux and EGD confirmed GERD on 3/15/2007. Vet prescribed Prilosec in service. VA exam, dated 3/1/2014, shows diagnosis of GERD with symptoms of regurgitation and pyrosis. What is the correct effective date for GERD?7/18/13

4. EOD: 7/13/02, RAD: 9/17/07; 110(p); Vet submitted VAF 4138 on 4/13/2013, on which Vet claims service connection for right knee strain. VAF 526EZ was received on 9/1/2013. STRs show repeat treatment for right knee sprain. VA exam, completed on 11/15/2013, shows diagnosis of right knee patellofemoral pain syndrome. VA examiner opined that Vet’s current disability is a progression of the right knee condition treated in service.What is the effective date?9/1/12

5. RVN service confirmed by DD Form 214; EOD: 7/13/1962, RAD: 9/17/1967; 110(p)

W. Rees 118 updated 7/25/18

VAF 4138, received on 5/1/2012, Vet claimed CLL. VA letter, dated 10/01/2012, informed Vet that submission of a completed 526 was needed to substantiate his claim. VA Form 526, received on 5/26/2013, Vet claimed right shoulder condition, CLL, depression. STRs are unavailable and Vet submitted only one document in support of claim. Document received shows Vet was diagnosed with CLL on 7/1/2010. An interim decision is needed. What is the effective date for CLL?5/1/12

6. RVN service confirmed by DD form 214; EOD: 7/13/1962, RAD: 9/17/1967; 110(p)Vet submitted VAF 4138 on 4/13/2013, on which Vet claims service connection for multiple myeloma. VAF 526EZ, received on 9/1/2013, with private treatment records showing an initial diagnosis of multiple myeloma on 1/1/2013. VA exam, completed on 11/15/2013, shows diagnosis of multiple myeloma. What is the effective date for the multiple myeloma?1/1/13

7. Air Force Vet, RVN service confirmed by DD Form 214; EOD: 7/13/1962; RAD: 9/17/1967; 110(p), 526EZ received on 3/1/2014Vet submitted a VAF 526EZ on which Vet claims diabetes. Vet submitted private treatment records showing diagnosis of DMII, dated 7/13/1990. Veteran was prescribed Metformin on 4/1/1997. What is the effective date for DMII?3/1/12

From TMS assessment:The Veteran served 30 years in the Army, retiring on March 30, 2008. On November 29, 2008, he suffered a massive coronary and died. In December 2008, the Veteran’s spouse submitted a claim for Dependency and Indemnity Compensation (DIC) and was denied for failure to prosecute. On September 2, 2009, the spouse again submits a claim for DIC and is granted DIC benefits. What is the effective date of this award? 11/1/08, first day of the month of death

The Veteran claimed service connection for amyotrophic lateral sclerosis in June 1986, with private treatment records indicating a diagnosis of amyotrophic lateral sclerosis in May 1986. He was denied service connection. He reopened his claim on November 1, 2008 and service connection was granted. What is the effective date of this award? 9/23/08, the date ALS was added

Veteran meets the wartime service requirement for disability pension. On April 6, 2004, she files a claim for disability pension. The documentation in her private treatment record dated February 2004 demonstrates that she meets the requirements. What is the effective date of this award? 4/6/04, date of receipt of claim

The Veteran discharged 05/31/2011, she filed her original claim on 07/19/2011. Her gen med exam on 09/16/2011 had shown she had urinary incontinence (which was also found in her STR’s, not on 526). The claim was then brokered and rated on 04/15/2013 with an auth note to invite claim for urinary incontinence and the notification was sent 05/02/2013. The Veteran filed for urinary incontinence 03/05/2014, file was reviewed and annotated for the C&P exam, the doctor came back with a positive opinion. What is the appropriate effective date? 3/5/14, date of receipt of claim [but IU can go prior to DOC if invited/solicited]

A Veteran served 20 years in the Army and retired on December 30, 2009. On June 29, 2010, the Veteran suffered a massive coronary and died. The Veteran's spouse submitted a claim. What is the effective date rule that governs this claim? First of the month of the month of death

A Veteran’s initial claim for service connection was denied on December 12, 1992, due to lack of records to substantiate the claim. On May 16, 2009, VA received recently declassified records that allow for service connection to be granted. What CFR section provides the rule for the effective date for this claim? 3.156

The surviving spouse has been receiving Death Pension benefits since May 1, 1990. The VA receives an Aid and Attendance claim on July 10, 2003. The RVSR determines that private treatment records dated June 26, 2003 prove the need for Aid and Attendance. What is the effective date? 7/10/03

Which of the following rules applies to the effective date for claims based on injury due to hospitalization (38 USC 1151 claims)? Select all that apply. Date of injury, if received within one year AND Date of receipt of claim

H:\VSC\Training\NTC Class Material\Effective Dates\Effective Dates 3950443HO (2015).pdf

Notes from November 2015 Effective Dates Training (Carlos Rosario):

as of 3/24/15, need to set a diary if hospital report shows no entitlement to 4.29 or 4.30, but does show increase warranted, but have no claim, per III.ii.2.C.6.d; for why, see VA Pulse, https://www.vapulse.net/message/27432

W. Rees 119 updated 7/25/18

as of 3/24/15, what we previously called an informal FDC (III.i.3.A.2.j says should be “incomplete FDC” instead of “informal FDC”) is now a Request for Application (RFA)

submission of an ITF under the FDC program is not an exclusion

prior to 3/24/15, if filed informal claim for an original claim (Brokowski does not apply), then submitted formal application, then added another contention after submitting the formal application, the effective date of the informal claim applies to ALL contentions

if find records prior to 3/24/15, can use 3.157 to apply date of increase in records; but if records are 3/24/15 or later, have to have evidence of increase within a year prior to the claim

a claim for tinnitus is NOT a claim for hearing loss

can use TRs for increase if receive either (1) claim on prescribed form or (2) ITF followed by complete claim (w/I 1 year of ITF), within 1 year of date of treatment

if new ship added to AO ship list & can now grant, use DOC of previously denied claim as effective date (similar to supplemental STRs / missing STRs or SPRs & declassified info)

From: VAVBASDC/RO/VSC Sent: Friday, May 11, 2018 10:17 AMSubject: Q-Tip: Considerations when determining effective dates

Q-Tip:  Considerations when determining effective datesTarget Audience: RVSRs/DROs:The Live manual was updated on September 22, 2017 to include a specific area which discusses general principles when determining the correct effective date for rating purposes.  An update to this section was completed on January 2, 2018.  The section of the manual which provides this guidance is M21-1 III.iv.5.C.This section contains information in line with 38 CFR 3.400, and also includes additional guidance when considering entitlement to benefits under historical 38 CFR 3.157 and 3.155.

For your convenience, this section of the manual has been attached for your review/reference.  Please note the guidance provided in this section will not be all inclusive to address every scenario; however, additional assistance/guidance can be provided by your team SME or QRT liaison as necessary.

For any questions relating to this topic, please contact your team SME or QRT liaison.

3.114 Change of law or Department of Veterans Affairs issue – can pay benefits from the effective date of the law or VA issue if the claim is reviewed within 1 year of the effective date, can pay benefits from 1 year prior to the date of administrative determination of entitlement if the claim is reviewed more than 1 year after the effective date; veteran has to have the condition at the date of the change in the law to go back to the law change or give 1 year prior (also applies to secondary conditions- have to have them at the date of the change in the law to go prior to DOC)

effective dates for increase under new evaluation, per 3.114: date of the change in the law, if filed within one year of change one year prior to DOC, if filed more than one year after change

Part 4 changes – Appendix A, III.iv.7.B & 3.951, http://vbaw.vba.va.gov/bl/21/publicat/Regs/Part4/Changes/11-12-08.doc

III.iv.5.C.7 - III.iv.5.C.7.n Effective Dates Based on Judicial Precedents

IV.ii.2.K.6 GC 88-90- 3.114 does not apply to GC opinions

GCs 10-94 & 9-94- 3.114 does not apply to Court Cases

GC 11-99-

limitations on the meaning of what constitutes “liberalizing laws or issues” in 38 CFR 3.114, GC opinion not included

GC 3-00

W. Rees 120 updated 7/25/18

Nehmer v. US Veterans Administration- early effective date with herbicide exposure

Karnas v. Derwinski (6/11/91) - Where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to an appellant applies unless Congress provided otherwise or permitted the Secretary to do otherwise and the Secretary did so.

VAOPGCPREC 7-2003 (11/19/03) - Kuzma v. Principi overruled Karnas v. Derwinski so that when a new statute is enacted or a new regulation is issued while a claim is pending before VA, VA must first determine whether the statute or regulation identifies the types of claims to which it applies. If the statute or regulation is silent, VA must determine whether applying the new provision to claims that were pending when it took effect would produce genuinely retroactive effects. If applying the new provision would produce such retroactive effects, VA ordinarily should not apply the new provision to the claim. If applying the new provision would not produce retroactive effects, VA ordinarily must apply the new provision. As a general matter, rules announced in judicial decisions apply retroactively to all cases still open on direct review when the new rule is announced. Statutes and regulations, in contrast, are presumed not to apply in any manner that would produce genuinely retroactive effects, unless the statute or regulation itself provides for such retroactivity. In VAOPGCPREC 11-2000, we concluded that all of the VCAA's provisions apply to claims that were filed before November 9, 2000, but had not been finally decided as of the date. Because VA's August 2001 final-rule notice amending 38 CFR 3.159 expressly and validly provided that VA's regulations implementing the VCAA will apply to all claims that were pending before VA as of November 9, 2000, any further reliance on VAOPGCPREC 11-2000 is unnecessary. We hereby withdraw VAOPGCPREC 11-2000.

Liesegang, et al, 12/10/02.  Federal Circuit case, 312 F.3d 1368, 1374-75 says:

Liesegang, et al v. Secretary of Veterans AffairsOn December 10, 2002, the US Court of Appeals for the Federal Circuit issued a decision in the case of Liesegang, et al v. Secretary of Veteran Affairs.  The Court held that the correct effective date for our regulation adding Type 2 diabetes to the list of presumptive disabilities related to herbicide exposure is May 08, 2001, instead of July 9, 2001.

As a result of that decision, VA issued an automatic one-time adjustment to 9,340 Veterans granting an earlier payment date of June 1, 2001. The one time payment was made on August 4, 2003.  In each adjusted case a notice was issued to the Veteran, POA, and RO.   An additional 4,680 cases were manually reviewed.  When reviewing the current Nehmer cases that may have previously involved Type 2 diabetes you must assure that this adjustment was actually made.  This may require a thorough review of the claims folder.  It is important that the Veteran gets paid correctly when entering the information into the prior payment field in VETSNET for retroactive awards.

October 2014 Rating Quality Call Notes –

Scenario: A Veteran with verified in-country service in Vietnam submits an original claim for service connection for Type 2 diabetes mellitus (DM) on January 1, 2014, along with evidence dated January 1, 1999, showing confirmed diagnosis of diet-controlled DM. A VA examination (VAE) conducted on February 3, 2014, shows the Veteran uses insulin.

Should you grant 10% from January 1, 2013, then increase to 20% on February 3, 2014? Or, should you grant 20% from January 1, 2013? In addition, what date would be used if the claim was submitted with evidence showing insulin was started on January 3, 2005?

Per 38 CFR 3.114(a)(3), a one year retroactive effective date is warranted, which would be January 1, 2013, in this scenario

10% warranted from January 1, 2013, since the evidence showed only diet-controlled DM, then assign

20% from date of exam, February 3, 2014, the first time the evidence showed a higher level of care was warranted

If evidence dated January 3, 2005, shows the Veteran met the 20% criteria, then 20% would be granted from January 1, 2013, with no staging

January 2015 Rating Quality Call Notes –

Question: If an informal claim is received and is properly formalized for a condition that qualifies for a retroactive payment under 38 CFR 3.114, should you calculate the effective date by using the informal date of claim (DOC) or the formal DOC? Answer: The 3.114 rules should be applied using the informal DOC.

W. Rees 121 updated 7/25/18

3.1 Definitions – (d) veteran- “discharged or released under conditions other than dishonorable”- also see 3.12; (p) (11/4/96) claim/application- “formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit,” (y) former prisoner of war- see reg

DIRECT SERVICE CONNECTION

Claim Received Within 1 Year of Release from Active Duty (RAD):

Effective Date(STRs include evidence of in-service incurrence)04/09/12

RAD Date of Claim04/08/12 08/08/12

Claim Received After 1 Year of Release from Active Duty (RAD):

Evidence Meets Criteria to Establish Entitlement to Service Connection

Effective Date 06/08/13

RAD Date of Claim04/08/07 06/08/13

Evidence Does Not Meet Criteria to Establish Entitlement to Service Connection

Effective Date(Date Entitlement Arose)07/30/13

RAD Date of Claim Medical evidence showing intial diagnosis of 04/08/07 (No Evidence of Current Disability) Disability on 07/30/13

06/08/13

PRESUMPTIVE SERVICE CONNECTION

Claim Received Within 1 Year of Release from Active Duty (RAD):

Effective Date(Date Entitlement Arose)07/04/11

RAD Date a 3.309(a) condition Date of Claim04/08/11 manifested to a compensable degree 01/08/12

07/04/11

Claim Received After 1 Year of Release from Active Duty (RAD):

Effective Date09/08/13

W. Rees 122 updated 7/25/18

RAD Date a 3.309(a) condition Date of Claim04/08/11 manifested to a compensable degree 09/08/13

07/04/11

3.114 Claim Received Within 1 Year of change in law:

Effective Date(Date of Change in Law)08/31/10

Diagnosis of Date of Law Change Date of ClaimDisability 08/31/10 09/30/1008/09/09

3.114 Claim Received After 1 Year following change in law:

Effective Date(One year prior to date of claim)09/30/11

Diagnosis of Date of Law Change Date of ClaimDisability 08/31/10 09/30/1208/09/09

Nehmer Claim Based on Herbicide Disability Added to 38 CFR 3.309(e):

Effective Date08/08/86

Diagnosis of Date of Claim Date of Denial Date of Reopened ClaimHerbicide Disability 08/08/86 09/30/87 05/30/0808/09/82

SECONDARY SERVICE CONNECTION

Effective Date(General Rule Applies)03/27/13

SC Established Additional Date of Claim for VA Medical Opinion of CausalFor Primary Disability Disability Secondary SC Relationship Between Disabilities11/22/99 Diagnosed 03/27/13 09/22/13

08/20/03

REOPENED CLAIMS BASED ON NEW AND MATERIAL EVIDENCE

Claim Received With N&M Evidence Other Than Service Department Records:

W. Rees 123 updated 7/25/18

Effective Date(receipt of new claim or date entitlement arose, whichever is later)05/06/13

Date of Previous Decision Final Date of Reopened VA Exam with Denial 05/03/05 Claim with N&M Evidence Positive Opinion05/03/04 05/06/13 08/02/13

Claim Reopened Based on Additional Service Treatment Records:

Effective Date(based on original claim)05/03/56

Date of Claim Date of Denial Additional STRs Received from Service Dept05/03/56 06/30/57 05/30/13

INCREASED COMPENSATION BENEFITS

Claim For Increased Evaluation Received Within 1 Year of Increased Disability (Based on Private or VA Treatment Records):

Effective Date(date it’s factuallyascertainable that disability increased)09/08/12

Date of Grant of Medical Record of Date of Claim for IncreaseSC for Knee Disability Total Knee Replacement (within one year of TKR)08/20/02 09/08/12 05/06/13

Claim For Increased Evaluation Received More Than 1 Year After Increased Disability, Based on Private Treatment Records:

Effective Date(date of claim > 1 year)12/15/12

Date of Grant of Private Medical Record of Date of Claim for IncreaseSC for Knee Disability Total Knee Replacement 12/15/1208/20/02 09/08/07

Under historic 3.157 rules: Claim For Increased Evaluation Received More Than 1 Year After Increased Disability, Based on VA Treatment Records:

Effective Date(date it’s factually ascertainable that disability increased)09/08/07

Date of Grant of VA Medical Record of Date of Claim for IncreaseSC for Knee Disability Total Knee Replacement 12/15/1208/20/02 09/08/07

W. Rees 124 updated 7/25/18

FDC Claim and Proper Application of the Provisions of Section 506 of PL 112-154:

Effective Date(evidence of record confirms severity justifies eval and date per PL)09/01/12

Veteran begins process of Online application submitted Rating decision granting SCfiling original, fully developed to VA – accepted as complete, and notes 30% level justified forclaim for service conection formal FDC for several yearsthrough VONAPP 09/01/13 12/12/1301/03/13

Effective Date(Veteran filed a formal claim within one year of informal claim andthere is no diagnosis of dsability until 09/13/13)09/15/13

Letter from VSO declaring Private medical evidence with Completed 21-526EZ submittedVeteran’s (with service in RVN FDC claim shows an initial to VA-claim for DMII andverified) intent ti file an original diagnosis of DMII on accepted as complete, formalClaim for benefits 09/15/13 FDC 02/15/13 03/30/14

From JRVSR Certification Boot Camp Notes (December 2012) –

Practice Questions

1.) Navy Veteran served from 4/1/1996-10/8/2012. VA form 21-526 was received on 8/4/2012 on which Veteran claimed service connection for tinnitus and hearing loss. Veteran showed no hearing loss in service but complained of tinnitus on several occasions. Veteran failed to report for audio VA exam. Veteran submitted private audiogram, dated 12/1/2012, on which Veteran is diagnosed with sensorineural hearing loss which would equate to 30 percent for VA purposes and tinnitus.

Please rate the case above:

Tinnitus: grant/deny/infer/deferIf grant, how service connected? Direct/presumptive/secondary/aggravatedIf grant, what is the effective date? 10/9/2012

Hearing loss: grant/deny/infer/deferIf grant, how service connected? Direct/presumptive/secondary/aggravatedIf grant, what is the effective date? 12/1/2012

2.) Army Veteran served from 7/4/1965 – 7/5/1969 and had service in RVN. Veteran faxed his original 526 to the Reno VAMC on 5/1/2009. The 526 was received at RMC on 6/7/2009. The 526 was received at VFW in Los Angeles on 10/7/2010. The 526 was received and date-stamped in the San Diego VARO file room on 11/4/2010.

What is the correct CEST date?

a.) 5/1/2009b.) 6/7/2009c.) 10/7/2010

W. Rees 125 updated 7/25/18

d.) 11/4/2010

3.) Veteran submitted an informal claim that was received on 4/1/2008. Veteran reported on informal claim that he would submit a claim in the future after he gathered private treatment records. VA letter, dated 4/6/2008, sent Veteran a VA Form 21-526. Original VA Form 21-526, received on 3/17/2009, claims tinnitus and sinusitis for service connection.

What is the CEST date? 3/17/2012, date of receipt of formal claimWhat is effective date for grants? 4/1/2008

4.) Veteran submits a claim to reopen his previous claim for hearing loss and a new claim for DMII, received on 7/4/2012. DD Form 214 shows Veteran served in Vietnam. Kaiser Permanente records show Veteran was diagnosed with DMII on 4/17/1999 and coronary artery disease on 7/12/1999. VA exam, completed on 9/28/2012, shows diagnosis of DMII and diagnosed peripheral neuropathy of the lower extremities at a mild level as secondary to DMII. VA examiner stated CAD is not related to DMII.

Rate the claim.

Diabetes: grant/deny/infer/deferIf grant, how service connected? Direct/presumptive/secondary/aggravatedIf grant, what is the effective date? 7/4/2011

Coronary artery disease: grant/deny/infer/deferIf grant, how service connected? Direct/presumptive/secondary/aggravatedIf grant, what is the effective date? issue not claimed, so we will solicit as evidence supports a grant

Peripheral neuropathy: grant/deny/infer/deferIf grant, how service connected? Direct/presumptive/secondary/aggravatedIf grant, what is the effective date? 7/4/2012

DISCUSSION WITH THIS QUESTION:

QUESTION: Please read the rest below. I don’t understand why a separately compensable disability covered by 7913 would not have an earlier effective date when it’s consider a part of the original service connected condition.

Reference: We no longer generally treat a claim for secondary service connection like a claim for increase. We cannot go earlier than the date of claim except for issues such as complications of diabetes where the evaluation criteria of DC 7913 includes the presence of complications as a determinant of the proper evaluation.

ANSWER: The issue is that the diabetes effective date is dictated by 3.114 in this instance. Since this is the original grant of service connection for diabetes, the grant for complications can’t go back further than the date of claim. It’s the same concept as receiving an original claim, with which the Veteran included PMEDs showing treatment for the claimed sinusitis since 1989. You wouldn’t grant service connection back to 1989, these treatment records only serve to show continuity, they do not establish entitlement to an earlier effective date.If the diabetes were previously service-connected, and PMEDs dated within one year showed a diagnosis of peripheral neuropathy, then en earlier effective date would be warranted.

HOWEVER, August 2013 Training Provided by Central Office by RQRS Challenge Instructors on Effective Dates - instructor said we can grant prior to date of claim for secondary conds based on 3.114.

W. Rees 126 updated 7/25/18

in March 2016, Carlos Rosario said “when we had training from Quality Assurance, at the time, they were not in agreement how to apply 3.114 to the secondary conditions” & “In the field, we have generally staged the rating after the service connection date, as long as we  have evidence that it pre-existed the date of claim.” He also stated that in the JRVSR Cert example “The diagnosis of diabetes was 4/17/99. Kaiser Permanente records did not show any complications. The scenario is saying peripheral neuropathy was diagnosed at the VA exam dated 9/28/12. So the effective date for the secondary condition is the date of claim, 7/4/12.”

5.) Master record shows Veteran with the following:Bilateral hearing loss0% from 1/13/1968

Tinnitus0% from 1/13/1968

Head injury 10% from 1/13/68 [COMBAT]

Combined 10% from 1/13/1968

Veteran submitted a claim for PTSD and TBI on 8/3/2012. Upon review of the Loma Linda VAMC treatment records, Veteran reported numerous complaints of ringing in the ears from 4/1998 to 8/2000 and continued complaints to the present. Veteran had a TBI exam, dated 7/1/2008, on which his VA physician noted the following symptoms: mild memory loss, moderate headaches, and poor attention and concentration.

When rating, what issues will need to be addressed?Rate PTSD as it was an expressed claim, grant earlier effective date for TBI to 10/23/2008, date of law change, as VA evidence shows increased severity & increase tinnitus to 10% as of 6/10/1999, date of law change as VA evidence shows an increase in severity at the time of the law change.

6.) Veteran was Med-Boarded out due to PTSD and Right knee arthritis.

Will you grant Voc Rehab benefits? Why? YES, 4.129, minimum eval for separation due to stress is 50%What is the minimum combined evaluation for service connection? 50%

7.) Rating Decision, dated 10/1/2011, granted service connection for prostate cancer at 100 percent. Veteran has claimed an increase, received on 11/7/2012, for prostate cancer to include voiding dysfunction that requires changing of absorbent material 4 times per day. VA exam, completed on 11/18/2012, shows Veteran underwent a total retropubic prostatectomy at the Long Beach VAMC on 9/17/2012. VA exam findings show that Veteran requires changing of absorbent materials 4 times daily and nighttime voiding more than 5 times.

Rate the claim.You will continue Veteran’s 100 percent evaluation for prostate cancer as Veteran underwent a prostatectomy. This will continue 6 months after date of procedure; therefore, til 3/17/2013. Prior to that date, we should obtain a new examination to obtain current residuals, but in your Rating Decision you will continue the 100 percent and propose to reduce to 60 percent. The 60 percent is warranted based on the 11/2012 examination findings.

8.) You are the Comprehensive Screener and review of the file to determine if it is ready to rate. Upon review, you see that the Veteran is service-connected for CLL presumptive for AO exposure with a routine future examination that is now 2 months overdue. What action should you take?

W. Rees 127 updated 7/25/18

Per TL 06-05 (see excerpt below*), no routine future examination (RFE) should have ever been scheduled. As a result, the appropriate action to take would be to cancel the diary for the RFE, and call a CUE to grant entitlement to Chapter 35 back to the effective date of the grant of service connection for CLL.

*CLL is evaluated under diagnostic code 7703, leukemia. CLL is different from the majority of leukemias because although it may have treatment phases throughout the course of the disease it does not have an inactive phase.

W. Rees 128 updated 7/25/18

MISC RATING NOTES -

RED = presumptive under 3.309(a)BLUE = POW presumptive under 3.309(c)ORANGE = Agent Orange presumptive under 3.309(e)AQUA = Mustard Gas presumptive under 3.316GREY = associated with Asbestos

SPECIAL OPERATIONS / SPECIAL OPS / SPEC OPS / SPECOPS

III.ii.3.D.7.a has segmented lane assignment criteria from 6/30/15, deleted on 3/18/17 update

Eff February 2016 (in anticipation of the NWQ), ONLY MST, POW & NEHMER are SpecOps to be worked by the SpecOps team

Eff April 2016, ONLY MST & Homeless

per email from VSCM 3/11/16, still get additional .25 weighted actions for:

Military Sexual Trauma (MST)

Prisoner of War/Former Prisoner of War (POW/FPOW)

Homeless

Very Seriously Injured / Seriously Injured (VSI/SI)

Nehmer (EP 405)

ALS –per Beth Perkins, should only be rated by Audrey Reid & Geoff Sauer

Parkinson’s Disease

Multiple Sclerosis (MS)

Clear and Unmistakable Error (CUE)

Traumatic Brain Injury (TBI) – SME is Geoff Sauer, per Beth Perkins, TBI Equitable Relief Review claims should only be rated by Audrey Reid & Geoff Sauer - TBI Equitable Relief Review (veteran flash) / TBI Exam Review (claim-specific special issue indicator on TBI issue/contention

1151

Special Monthly Compensation (SMC)

extra .25 actions (under “100 – Formal Ratings Other Eps regardless of no of issues,” then “112 – Special Operation Case – an additional .25 credit for special operations case”)

Per 4/29/16 email from Director says BDD claims should only be worked by Quick Start, everyone getting BDD & Quick Start effective May 10, 2016; III.i.2; My Notes: Quick Start discontinued 10/1/17

Eff August 2016, no more SpecOps team, but see above about ALS & TBI Equitable Relief Review claims

2 nd signing Standard Operating Procedures III.iv.6.D.7.e

1 – RVSR creates draft Narrative & Codesheet (& SMC calculator, if applicable).

2 – RVSR converts all drafts above into one Word document as follows (or save PDFs as Word documents, if you have that option in Adobe):

W. Rees 129 updated 7/25/18

Print codesheet, narrative (deferred & SMC calculator) to OneNote (do each PDF, one-at-a-time) On the right side of OneNote, select all the “Untitled pages” pertinent for review (hold CTRL, then click

on each page) With selection made, click File, Send, Send to Word, then Save from Word

3 – RVSR saves Word document with all drafts merged in their folder on the H drive. RVSR also creates a 21-0961 (see http://vbacodmoint1.vba.va.gov/bl/21/Transformation/docs/VBMS.doc) & saves it with Word document.

4 – RVSR creates draft deferral in VBMS, if applicable.

5 – RVSR adds “Local Mentor Review” special issue to first contention listed in VBMS. As of 3/31/17, also add “Second Signature” tracked item per National Work Queue – Phase 1 & 2 Playbook .

6 – RVSR emails 2nd signer that draft rating is ready for review (provide name & claim number).

7 – 2nd signer reviews Word document and makes notes of changes/additions needed with “Review,” then “New Comment.”

8 – 2nd signer reviews draft deferral in VBMS, if applicable. [If it’s a full deferral & ready to be finalized, 2nd signer will make a Claim Note & email RVSR, who will Finalize deferral & remove “Local Mentor Review” special issue.]

9 – 2nd signer saves Word document with comments & emails RVSR that rating has been reviewed & either 2nd draft is needed or RVSR can finalize rating. In some cases, additional drafts may be necessary.

10 – RVSR makes changes, re-creates new Word Document with “(2),” “(3)” added to name (do not save over the prior version) & emails 2nd signer that additional draft is ready for review.

11 – Once rating is ready to be finalized, 2nd signer signs 0961 & emails RVSR. RVSR removes “Local Mentor Review” special issue, marks the “Second Signature” tracked item as closed, finalizes rating & uploads 0961 to VBMS.

Before sending a draft to your second-signer, RVSRs should double-check that:

o service is verified

o complete STRs are of record (with EOD & RAD marked) OR a final notification letter has been sent (plus JLV was

reviewed, uploaded & listed in Evidence if we have few or missing STRs) OR you notify veteran of missing STRs in

RD (use NO-STR)

o a DBQ was requested if there is GW/SWA service & we have a disability/symptoms under 3.317 (see exceptions

under IV.ii.1.E.2)

o POA is correct in VBMS (box is checked) & in VBMS-R

o all identified TRs have been requested

o VATRs were reviewed, uploaded & listed in Evidence

o if treated at a MTF, JLV was reviewed, uploaded & listed in Evidence

o Virtual VA Documents were reviewed

o an earlier effective date is not warranted if it is an original FDC claim received 8/6/13-8/5/15

o claim is on a Standard Form (as of 3/24/15, https://www.vapulse.net/thread/3622)

o a 5103 notice was sent if the claim was on a non-EZ form

o the initiated date on an electronic claim is not different than the date submitted (these changed to EBN ITFs on

3/24/15)

o there is not an associated ITF with a different date than the complete claim

W. Rees 130 updated 7/25/18

o the appropriate SNL/VBMS-R denial reasons & rationales, plus required Free Text, were used

o Document Types are correct in VBMS (see Searchable Doc ID Guide (as well as “eFolder Maintenance Plan,”

which can be found under the “eRO” button at Compensation Service Transformation Initiative & Pilot (TIP) Sheets))

After given the go-ahead to finalize your rating, ensure that:

o the “Local Mentor Review” special issue is removed

MISC REFERENCES:

Hayes v. Brown (1993) – M21 provisions can be the equivalent of regulations

Rating Manual References

III.iv.6.B, IV.ii.2.A - decide all claims, clarify claims

III.iv.6.C - explain eval criteria & next higher, explain how military noise exposure is conceded (i.e. job duties related to MOS) as in-service event that supports the grant of service connection needs to be discussed

III.vi.1.A.1.g – advisory opinions, VACO, Policy Staff

3.383 Special consideration for paired organs and extremities – IV.ii.2.K.1, IV.ii.3.C; if SC blind in 1 eye, pay the other NSC eye as SC (eff 8/28/62) OR 20/200 or less bilaterally OR constricted to 20 degrees bilaterally (both eff 12/26/07); if SC 10% for HL in 1 ear, pay the other NSC ear (at least 0%) as SC (total deafness eff 12/1/65 & 10%-0% eff 12/6/02); loss/LOU one kidney, pay the other NSC kidney “involvement” as SC (eff 8/28/62 for “severe involvement” & 10/28/86 for “any involvement”); loss/LOU one hand/foot, pay the other loss/LOU hand/foot as SC (eff 12/28/86, SMC entitlement 10/1/78 to 10/27/86); permanent 50% for one lung, pay other lung disability as SC (eff 10/28/86)

3.700 General

4.23 Attitude of rating officers – no personal feelings, even if claimant is antagonistic, critical, or abusive; be fair and courteous Bielby v. Brown (1994) – be impartial, unbiased and neutral when asking questions

Historic Rating Codes1. SC Grant2. P&T Grant8. NSC/Denial9. P&T Denial*details and more codes can be found at M21-1, Appendix A

Extension 2-A is about prolonged exacerbations of service-connected disabilities requiring hospital treatment.Extension 7 is a change to multiple diagnostic codes including osteomyelitis.

My Notes: Ensure the Master Record (backfill) is correct & double-check that older ratings were completely backfilled.

From: VAVBASDC/RO/VSC Sent: Thursday, March 22, 2018 3:56 PMSubject: Backfill Ratings

Good afternoon,

W. Rees 131 updated 7/25/18

Please see the below guidance regarding when the rating activity must complete a record-purpose (or “backfill”) rating decision.Please contact your supervisor if you have any questions.

Subject: FW: Guidance to the Field - Backfill Ratings

March 21, 2018

Directors (00)Pacific District Regional Offices

Good morning,

At a recent off-cycle Exam Liaison call, matters pertaining to the challenges being faced in utilizing the new Exam Management System (EMS) for ordering of Compensation and Pension (C&P) exams were discussed. One of the most talked about issues was the question of utilizing “backfill ratings”. This is a situation wherein rating decisions which may be housed in a legacy system such as BDN are unable to be utilized by EMS for ordering purposes, and therefore a decision must be created in VBMS that is useable. The following guidance is given on this topic, please ensure this information is distributed promptly:

The rating activity must complete a record-purpose (or “backfill”) rating decision when deemed necessary by the development or authorization activity in order to update corporate record data. The outcome of such decision should not be communicated to the beneficiary, as is discussed in M21-1, Part III, Subpart v, 2.B.1.p. 

One example of a situation where this would be needed is as follows: 

In instances when a claim for increase is received and the contentions being claimed for increase were granted in BDN with no subsequent actions, the necessary examination request cannot be entered into EMS because the contentions are not shown in Corporate or VBMS as granted contentions. In those cases, the rating activity must complete a record-purpose rating decision that should not be communicated to the beneficiary. 

Compensation Service is in the process of updating the manual to clarify this situation. The field will be notified when the change is final. 

From: VAVBASDC/RO/VSC Sent: Tuesday, April 10, 2018 2:43 PMSubject: SOP For Legacy Backfill Ratings

Good afternoon,Attached is the new SOP on backfill ratings provided by VSC leadership. Please keep it as a reference.

SOP for Legacy Back fill.dox is saved at H:\VSC\Rating Reference

Backfill medical treatment ratings under Chapter 17 in the Master Record. It will say “Treatment Purposes Only.” If SC for treatment purposes has previously been established, we cannot deny SC.

June 2015 Quality Call Notes – Character of Discharge (COD) determinations, conditional discharge & statutory bar to benefits

Carlos Rosario said manual changed. VSRs will make a Chapter 17 decision & send a letter, but we still need to decide “Entitled to Chapter 17” or “Not Entitled to Chapter 17.” We are not doing a decision on SC, just medical treatment. However, we treat it the same as SC, if treated in service, have continuity & treated now, we grant Chapter 17. We will deny if no continuity. We do not get medical opinions. – chart at III.v.1.B.1.e says we will request “any medical opinions warranted”

III.v.1.B.1.f, III.v.1.B.4.b – even if Admin decision says entitled, we may still deny if no nexus

III.v.1.B.2.d - If the claimant is statutorily barred from receiving VA benefits under any of the offenses listed in 38 CFR 3.12(c), a rating decision addressing 38 U.S.C. Chapter 17 eligibility is not necessary.

W. Rees 132 updated 7/25/18

III.v.7.A.4, IX.ii.2.4 – Ratings if requested by VAMC

Centralized Printing in VBMS

to create package, check boxes next to documents you want sent to the veteran go to Actions drop-down & select “Add to Package” name package appropriately, then click “Add & Go to Package Manager” (if have all documents ready to go, if

need to return to add something, do so) fix order of documents (letter should generally be first, forms subsequently) Save go to Recipients tab & enter name & address (will only auto-populate if just a letter finalized in VBMS, not a

package you created) add Recipient if has POA & use address of claimant’s SOJ (can find SOJ in Profile, IPC & VSRs have

spreadsheet with all addresses) [would be great if we could just email the POA…] add forms, if needed Send Package (?for each recipient) Check for SUCCESS if veteran didn’t receive letter (if shows FAILED, generate again & send) When finalize a letter in VBMS, it will automatically create package, check addresses on both Recipients (may

have to add POA address); can also add more to that package on the Main Screen, if needed Send Package (?for each recipient) might have to enter Tracked Item

Appeals References

VACOLS – I.5.KRO77pobder

I.4 I.5 – see I.5.B.1.d for handling a time limit extension request; I.5.B.2.g-i - non-appeal issues on NOD are RFAs

on/after 3/24/15

III.ii.1.A.3 - III.ii.1.A.3.b table for claims inextricably intertwined with Appeals issues & notifying the veteran if contention is already on Appeal; December 2017 Quality Call Notes – IV.ii.2.F – RVSRs can rate IU with a rating EP, but if IU is denied, it will be incorporated into Appeal (if at RO & for CFI for disability claimed to cause IU); BUT, if have Appeal for IU & rating denies CFI for disability claimed to cause IU, that disability will NOT be incorporated into Appeal (unless specifically appealed by veteran)

III.ii.3 – III.ii.3.E.1.d – if not on 0958, it’s an RFA/request for NOD (but 0958 still must be timely, RFA for NOD does not extend 1 year timeframe); III.ii.3.E.1.j - if NOD not on 0958 & outside year, it’s an untimely NOD; must be on Sept 2015 version of 0958; incomplete NODs on valid form can get 60 days extension on the 1 year; III.ii.3.E.1.e – invalid premature NODs; III.ii.3.E.1.k table for how to handle NODs on pending claim issues; clarifications have to come in on 0958 too (have 60 days), unless on 0820

July 2014 VACOLS training (Destiny) – even if claiming IU d/t SC conds & SC conds are on Appeal, can still rate IU & can grant increases from current claim, but make a note that they are on Appeal

***BVA decisions are final as of the date of the decision for VBA purposes (per Bob Bogue on 11/16/06), if veteran wants to appeal BVA decision, they have to contact the court in 120 days

Smith v. Derwinski (5/8/91) - “Courts may take judicial notice of facts not subject to reasonable dispute.”

Brannon v. Derwinski (6/11/91) - NOD starts the ball rolling; what is “reasonably raised”

Proscelle v. Derwinski (7/24/92) - need valid NOD

Bernard v. Brown (3/22/93) - sets forth the requirement that a specific sequence of events must take place before claimant may secure appellate review by BVA

Grantham 114 F.3d. 1156 (Fed. Cir. 1997). (Vol. #5) - downstream analysis [follows Holland, states can only appeal W. Rees 133 updated 7/25/18

% & effective date AFTER SC is granted]

Stegall v. West (6/26/98) - compliance with BVA Remand instructions

Bailey v. West (11/9/98) -misinformation binds the VA

Breeden v. West (3/17/00) - sets forth the process of “plain meaning”

Redding v. West (5/22/00) - in order to obtain review by the court a person must be ‘adversely affected’ by that decision in to file a Notice of Appeal, also establishes who can file NOD

Watershow 3/474 - standing to appeal- need to be adversely affected

Myers v. Principi (8/13/02) - NOD, expression of dissatisfaction [liberally construe correspondence, “reconsideration” is an NOD]

Davis v. Principi (3/18/03) - presumption of regularity is discussed

McCullough 15/272 at 275 - presumption of regularity [if it’s put in the mail, we presume that it’s mailed, for final decisions]

Jaquay, 16/ 304 Fed. Rep. 3d, 1276 - tolling of period to file an NOA of a BVA decision with the Court when the notice is erroneously sent to RO which had been assisting with development of the claim

VAOPGCPREC 14-2001 (12/14/01) - BVA may either remand a case to the agency of original jurisdiction (AOJ) or direct its own personnel to undertake the action necessary

VAOPGCPREC 1-2003 (5/21/03) - The DAV decision does not prohibit BVA from developing evidence in a case, provided that the BVA does not adjudicate the claim based on any new evidence it obtains unless the claimant waives initial consideration of such evidence by first-tier adjudicators in the VBA. BVA may adjudicate claims where new evidence has been obtained if the appellant waives initial consideration of the new evidence by VBA.

VAOPGCPREC 8-2003 (11/22/03) - VA, upon receipt of a complete or substantially complete application, must notify the claimant of the information and evidence necessary to substantiate the claim for benefits. Upon receipt of a notice of disagreement in response to a decision on a claim, the “agency of original jurisdiction” must take development or review action it deems proper under applicable regulations and issue a statement of the case if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. If, in response to notice of its decision on a claim for which VA has already given the section 5103(a) notice, VA receives a notice of disagreement that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved, but section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue.

effective 4/26/13, any letter issued with Appeal Rights must include as an attachment the new VA Form 21-0958 Notice of Disagreement. Provisional Ratings should not include Appeal Rights. Provisional guidance is in VBA Letter 20-13-05 (April 19, 2013) and VBA Letter 20-13-07 (June 21, 2013) I.5.B

effective 3/24/15, a NOD for compensation must be on a VA Form 21-0958 (ensure one was sent with notification letter, as there was a period where they were not sent)

Rapid Appeals Modernization Program (RAMP) – law effective February 2019, three lanes (1-a Supplemental Claim lane, which provides an opportunity to submit additional evidence, 2-a Higher-Level Review lane, which consists of an entirely new review of the claim by a claims adjudicator with difference of opinion authority, and 3-an Appeal lane that provides an opportunity to appeal directly to the Board of Veterans’ Appeals (Board)), RAMP initiative starts 11/1/17 [as of 4/4/18, email Beth Perkins or Damon Jenkins if discover a RAMP election with the eFolder of an appellant] [as of 4/4/18, letter tells them can see if can opt-in to RAMP on vets.gov]; will have 682 (for Higher Level Review) or 683 (for Supplemental Claims), 5 pilot stations only; VACOLS status will say “HIS”

RAMP_03212018.dox is saved at H:\VSC\Rating Reference

Insurance ratings – IX.ii.2.9; an insurance rating does not allow for $, but if a veteran files a 21-526 later, we can’t deny, but we won’t pay back to the insurance rating date (per Sue Haak), same w/dental (3.381) & VocRehab ratings

III.iii.4.10 & III.v.4.D – Federal Employee’s Compensation (FEC) Benefits, paid by the Office of Workers’ Compensation Programs (OWCP)

W. Rees 134 updated 7/25/18

Workers’ comp / workmans’ comp / worker’s comp / workman’s comp

Centralized Claims – III.ii.5.A

Foreign claims – Pittsburgh RO (311) as of 10/20/14

VA-employee veteran working in office in foreign country/region – San Diego RO (377) as of 11/3/16

Ch. 18 – Denver RO (339), VI.1.1

Radiation claims – IV.ii.1.B, IV.ii.1.C - Jackson RO (323) as of 10/06, must have medical evidence of one of the below disabilities prior to routing to Jackson, add the Radiation Radiogenic Disability Confirmed special issue indicator to the contention(s) before the claim can transferred to the Jackson RO for processing

Diseases specific to 3.309(d) radiation-exposed veterans –

The diseases listed below shall be service-connected if they become manifest in a radiation-exposed veteran anytime after service as defined in paragraph (d)(3) of this section.

Leukemia (other than chronic lymphocytic leukemia) 5/1/88Lymphomas (except Hodgkin’s disease) 5/1/88Multiple myeloma [7799-7709] 5/1/88Primary liver cancer (except if cirrhosis or hepatitis B is indicated) 5/1/88Cancers of the:

bile ducts 5/1/88breast 5/1/88esophagus 5/1/88gall bladder 5/1/88pancreas 5/1/88pharynx 5/1/88small intestine 5/1/88stomach 5/1/88thyroid 5/1/88salivary gland 10/1/92urinary tract (including kidneys, renal pelves, ureters, urinary bladder, and urethra) 10/1/92bone 3/26/02brain 3/26/02colon 3/26/02ovary 3/26/02lung 3/26/02

Note: Originally 30 year period for leukemia & 40 years for all others; 8/14/91 leukemia is extended to 40 years; 10/1/92 limits removed.

3.311 Claims based on exposure to ionizing radiation –

For purposes of this section the term “radiogenic disease” means a disease that may be induced by ionizing radiation and shall include the following (diseases must become manifest 5 years or more after exposure, unless otherwise noted):

All forms of leukemia except chronic lymphatic (lymphocytic) leukemia (can manifest anytime)Bone cancer (30 year presumptive period)Breast cancerCancer of the rectumColon cancerEsophageal cancerKidney cancerLiver cancerLung cancerLymphomas other than Hodgkin’s diseaseMultiple myeloma (7799-7709)Non-malignant thyroid nodular diseaseOvarian cancerPancreatic cancer (7343)Parathyroid adenoma

W. Rees 135 updated 7/25/18

Posterior subcapsular cataracts (must become manifest 6 months or more after exposure)Prostate cancerSalivary gland cancerSkin cancerStomach cancerUrinary bladder cancerThyroid cancerTumors of the brain and central nervous systemAny other cancer

Mustard Gas – IV.ii.1.F, Muskogee RO (351) as of 1/19/05

3.316 - Claims based on chronic effects of exposure to mustard gas – I.1.B.1.f – need to send additional notice, per IV.ii.1.F.3.b IV.ii.2.C.9 – claims based on mustard gas or lewisite

IV.ii.1.F - full-body exposure to mustard gas or lewisite (IV.ii.1.F.2.b confirms Muskogee, need Mustard Gas special issue indicator on relevant contention)

Except as provided in (b) of this section, exposure to the specified vesicant agents during service under the circumstances described below together with the subsequent development of any of the indicated conds is sufficient to estab S/C for that cond:

(1) Full-body exposure to nitrogen or sulfur mustard during active military service together with the subsequent development of:conjunctivitis (chronic) lung cancer (except mesothelioma)corneal opacities nasopharyngeal cancerkeratitis scar formationlaryngeal cancer squamous cell carcinoma of the skin

(2) Full-body exposure to nitrogen or sulfur mustard or Lewisite during active military service together with the subsequent development of:

asthma laryngitis (chronic)bronchitis obstructive pulmonary disease emphysema (chronic)

(3) Full-body exposure to nitrogen mustard during service w/ subsequent development of: acute nonlymphocytic leukemia.

Operation Ranch Hand (ORH) C-123 – IV.ii.1.H.3.a, St. Paul RO (335) as of 4/15

Mustard Gas/Lewisite Readjudication (issued 6/7/18, based on Section 502 of PL 115-48, signed on 8/16/17)

MustardGas_06072018.dox is saved at H:\VSC\Rating Reference

From: VAVBASDC/RO/VSC Sent: Thursday, June 14, 2018 2:01 PMSubject: FW: Mustard Gas - Public Law 115-48

For information purposes:As discussed on today’s call, Section 502 of Public Law 115-48, which was signed on August 16, 2017, requires VA to readjudicate all previously denied disability compensation claims for Veterans who alleged full-body exposure to mustard gas or Lewisite during WWII at one of the sites specified in the bill or any other site VA determines is appropriate.  Please note that this public law is also known as the Harry W. Colmery Veterans Educational Assistance Act of 2017.  Claims involving mustard gas or Lewisite are processed at the Muskogee Regional Office and claims processors should ensure the special issue of “Mustard Gas” is added as soon as a contention of mustard gas is identified. VA will continue efforts to locate Veterans by various means to ensure they are afforded the opportunity to file under the guidelines of the new legislation.

If you have any questions, please do not hesitate to ask your Coach and or Assistant Coach.

Quick Pay Disabiltiy (QPD) program - III.i.5 – rescinded 1/2/18

Pre-Discharge / BDD / Quick Start (My Notes: Quick Start discontinued 10/1/17) - III.i.2 (updated 10/1/17) –

within 180 to 90 days before discharge, be available for exam between 10 & 4th day after claim submitted W. Rees 136 updated 7/25/18

(III.i.1.A.1.d), provide copy of STRs from current period of service, prescribed form; also cannot need COD or be pregnant/hospitalized/terminally ill/VSI/SI/SPC/foreign (except Landstuhl, Germany or Yongsan, Korea); BDD-excluded for additional contentions submitted with fewer than 90 days before discharge (will have concurrent EP 020 [if 110 or 010 pending] or 021 [if 020 pending])

ratings will be done while servicemember is still on active duty (CANNOT do partial ratings, per III.i.2.B.4.e)

o Replace the language in the introduction paragraph with the below text:

The records reflect that you are a veteran of the [service era] Era. You served in the [branch of service] from [MM/DD/YYYY] to [MM/DD/YYYY] and for the current period of service beginning on [MM/DD/YYYY]. You filed an original disability claim that was received on [MM/DD/YYYY]. Based on a review of the evidence listed below, we have made the following decision(s) on your claim.

Please Note: The determination of entitlement to VA benefits is contingent upon your discharge from service and upon having the requisite character of service. We will review all evidence of record upon discharge to ensure the information provided in this decision is accurate. This rating decision will only be corrected, if necessary, based on the final review after your discharge.

o Rate the claim as normal with consideration given to the fact that the rating decision is being conducted while the SM is still on active duty so a future effective date would be assigned.

o Finalize the rating decision.

o Add a bookmark stating, “DRAFT: Rating document should not be released until after the award is authorized.”

o Following finalization of the rating decision, update the claim level suspense date in VBMS to the day following the SM’s anticipated discharge date. This is key to the success of the Pre-Discharge redesign.

7/25/13 QRT email on “PRE-DISCHARGE CLAIMS ADJUDICATIVE REMINDERS” – Compensation Services Policy Staff has provided adjudicative clarification on the following situations for Pre-Discharge claims, which is good reminder for VSRs and RVSRs.

1)  If a Veteran undergoes a pre-discharge examination, and the VAE report date is prior to discharge, the VAE report carries the same evidentiary weight as a STR.  If it (the VAE report) contains a diagnosis of a disability, it matters not whether the disability is noted elsewhere in the claimant’s STRs.  The diagnosis was made during service, and barring any other factor that would preclude the establishment of S/C, the disability should be granted.

2) A condition for which S/C is formally claimed while still in service would be considered as showing evidence of a complaint in service (considered an “event” as indicated under 38 CFR 3.159(c)(4)(i)(B)), even if there were no record of treatment for the claimed condition in the STRs.

3) In the case of a claim filed during active duty (considered an “event” for purposes of S/C), where VAEs are delayed until after separation from active duty, but the VAEs provide diagnoses for the claimed conditions, no nexus opinion would be required, in most cases, to establish S/C because there is no significant chronological gap that would cast doubt on continuity of symptomatology.

Notes from TMS Introduction to Pre-Discharge Programs Training –

Quick Start (My Notes: Quick Start discontinued 10/1/17) - fewer than 60 days prior to discharge date (need copy of STRs, does not qualify for BDD because not able to attend local exams); Consolidated Processing Site (CPS) does decision

BDD - 60-180 days prior to discharge date (need copy of STRs & must remain in intake site area for exams); Rating Activity Site (RAS) does decision

cannot do Quick Start or DD if missing STRs, claiming radiation exposure or GW undiagnosed illness, need stressor verification or service member is pregnant

IDES - enrolled in IDES by Military, then if Military finds them unfit for duty, VA provides decision; Disability Rating Activity Site (DRAS) does decision, III.i.2.D

From: VAVBASDC/RO/VSC Sent: Monday, February 08, 2016 2:28 PMSubject: Quick Start Ready for Decisions (Audience - RVSRs)Good afternoon Rating VSR’s:

W. Rees 137 updated 7/25/18

Please be advised that due to an increase in Quick Start claims, some of the cases in the Ready for Decision cycle will be incorporated into the daily workload assignments for RVSR’s currently working predominately VSC cases.    Below and attached are some reminders to keep in mind when rating a Quick Start claim.   

1)  If a Veteran undergoes a pre-discharge examination, and the VAE report date is prior to discharge, the VAE report carries the same evidentiary weight as a STR.  If it (the VAE report) contains a diagnosis of a disability, it matters not whether the disability is noted elsewhere in the claimant’s STRs.  The diagnosis was made during service, and barring any other factor that would preclude the establishment of S/C, the disability should be granted.

2)  A condition for which S/C is formally claimed while still in service would be considered as showing evidence of a complaint in service (considered an “event” as indicated under 38 CFR 3.159(c)(4)(i)(B)), even if there were no record(s) of treatment for the claimed condition in the STRs.

3)  In the case of a claim filed during active duty (consider this an “event” for purposes of S/C), where VAEs are delayed until after separation from active duty, and the VAEs provide diagnoses for the claimed conditions, no nexus opinion would be required, in most cases, to establish S/C because there is no significant chronological gap that would cast doubt on continuity of symptomatology.  If the VA examinations are conducted more than a year following service, a nexus medical opinion is required.

4)  If QS claims do not show any treatment for complaints in service, the 21-526 filed on Active Duty is a complaint for that condition.  The complaint in service is evidence of the onset of disability (i.e. incurred in).  Consider this the same as “noted in the STRs.”

Please refer to the M21-1, Part III, Subpart I, Chapter 2, Section B – Division of Responsibilities for Processing Benefits Delivery at Discharge (BDD) and Quick Start Claims additional information.  

My Notes: Quick Start discontinued 10/1/17

Pre-Discharge Claims Exams QA with changes(rec’d with the above email on 2/8/16)

VA EXAM CONDUCTED DURING SERVICE

Question: When processing pre-discharge program cases (BDD, QS, etc.), is it proper to grant service-connection for claimed disabilities shown on VA examinations that are conducted during active military service, but not shown in Service Treatment Records (STRs)?

Answer: Yes, we must grant service-connection because the disabilities were diagnosed during active military service [38 CFR 3.303(a)]. For example, the Veteran submits a pre-discharge claim for right knee pain while he/she is still on active duty. The STRs are negative for any right knee event, injury, or disease. The VA examination conducted during active duty shows a diagnosis of right knee patellofemoral syndrome. Service connection for right knee patellofemoral syndrome is warranted.

VA EXAM CONDUCTED AFTER SERVICE

Question: What is the proper procedure to follow when Veterans in the pre-discharge program claim disabilities during active service, STRs are negative, VA examinations, conducted within a year following service, show diagnoses?

Answer: Grant SC. A medical opinion is not needed. Consider the 12 months following service the same as medical evidence of continuity [38 CFR 3.303]. For example, the Veteran submits a pre-discharge claim for right knee pain while he/she is still on active duty. The STRs are negative for any right knee event, injury, or disease. The VA examination conducted 6 months following service shows a diagnosis of right knee patellofemoral syndrome. Service connection for right knee patellofemoral syndrome is warranted.

Question: What is the proper procedure to follow when Veterans in the pre-discharge program claim disabilities during active service, STRs are negative, VA examinations, conducted more than a year following service, show diagnoses?

Answer: A medical opinion is required to link the current diagnoses to the disabilities claimed during active military service [38 CFR 3.159(c)(4)] [M21-1MR Part I.1.C.7.b] For example, an active duty serviceperson in the pre-discharge program submits a VA Form 21-526 showing a claim for right knee pain. The STRs are negative for any right knee event, injury, or disease. The VA examination conducted 13 months after discharge from active duty shows a diagnosis of right knee patellofemoral syndrome. An opinion is necessary to link the current diagnosed disability to the complaint of knee pain shown on the VA Form 21-526 during active military service.

W. Rees 138 updated 7/25/18

DEGENERATIVE CHANGES VERSUS ARTHRITIS

Question: Is an opinion necessary when STRs show arthritis and VA examinations show degenerative changes (or vice versa)?

Answer: An opinion is not necessary. The phrase “degenerative changes” refers to osteoarthritis. Osteoarthritis is the most common form of arthritis. Doctors may also refer to it as degenerative arthritis or degenerative joint disease [38 CFR 3.303(b)] [Merck Manual] [Mayo Clinic].

Deferrals / Claim Clarifications Dos & Don’ts with changes(rec’d with the above email on 2/8/16)

1. Do defer if the claim is not fully developed, e.g., VCAA, STRs, 4142s, etc. (Grant any issues that you can. It the claim in its entirety is not ready to rate, return file directly to VSR.)

2. Do defer an issue if the examination is insufficient for rating purposes. 3. Do defer an issue if the exam contains contradictory statements or unsupported conclusions.4. Do defer an issue if the examiner fails to provide OR RULE OUT a diagnosis. (Answer “no” to Section I- Diagnosis on

DBQ is sufficient for a “ruled out” diagnosis if everything else is normal.)5. Do defer IU when inferred appropriately. (See 4.16) 6. Do defer a medical opinion if it lacks rationale.7. Do grant SC and deferred the evaluation for clarification when the current level of disability cannot be determined.

This includes SC at a non-compensable level.

1. Do NOT render a decision and defer when SC is at issue and the VA examination is insufficient. 2. Do NOT defer an issue if you can rate the issue without violating any law or regulation.3. Do NOT defer an issue because you disagree with the examiner’s diagnosis, conclusion, or opinion. The examination

must be inadequate or incorrect to send it back. 4. Do NOT defer an issue to ask for specialty exams, additional testing, or different DBQ completion because you

disagree with the examiner’s assessment. (Exception: When the VA examiner recommends a specialty test or examination, please defer for it and state that it is at the examiner’s request).

5. Do NOT defer an issue if the veteran fails to report to an examination without cause. Rate on the evidence of record.6. Do NOT infer and defer IU unless there is supporting evidence that the veteran is unable to work (even if schedular

requirements are met – you may note the reason that IU was not considered in the notation box).7. Do NOT defer an issue that has not been specifically claimed and do not blue plate an issue for a diagnosis or to

clarify objective findings of a condition if it has not been claimed.

Tips for Deferrals/Clarifications:

1. Be concise and specific when formulating your questions. You do not need to list everything in the STRs, or reiterate all of the examination findings. Just ask the question in the simplest, clearest way possible to get what you need to rate the issue. The VSR cannot read your mind.

2. Please indicate clearly on the blue plate if you are deferring for development (VCAA, STRs, 4142s). 3. Always reference the appropriate DBQ and particular question on the DBQ you need answered. Do not ask for just

“completion of DBQ.”

Example #1:1. VA examiner diagnosed exercise induced asthma. 2. PFTs results were not provided, per DBQ for Respiratory Conditions.

ACTION: Please ask the examiner for PFTs results or to explain why the test would not be useful or valid per DBQ for Respiratory Conditions.

Example #2:1. VA examiners diagnosed PTSD and TBI. Examination reports did not sufficiently delineate which symptoms are due to each condition.

ACTION: Please ask the VA examiner(s) to review findings and state which symptoms are due to PTSD and which symptoms are due to TBI. If this is not possible without speculation, please ask the examiner(s) to state so.

III.i.2.B.4.e says replace Intro with this if rating case while veteran is still on AD:W. Rees 139 updated 7/25/18

The records reflect that you are a Veteran of the [service era] Era. You served in the [branch of service] from [MM/DD/YYYY] to [MM/DD/YYYY] and for the current period of service beginning on [MM/DD/YYYY]. You filed an original disability claim that was received on [MM/DD/YYYY]. Based on a review of the evidence listed below, we have made the following decision(s) on your claim.

Please Note: The determination of entitlement to VA benefits is contingent upon your discharge from service and upon having the requisite character of service. We will review all evidence of record upon discharge to ensure the information provided in this decision is accurate. This rating decision will only be corrected, if necessary, based on the final review after your discharge.

Add a bookmark stating, “DRAFT: Rating document should not be released until after the award is authorized.”

Following finalization of the rating decision, update the claim level suspense date in VBMS to the day following the service member’s anticipated discharge date.

Per QRT/GiaBao Nguyen, 12/1/17 - Policy Letter 21-17-01: Hurricane Harvey’s and Maria’s Impact on Date of Receipt for Impacted Correspondence

For claims and intent to file a claim received September 1-7, 2017, that were impacted by Hurricane Harvey, i.e., Houston RO jurisdiction, field personnel should consider these as received prior to the end of month of August, or August 31, 2017 (use postmark date if earlier than received date).

For claims and intent to file a claim received October 1-6, 2017, from residents of Puerto Rico and US Virgin Islands, field personnel should consider these as received prior to the end of month of September, or September 29, 2017 (use postmark date if earlier than received date). – Federal Register actually says October 1-31, 2017, and no later than September 30, 2017

Disruption of Mail Service guidance due to Hurricanes 2018-06766 (including zip codes) is saved at H:\VSC\Rating Reference

W. Rees 140 updated 7/25/18

Diagnostic and Analogous Codes:

4.20 Analogous ratings – rate unlisted conditions under a closely related disease or injury, including function, location and symptomatology, ANALOGOUS

4.27 Use of diagnostic code numbers – 4.20, III.iv.5.B.1; numbers are arbitrary, use them or use analogy, “In the citation of disabilities on rating sheets, the diagnostic terminology will be that of the medical examiner, with no attempt to translate the terms into schedule nomenclature.” “Residuals of diseases or therapeutic procedures will not be cited without reference to the basic disease.”

III.iv.6.E.2 – can use 99 modifier codes for denials of SC nonspecific conditions

http://epss.vba.va.gov/mepss/ - MEPSS also has analogous codes under the medical symbol button

The Index of DBQ/Exams by Disability also has diagnostic codes.

…

actinic keratosis / keratosis / seborrheic keratosisVA examiners idenitify seborrheic keratosis as a “keratinization skin disorder” 7824alcoholism/alcohol abuse (can be considered as a symptom of a SC disability, per IV.ii.2.K; alcohol and substance abuse can be considered secondary to, and evaluated with, a mental condition (even if in remission), per QRT Bulletin September/October 2012 [include “in remission” in name of disability] 9399-9326angina pectoris / anginal syndrome 7099-7005aortic valve insufficiency; per III.iv.4.G.3.i, evaluate hypertension as part of aortic valve insufficiency if it is the cause, no separate evaluation for hypertension is allowed (also aortic regurgitation) 7000aphonia (complete) – not aphasia 6519aphonia (incomplete) – not aphasia 6519-6516arrhythmias [abnormal heart rhythm; also called tachycardia [heart rate that exceeds normal resting rate] or bradycardia [decreased/slow heart rate] (both general terms)] rate under ventricular arrhythmias (sustained) (7011) **only SC if sustained & on meds**or rate under supraventricular arrhythmias (7010) if given that dx or called “paroxysmal atrial fibrillation,” “supraventricular tachycardia (SVT)” or “permanent atrial fibrillation (lone atrial fibrillation)” 7011 or 7010atrial fibrillation (see arrhythmias) [a type of arrhythmia/tachycardia, rapid & irregular rhythm, the most common abnormal heart rhythm] rated under supraventricular arrhythmias (7010) 7010AV heart block / AV block / atrioventricular block (see arrhythmias)[a type of arrhythmia] 7015bunion / hallux valgus (can assign separate evals from other feet conds since criteria are distinct) (do each foot separately)Rating Note: Policy was clarified, around 2015, that we should assign separate evaluations (from other foot conditions) for hallux valgus since the criteria are distinct, and we should evaluate each foot separately.

5280

calcaneal spur 5284carpal tunnel syndrome 8515/8615/8715chlamydia 7599-7504chondromalacia patella (CMP) November 2014 Rating Quality Call Notes – Chondromalacia patella should not be rated

analogous to osteomalacia, nor recognized as a chronic disease subject to presumptive service connection under 38 CFR 3.309(a). Chondromalacia patella should be rated under the appropriate diagnostic code for a knee disability, which, in most cases, would be diagnostic codes 5257, 5260, or 5261, per April 2011 CS Bulletin.

5257, 5260, or 5261

chronic diarrhea 7/11/14 DBQ Call – chronic diarrhea and chronic constipation are only listed as diagnoses

7399-7319

W. Rees 141 updated 7/25/18

so that the examiner can enter a diagnosis and complete the DBQ, otherwise if there is no diagnosis most of the DBQ is disabled and can’t be answered.

costochondritis May 2012 QRT Q&A Session said 5297-5021

in September 2013, Larry Townsend said 5299-5321 & muscle DBQ [*in EB (use VEB, not LEB), choose Musculoskeletal System and Muscle Injuries, then Anatomical Region, then Torso & Neck, usually select no symptoms, then (on diff page than no sx) select XXI]

Index of DBQ/Exams by Disability shows 5399-52975299-5321 or 5399-5297

Crohn's disease 7399-7323

diabetic neuropathy (lower extremities), per DBQ

*III.iv.4.N.4.e says use 8521 if examiner is unable to specify the affected nerve(s) & there is no other evidence adequately documenting the affected nerve

sciatic (8520/8620/8720), anterior crural/femoral (8526/8626/8726)

diabetic neuropathy (upper extremities), per DBQ

*III.iv.4.N.4.e says use 8514 if examiner is unable to specify the affected nerve(s) & there is no other evidence adequately documenting the affected nerve

musculospiral (radial) (8514/8614/8714), median (8515/8615/8715), ulnar (8516/8616/8716)

dry eye syndrome

July 2012 QRT Q&A Session - this is a disability

QRT Bulletin September/October 2012 - this is a disability unless it’s a residual of LASIK or other refractive surgery where is it an “expected outcome” and should be denied), confirmed by October 2014 Rating Quality Call Notes & III.iv.4.C.3.d

June 2013 Compensation Service Bulletin (CSB) - 6099-6018 (chronic conjunctivitis, nontrachomatous, inactive 0%, active 10%)

or 6099-6025 (disorders of the lacrimal apparatus, unilateral 10%, bilateral 20%

Rating Vision & Eye Conditions training (video) says disorders of the lacrimal apparatus is commonly referred to as dry eye - 10% or 20% under 6025

LEB - choose "dry eye syndrome" (gives 6018 or 6025)

III.iv.4.C.3.c - also called keratoconjunctivitis sicca, confirms DCs 6013, 6018 or 6025 depending upon the nature & symptomatology; also says minimal symptomatology only requiring treatment by non-prescription eye drops would typically warrant a 0% evaluation

6099-6018 (usually most appropriate)

or 6025-6066 – 0%

Dupuytren's contracture (if surgically repaired, rate on LOM, 5228/5229/5230)Index of DBQ/Exams by Disability shows 5216 to 5230 5299-5224/5/6/7Dysphagia 7203

essential tremor8199-8103 or 8099-8004

eustachian tube dysfunction (usually 0%)Rating Note: A 10% evaluation under 6299-6204 for bilateral eustachian tube dysfunction is not warranted because there are no objective findings supporting a diagnosis of vestibular disequilibrium, which are required for a compensable evaluation. 6299-6204eye injury 6099-6066ganglion cyst, wrist 5020-5215gastroesophageal reflux disease (pyrosis=heartburn)

Local Narrative Oct 2012 says reflux is a term for regurgitation [aligned with 7346 criteria; contradicts Local Narrative Nov 2012 and DBQ]

7346 criteria lists dysphagia, pyrosis and regurgitation [not reflux] [aligned with Local

7399-7346

W. Rees 142 updated 7/25/18

Narrative Oct 2012; contradicts Local Narrative Nov 2012]

Local Narrative Nov 2012 says can choose both reflux and regurgitation to get a 10% [aligned with the DBQ; contradicts Local Narrative Oct 2012 and 7346 criteria]

Esophageal Conditions DBQ lists “pyrosis (heartburn),” reflux and regurgitation (all separately) [aligned with Local Narrative Nov 2012; contradicts Local Narrative Oct 2012]

VEB & LEB both list “pyrosis (reflux)” and regurgitation [reflux and regurgitation separately aligns with Local Narrative Nov 2012 and DBQ while contradicting Local Narrative Oct 2012; BUT pyrosis as reflux contradicts DBQ which says pyrosis is heartburn]; as of 1/14, both EBs say “pyrosis (heartburn and/or reflux)”

Rating Note: Although the EB shows "pyrosis (reflux),” the DBQ lists “pyrosis (heartburn)” and Local Narrative Oct 2012 says reflux is a term for regurgitation.

*The problem lies when the DBQ shows reflux and regurgitation, as then you’re assigning a 10% for the same symptom!

genital warts 7819gingivitis (also see periodontal disease; cannot SC) 9999-9900Helicobactor Pylori / H. pylori (lab finding) 7399-7307helminthiasis (POW presumptive disability) 7399-7324herpes simplex virus I & II (HSV) 7820-7806Herpes zoster / shinglesDBQ 9/17 showed “infections of the skin”MEPSS shows 7899-7806 7820 or 7806impetigo 7899-7823ingrown toenailsif painful, maybe 7806-7804 7813-7806insomnia (can only SC if given as Axis I diagnosis of primary insomnia, per STAR quality call - FEB 2010 Q&As) My Notes: It is unclear, but it seems it can be “insomnia” or “insomnia disorder” or “primary insomnia” or “sleep disorder,” per https://mhreference.org/dsm-codes/dsm-category/ 9499-9440labyrinthitis 6204lateral femoral cutaneous nerve 8599-8529lobectomy 6844macular degeneration 6006meniscectomy 5259neurogenic bladder, loss of bladder control 7542onychomycosis (choose tinea unguium of nails) 7813-7806

patellofemoral pain syndrome (PFPS) 5257, 5260, or 5261

peripheral vascular disease 7199-7114pinguecula 6037plantar fasciitis July 2013 Compensation Service Bulletin (CSB) says analogous to 5276 and evaluate feet

together August 2014 EB Override Training with Christopher Whynock said 5276 is correct for plantar

fasciitis (so I guess 5299 isn’t needed even though says analogous…) III.iv.4.A.7.e says analogous to 5276

5299-5276EB gives just 5276

plantar wartsMEPSS shows 7899-7820 7819 or 7820premature ventricular contraction (PVC/PVCs) [a type of arrhythmia, felt as skipped beat or palpitations] (only SC if sustained & on meds) 7099-7011prostatitis/prostatism 7599-7527pseudofolliculitis barbae (PFB) – choose dermatophytosis in VEB (My Notes: Evaluate under scars, 7820-7800, if that allows for a higher evaluation.)*Salt Lake City does PFB analogous to acne, 7899-7828, as of 10/14*Togus does 7820-7806 as of 8/13MEPSS says folliculitis is 7828 or 7829 7813-7806

W. Rees 143 updated 7/25/18

reactive airway disease 6699-6602restless leg syndromeMy Notes: There has been discussion that RLS is also a DSM-V diagnosis, so mental DBQs can be requested & it can be evaluated under a mental DC, but we have been advised to evaluate it as a neurological disorder.

8199-8103OR maybe best under an actual peripheral nerve…

shin splints / tibial stress fractures / medial tibial stress syndrome / anterior compartment syndrome (different from compartment syndrome requiring a fasciotomy) / stress fractures (as of 12/15, use VEB, may have to “Unfilter” to get Musculoskeletal – Other)III.iv.4.A.6.j – good info on if rate with knee/ankle, or separate & how to name it, confirms that use Musculoskeletal - Other calculator within VBMS-RIII.iv.4.A.6.k – examples*manual does not distinguish stress fracture from other fractures, so can SC like a fracture if have x-ray (or other) evidence in service, per III.iv.4.A.8.a 5299-5262shoulder impingement or tendonitis

III.iv.4.A.1.m - “For a claimant with a shoulder disability resulting in painful motion of the shoulder joint, the appropriate DC for the joint involved would be 38 CFR 4.71a, DC 5201, and 20 percent would be the minimum compensable rating.”

May 2016 Compensation Service Bulletin (CSB) says change is result of Court of Appeals for Veterans Claims recent decision in Sowers v. McDonald, 27 Vet.App. 472 (2006)

*MEPSS says tenosynovitis is also known as tendonitis (tendinosis is the same as tendonitis)

5201(add 5024 if tendonitis)

impairment of sphincter control 7332spermatocele 7599-7529sprain or strain of any joint [per QRT, Feb/Mar 2013 Bulletin, 10% not warranted with non-compensable loss of motion with no objective evidence of a limiting factor (pain, etc.) with no diagnosis of arthritis, tendonitis, tenosynovitis, or any other compensable diagnosis] *MEPSS says tenosynovitis is also known as tendonitis (tendinosis is the same as tendonitis)

5201, 5206, 5215, 5252, 5260, 5271, etc.

substance/drug abuse (see alcoholism/alcohol abuse above) 9399-9326substance abuse mood disorder (for pension) 9326supraventricular arrhythmias [or supraventricular tachycardia (SVT)] (see arrhythmias) 7010tachycardias [general term for rapid heart rate] (specific diagnoses are atrial fibrillation (see above), atrial flutter, supraventricular tachycardia (SVT) (see above), ventricular tachycardia and ventricular fibrillation) **need a specific diagnosis for a grant, not just unspecified tachycardia 7099-7010

tardive dyskinesia

8199-8103OR maybe best under an actual peripheral nerve…

tarsal tunnel syndrome (posterior tibial nerve) 8525/8625/8725varicocele 7599-7529vertigo - III.iv.4.N.1.e says grant for disability that accounts for symptom of vertigo, if have such a diagnosis, only grant for vertigo if have no other diagnosis/etiology 6204verruca vulgaris / wart (I guess we grant this as of 2017…) 7819ventricular arrhythmias / ventricular tachycardia / ventricular fibrillation (see arrhythmias) 7011

COMMON MEDICATIONS

ACNE (& INFECTIONS)TetracyclineValtrex (herpes, HSV)

ANGINACardizemDilacorImdur(any type of Nitrate)

Nitrostat

ANXIETY/INSOMNIAKlonopin (Benzodiazapines- CNS depressant)

DEPRESSIONElavilWellbutrin

Zoloft

DIABETESActos -antidiabetic agentAvandiaGlipizide -hypoglycemic agentMetformin (Glucophage) -hypoglycemic agentGlucotrol/Glyburide

W. Rees 144 updated 7/25/18

Glyburide & Metformin = GlucovanceLevemir - insulinMicronaseTolinasePioglitazone

EPILEPSY/SEIZURESTopamax

GERD & ULCERSPrilosecZantac

GLAUCOMATimolol

HEART ATTACK/STROKE/BLOOD CLOT (prevention)Aspirin, sodium bicarbonate, and citric acid combination [ASA is acetylsalicylic acid or aspirin (group called salicylates)]ClopidogrelEcotrinPlavix

HIGH CHOLESTEROL/TRIGLYCERIDESAtorvastatinGemfibrozil (Lopid)LipitorZocor

HYPERTENSIONAmlodipine (& chest pain)Atenolol CardizemClonidineCozaarDilacorDiltiazemEnalaprilFelodipineFosinoprilHydrochlorothiazide (HCTZ) [w/something else]InderalLisinoprilLopressorLosartanMetoprololMonoprilPrazosinPropranololTenorminVerapamilZestril

MIGRAINES

ImitrexMidrin

PSYCHOTIC DISORDERSZyprexa

MISC MEDSAugmentin – antibioticPrednisone – steroid

W. Rees 145 updated 7/25/18

W. Rees 146 updated 7/25/18

DIRECT SERVICE CONNECTION –

Issue: Service connection for {}.

Decision: Service connection for {} is denied.

III.iv.5.C.3 – effective dates

IV.ii.2.B.1o IV.ii.2.B.1.b – grant if shown in STRs & there is a claim within one year of diagnosis (“near-contemporaneous”

“dated approximately within one year prior to the date of the claim being submitted”), even if not shown / resolved on DBQ a few months later

Rating Note: Although the {} DBQ shows "{} resolved" / there is no current diagnosis because there is no pathology to render a diagnosis, the STRs show a diagnosis of {} on the {date} separation exam, which is a near-contemporaneous diagnosis, per IV.ii.2.B.1.b.

Rating Note: The STRs show complaints of {} on the {date} separation exam, but no diagnosis, so it does not qualify as a near-contemporaneous diagnosis, per IV.ii.2.B.1.b.

o IV.ii.2.B.1.e – Establishing Direct SC Under 38 CFR 3.303(a)

April 2017 Quality Call Notes –

Question: Typically, a medical opinion is not requested when the Veteran submits a claim within a year of discharge. The General Medical examination is conducted and any specialty examinations, but typically no medical opinion is requested/provided. According to M21-1 IV.ii.2.B.1.e (and, previous guidance provided during Changing the Game), establish service connection under 38 CFR 3.303(a) if the Veteran had an in-service diagnosis of a specific disability and the examiner provided the exact same diagnosis. So, service connection could be granted without the need for a medical opinion. Is my understanding of this correct, or are we required to return the examination for a medical opinion, simply because it was not a condition listed under 3.309a?Answer: Your understanding is entirely correct. 38 CFR 3.303 does require that a medical nexus shown after discharge is required to support claims not based on chronic disabilities under 38 CFR 3.309(a); however, in claims received less than one year from RAD, this nexus is shown by the diagnosis on examination matching the diagnosis in service – i.e., continuous symptoms with minimal interruption from service as noted in your manual reference. If the disability diagnosed on examination is different than the diagnosed disability in service, a medical nexus must be shown by medical opinion linking the current diagnosed disability to the in-service complaint(s).

…

3.303 Principles relating to service connection

3.303(a) - General

3.303(b) - Chronicity and Continuity - discusses 3.309(a), chronic disease

3.303(c) - Preservice disabilities noted in service

3.303(d) - Postservice initial diagnosis of disease

3.304 Direct service connection; wartime and peacetime –

Collette v. Brown (4/23/96)

Belcher, 214 F.3d at 1336. 38 C.F.R. § 3.304(b)(3) - signed statements against interest made by veterans in service related to the origin of disease or injury cannot be held against the veteran unless the statement is independently corroborated. Belcher argued that section 3.304(b)(3) should be interpreted to include oral statements, and that under such an interpretation the Secretary could not use Belcher’s statements to overcome the presumption of regularity.

VAOPGCPREC 3-2003 (7/16/03) - To rebut the presumption of sound condition VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The provisions of 38 CFR 3.304(b)are inconsistent with 38 U.S.C. 1111 insofar as

W. Rees 147 updated 7/25/18

Sec. 3.304(b) states that the presumption of sound condition may be rebutted solely by clear and unmistakable evidence that a disease or injury existed prior to service. Section 3.304(b) is therefore invalid and should not be followed. 3.306(b), which provides that aggravation may not be conceded unless the preexisting condition increased in severity during service, is not inconsistent with 38 U.S.C. 1111 and properly provides that a preexisting injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. The requirement of an increase in disability in 38 CFR 3.306(b) applies only to determinations concerning the presumption of aggravation and does not apply to determinations concerning the presumption of sound condition.

If veteran claims combat injury, but has no combat medal or confirmed combat: We do not have any confirmatory evidence that you are a combat veteran, which would allow us to use your report as satisfactory lay evidence that an injury was incurred in combat even though there is no official record of such incurrence.

III.iv.4.A.8.a – STRs need to document the fracture (x-ray, surgical report, casting, PEB) and veteran needs to claim the fracture/fracture residuals. Can grant healed fracture even without residual LOM or functional impairment. (My Notes: Can probably grant stress fractures too.)

Rating Note: Although the VA examiner indicates that the {} fracture is resolved and that there is no {} condition that can be associated with military service, the STRs show x-ray evidence of {}, and III.iv.4.A.8.a says “SC will be established for a healed fracture even without current residual limited motion or functional impairment of a joint.”

IV.ii.2.A.1.d – invite fractures shown on x-ray (or other objective evidence) in STRs

4.9 Congenital or developmental defects – “congenital or developmental defects,” “absent, displaced or supernumerary parts” (listed under III.iv.4.A.8.h, along with subluxation (partial dislocation of a joint), deformity or exostosis (bony overgrowth) of parts, and/or accessory parts), “refractive error of the eye,” “personality disorder,” “mental deficiency” are not diseases or injuries in the meaning of applicable legislation for disability compensation purposes

III.iv.4.A.8.h – congenital musculoskeletal defects are absence of parts, subluxation (partial dislocation of a joint), deformity or exostosis (bony overgrowth) of parts, accessory or supernumerary (in excess of the normal number) parts, spondylolysis, spina bifida, unstable or exaggerated lumbosacral joints or ankle, incomplete sacralization

IV.ii.2.B.6.a – examples of congenital or developmental defects are vertebral anomalies such as block (fused) vertebrae, atrial septal defect, pectus excavatum, mental deficiency, absent / displaced / supernumerary parts, personality disorder and undescended testicles (these are not diseases or injuries, presumption of soundness does not apply)

IV.ii.2.B.6.b, IV.ii.2.B.6.c - distinguish developmental or hereditary diseases (1-polycystic kidney disease, 2-sickle cell disease, 3-retinitis pigmentosa, 4-Huntington’s chorea) & can grant if first manifested in service (or worsened by service)

VAOPGCPREC 1-85 (3/5/85) – distinguished between congenital defects (a structural or inherent abnormality, generally incapable of improvement or deterioration) and congenital disease (capable of improvement or deterioration)

VAOPGCPREC 8-88 (11/7/88) – SC may be granted for hereditary disease which either first manifest themselves during service or which preexist service and progress at an abnormally high rate during service, and the presumption of soundness is not rebutted merely by the fact a disease is hereditary, as a genetic or other familial disposition to develop a disease does not constitute having the disease

VAOPGCPREC 1-90 (3/16/90) – presumptive service connection may be granted for disease of hereditary origin since SC may be granted for disease of congenital, developmental or familial (hereditary) origin where such disease was first manifest themselves during service or progressed at an abnormally high rate during service (specifically organic disease of the nervous system); only rebutted by intercurrent causes or willful misconduct

OGC Precedent Opinions 67-90 and 82-90

Per QRT Bulletin June 2012 Addendum – can grant SC for ADHD (My Notes: Use 9499-9440)

O’Bryan v. McDonald (11/20/14) – 3.303(c) holds that congenital defects are static conditions that are incapable of improvement or deterioration, whereas diseases are capable of such progression

W. Rees 148 updated 7/25/18

4.17a Misconduct etiology – ignore misconduct disability if 100% or unemployable from innocently acquired disabilities

3.300 Claims based on the effects of tobacco products –

Judicial Conf Call 1/8/04 - tobacco-related conds as secondary to SC conds

Kane, 17/not published - denial of DIC when SC had previously been granted for tobacco use [new claim, nothing granted after end date]

Kane v. Principi (5/8/03) - retroactive effective date of June 9, 1998, as specified by the statute; the court stated that Congress clearly intended that the statute have an effective date of June 9, 1998

VAOPGCPREC 6-2003 (10/28/03) - A finding of secondary service connection for a disability related to the veteran's use of tobacco products after the veteran's service, where that disability is proximately due to a service-connected disability that is not service connected on the basis of being attributable to the veteran's use of tobacco products during service, is not prohibited. The questions that adjudicators must resolve with regard to a claim for service connection for a tobacco-related disability alleged to be secondary to a disability not service connected on the basis of being attributable to the veteran's use of tobacco products during service are: (1) Whether the service-connected disability caused the veteran to use tobacco products after service; (2) if so, whether the use of tobacco products as a result of the service-connected disability was a substantial factor in causing a secondary disability; and (3) whether the secondary disability would not have occurred but for the use of tobacco products caused by the service-connected disability. If these questions are answered in the affirmative, the secondary disability may be service connected. Further, the secondary disability may be considered as a possible basis for service connection of the veteran's death, applying the rules generally applicable in determining eligibility for dependency and indemnity compensation.

3.306(b)(1) says: The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service.

Per May and August 2009 STAR errors – cesarean section scars should be granted if the surgery was performed while on active duty.

alcoholism/substance abuse, 9399-9326:New since alcoholism/substance abuse is okay under mental conditions: If granting all: grant mental condition, discuss alcoholism/substance abuse in the “Reasons for Decision” & put “also

claimed as alcoholism/substance abuse” in the issue If claimed alcoholism/substance abuse & denying it, but granting mental: discuss under mental condition, but code

separately as Willful Misconduct If claimed alcoholism/substance abuse & denying all: deny each separately

IV.ii.2.K - Establish service connection under 3.310(a) for any diseases or disabilities resulting from alcohol abuse, if alcoholism is determined to be secondary to an SC disability. Note: Alcohol abuse may also be considered a symptom of an SC disability.

May 2015 Quality Call Notes - Per VAOPGCPREC 2-98, cannot grant increased eval for disability resulting from alcohol or drug abuse granted prior to 10/31/90

Service –

3.12 Character of discharge – OTH or DIS require an Administrative Decision as to “Dishonorable for VA purposes (DVA)” or “Honorable for VA purposes (HVA)”

III.ii.6.B.3.b & III.ii.3.C.7.a - "Y" or "D" in the VADS field, The entry "D" is added from Defense Manpower Data Center (DMDC) processing.); if no service verified, admin denial; Veterans Information Solutions (VIS) is considered an electronic DD214, but the DD214 is more reliable; as of 10/27/15, III.ii.6.B.3.c says have to add 1 day to RAD provided by VIS for retirees & that VADIR in Virtual VA is same info as VIS; list of all forms; III.ii.6.B.3.b says a separation reason of DEV means further development may be required; Important under III.ii.3.C.7.a says “Service information in VA systems that has been verified through VADS but is proven to be

W. Rees 149 updated 7/25/18

incorrect by other credible evidence should be updated or replaced with the correct information, however applicable.”

III.ii.7 – admin denial for no qualifying service or character of discharge

III.v.1.A & III.v.1.B – Administrative Decisions & CODs; III.v.1.B.3.b & August 2016 Compensation Service Bulletin (CSB) – regulatory bar to benefits in 3.12(d)(1) is only for undesirable discharge in lieu of trial by general court martial & cannot be applied to summary or special court martial (check DD-458, Charge Sheet), if do not have confirmation that was general court martial, apply reasonable doubt & do not apply 3.12(d)(1)

III.v.1.E.1 & IX.ii.2.6 – insanity

From: VAVBASDC/RO/VSC Sent: Monday, March 13, 2017 2:27 PMSubject: Q-Tip Character of Discharge (COD) - Consideration of Multiple Periods of Service

Character of Discharge (COD) Q-Tip:  Consideration of Multiple Periods of ServiceTarget Audience:  All VSRsDue to a recent increase in errors cited by STAR for Character of Discharge (COD) decisions, we are issuing the Q-Tip below as a reminder on the correct development actions to take when a veteran has multiple periods of service, there is re-enlistment prior to the end of the veteran’s service period (contract), and one period (or more) is considered “dishonorable for VA purposes (DVA).” 

When a veteran has multiple periods of service that overlap, each individual period of service must be completed satisfactorily in order to be considered “honorable for VA purposes (HVA).” 

Example:  Joe Veteran signed an initial enlistment contract for a period of 4 years on 10/01/2009.  The veteran signed a re-enlistment contract on 7/23/2012 for another 4 years.  On 5/01/2013, the veteran tested positive on urinalysis for Tetrahydrocannabinol (THC) or marijuana.  Non-judicial punishment was issued for this incident.  The veteran again tested positive on urinalysis on 11/27/2013 and 01/05/2014.  On 03/17/2014, a urinalysis showed the veteran was positive for methamphetamines.  The veteran was processed out of the military with a “bad conduct discharge (BCD)” and separation reason of “pattern of misconduct/illegal drug use.”  In the facts and circumstances, the veteran’s file shows a pattern of this misconduct beginning during the initial enlistment.  All incidents of misconduct were used as the basis for the veteran’s bad conduct discharge. 

In this case, the incidents leading to the bad conduct discharge started prior to the completion of the first period of service; therefore, both periods of service are considered dishonorable for VA purposes.  A full review of the veteran’s file should be completed, as the facts and circumstances will show the incidents considered for the dishonorable discharge.

III.v.1.B.5.a.  Provisions of 38 U.S.C. 101(18) for Reenlistment Prior to Discharge

 

38 U.S.C. 101(18) provides that an individual who enlisted or reenlisted before completion of a period of active service may establish eligibility for VA benefits if he/she satisfactorily completed the period of active service for which he/she was obligated at the time of entry.  The satisfactory completion of one contracted period of enlistment while serving on a subsequent contracted period of service under a new enlistment is considered a conditional discharge.

April 2017 Quality Call Notes – Character of Discharge (COD)

Issue: Whether the Veteran insane at the time of the commission of offenses resulting in an {Other Than Honorable / Undesirable / Bad Conduct / Dishonorable} discharge.

Decision: The Veteran {was / was not} insane at the time of the commission of the offense(s) resulting in an {Other Than Honorable / Undesirable / Bad Conduct / Dishonorable } discharge.

Reasons for Decision: The Veteran {was / was not} insane at the time {he / she} committed {an offense / offenses resulting in an {Other Than Honorable / Undesirable / Bad Conduct / Dishonorable } discharge.

Training documents are under “Determinations of Insanity” at https://vba-tpi.vbatraining.org/lc

Winter v. Brown (1/8/93) - application of 3.12(c)(6) [AWOL for 180 days is misconduct unless good reason; if fewer than 180 days, not entitled to exceptions]

Lane v. Principi (8/7/03) - character of discharge, good discussion of 3.12(c)(6)

W. Rees 150 updated 7/25/18

From 8/3/10 Rating Team POD:

When Not to Make a Character of Discharge DeterminationDo not make a character of discharge determination for VA claim purposes

before an application from a claimant places the matter at issue if there is a separate period of honorable service, which qualifies the person for the benefits claimed if there was another period of honorable service prior to the service at issue and the veteran was eligible for, or

received, an unconditional discharge unless eligibility to the benefits claimed requires the later period of service, for example, disability incurred during such

period, or disability or death pension eligibility requires wartime service and the discharge from such period was under

other than honorable conditions.

III.v.1.A.3.a. Notification Prior to a Determination III.v.1.AIn any case in which a character of discharge determination is necessary, including dishonorable discharges

inform the claimant in advance of the need for a determination, and provide information concerning legal and procedural rights.

III.v.1.A.3.b. Required Elements for Initial Notice III.v.1.A

Element Purpose and Description

Reason for Determination

Explains the reason why a character of discharge determination is necessary.

Note: Basic eligibility for VA benefits is contingent upon a discharge under other than dishonorable conditions.

Criteria Used to Make Determination

Explains the criteria that will be used to make the determination.

Explains and cites the applicable VA regulations.

Request Placed to Service Department

Explains that VA has asked the service department for a report or information about the discharge proceedings.

Note: VA will not request discharge proceedings if a dishonorable discharge was issued unless the issue of insanity is involved.

Claimant's Right to Submit Evidence

Explains the claimant's right to submit any evidence, contention, or argument bearing on the issue.

Claimant's Right to a Hearing

Explains the claimant's right to request a personal hearing prior to the determination.

Note: Inform the claimant that VA will furnish the hearing room, provide hearing officials, and prepare a transcript of the proceedings, but will not pay any other expense connected with the hearing.

60 Day Limit

Explains that if the claimant does not reply within 60 days, VA will

* assume he/she has no additional evidence to submit and does not desire additional time for presentation of the case, and

* make a decision based on the evidence available.

Effect of Determination

Fully explains that a statutory bar prevents entitlement to

* the benefit claimed, and

* all other gratuitous VA benefits.

Statement of Policy

Include statements to the claimant explaining:

* the established policy of VA is to assist a claimant in developing the facts pertinent to a claim, and

* that VA will make a decision that grants the claimant every benefit that can be supported in law, while protecting the interest of the Federal Government.

W. Rees 151 updated 7/25/18

From: VAVBASDC/RO/VSC Sent: Tuesday, June 14, 2016 2:18 PMSubject: Q-Tip Proper Verification of Military Service : Target Audience: RVSRs and VSRs

Attention RVSRs and VSRs:

The following Quality Tip is provided as it pertains to the proper verification of military service.

Active service includes:

active duty any period of active duty for training (ADT) during which a person is disabled or dies from a disease or injury

incurred or aggravated in the line of duty any period of ADT or inactive duty for training (IADT), during which a person is disabled or dies from an injury

incurred or aggravated in the line of duty or any of the following conditions o acute myocardial infarctiono cardiac arrest, oro cerebrovascular accident.

Important:  A Veteran may meet the minimum period of active duty without completing 24 months of active duty. 38 CFR 3.12a (a)(1) defines the minimum period as

24 months of continuous active duty, or the full period for which a person is called or ordered to active duty.

The acceptable forms of evidence of qualifying service (to include DD214s) can be found  under M21-1. III.ii.6.6.a. (My Notes: Should be III.ii.6.B.3.a) If the documents listed in this section are not available, service can be verified by:

The VID tab in SHARE that is complete and shows VADS verified service (D or Y in the VADS field). Virtual VA- the information obtained from VA/DoD Identity Repository (VADIR) is considered an electronic DD

form 214, and is acceptable for verification of service. VIS- The information retrieved from VADIR is identical to the information accessible in VIS, and can be viewed in

either Virtual VA or VIS.

Important: Obtaining a DD214 or equivalent is always recommended; However, having a DD214 of record  is not always necessary (QS or VSC claims). If service is otherwise verified by one of the methods mentioned above, then the claim can be decided depending on the type of claim. A DD214 be necessary based on the type of claim received such as PTSD because the DD214 usually provides critical information that may not be found anywhere else.

A DD214 or equivalent will always be the ultimate source for verification or service, and the information found within will take precedence over service information reflected on an electronic system.

Notes: 

If there are discrepancies between the information displayed in VIS and evidence provided by the service member pertaining to the dates of service or character of discharge, develop for the DD Form 214.

For reservists and National Guard members, a DD Form 214 is filed for each segment of active duty.  VIS will display the dates a reservist or National Guard member entered and exited active duty with the same unit.  VIS will not display dates for activation within a unit.

For retirees, a known discrepancy exists in VIS showing a one day difference between the RAD provided by VIS and the RAD on the DD Form 214.  The RAD data in VIS is the last day the service member is paid by the military.  To arrive at the same separation date shown on a retiree’s DD Form 214, add one day to the RAD date displayed in VIS.

W. Rees 152 updated 7/25/18

To qualify for VA benefits, a veteran must be discharged or released under conditions other than dishonorable. Any other type of discharge may require a character of discharge determination (COD) and service will be verified/updated based on the results of the COD.

o At all times when the type and nature of the service has been verified, rating action is required following complete development of the claim.

If the evidence shows the claimant’s service as active service develop for any required evidence and then send to rating for death/service connection determination.

If the evidence shows the claimant’s service as ADT or IADT, then the service is not active duty. However, develop for any required evidence and then send to rating for death/service connection determination. If the claimed conditions or death are found to be due as a result from an injury or disease incurred or aggravated in the line of duty, then the period of ADT/IADT qualifies as active service and must be updated in VA systems. If the veteran has multiple periods of ADT and or IADT, not all periods are automatically considered active duty just because service connection has been granted for some disabilities that occurred in one of those service periods.

National Guard service is not qualifying service unless they are called into “Federal service” under the authority of Title 10 or specific sections of Title 32. Ref: M21-1 III.ii.6.3.a thru d and 38 CFR 3.7(m)

References: M21-1. III, Subpart ii, Chapter 6 - Determining Veteran Status and Eligibility for Benefits                                 III.ii.6.6.b.  Verification of Service Using the VID Tab in Share                                                                III.ii.6.6.c.  Acceptable Alternative Evidence for Verification of Service

My Notes: As of 7/8/16, above references are changed to III.ii.6.A.2.b & III.ii.6.A.2.c

o Updating Military service information in VA systems

All periods of active duty and periods of service reported by the Veteran as related to claimed issues must be verified and updated in the systems.

W. Rees 153 updated 7/25/18

Update service in both BIRLS and in Participant Profile. BIRLS can only display three periods of service, therefore, any additional service periods must be entered in participant profile.

Changes made in Participant Profile will not automatically update the information shown in BIRLS.  Users should check both systems to ensure the Veteran’s military service is complete.

To properly verify active military service, the following information must be available entered on date (EOD) date of release from active duty (RAD) branch of service character of service, and separation reason. 

o References: M21-1.III.ii.3.C.7.a.  Military Service Verificationo III.ii.3.C.7.d.  Active Military Service by Reason of Award of SCo III.ii.3.C.7.b.  Information Required to Verify Military Service

For the regulatory and statutory definitions of active duty, active duty for training, inactive duty training, and active service, see

38 CFR 3.6 38 U.S.C. 101(21) through (24) , and 38 U.S.C. 106 (d) .

o Each and every employee should ensure that service is correctly updated in SHARE and VBMS during claims review.     Any questions should be brought to the attention of your Team Coach or QRT member.

Intro: You served in the Marine Corps from August 28, 2006 to April 26, 2011 and the period from August 28, 2006 to August 27, 2010 was determined to be honorable for VA purposes, but the period from August 28, 2010 to April 26, 2011 was determined to be dishonorable for VA purposes.

Service connection can only be granted for a disability which began during a period of honorable military service or was caused by some event or experience during honorable service.

There is no basis for service connection for {} because treatment first occurred during a period of service which was determined to be dishonorable for VA purposes, creating a statutory bar to benefits.

ORAlthough the service treatment records show a diagnosis of and treatment for {} starting in {}, since this condition occurred during a period of service which was determined to be dishonorable for VA purposes, creating a statutory bar to benefits, there is no basis for service connection for {}.

For opinion requests: The service period from {} to {} has been determined to be dishonorable for VA purposes and treatment/events during this period cannot be considered for the claim, as that period has a statutory bar to benefits.

Effective Date if filed within one year of dishonorable / DVA period: Service connection has been established from the day VA received your claim. When a claim is received more than one year after a period that was determined to be honorable for VA purposes, the effective date is the date VA received the claim.

If filed (pre-discharge/BDD claim) during DVA period, eff date is day after discharge from that DVA period:the day after your separation from the period of service determined to be dishonorable for VA purposes, as your claim was received while you were on active duty.

3.301 Line of duty and misconduct –

W. Rees 154 updated 7/25/18

III.v.1.D III.iv.4.I.4.a for venereal disease & HIV

IV.ii.2.K Forshey v. West (12/3/98) & Forshey v. Principi (4/1/02) - denied DIC because of vet’s misconduct,

presumption of SC for cause of death while on active duty, that is overcome, good expression of the law [Russian roulette case]

Martin v. McDonald (8/5/14) – military discharge for “alcohol rehabilitation failure” does not always constitute willful misconduct

Training documents are under “Line of Duty – Willful Misconduct” at http://hvnc.gdit.com/lc/

Notes from May 2013 Willful Misconduct Training

Line of Duty has to do with STATUS when injury occurred - AWOL, Desertion, being held for Felony, drugs or alcohol involved – our regs say NOT in the line of duty (Service

regs are sometimes different) If Service Dept says “not in the line of duty,” we also make a determination; but if Service says “in the line of duty,”

we do not re-do the determination (Findings are binding on the VA unless it is patently inconsistent with the requirements of laws administered by the VA)

Willful Misconduct has to do with PROXIMATE CAUSE of injury

A service department finding that injury, disease, or death was not due to willful misconduct will be binding on the Department of Veterans Affairs (VA) unless it is patently inconsistent with the facts and the requirements of laws administered by the VA.

See SA1 in VBMS-R codesThen can use VBMS-R System-Generated Text

Reserves - has its own codes in VBMS-R – SE1 and SE2

P.L. 106-419, Section 301—Strokes and Heart Attacks in Reservists

This section establishes entitlement to service-connection for heart attacks and strokes incurred while performing, or in transit to or from, inactive duty for training. This provision covers strokes and heart attacks which occurred prior to November 1, 2000, as well as future events.

The conditions covered by this legislation are limited to:* acute myocardial infarction * cardiac arrest * cerebrovascular accident

Verification: The reserve components prepare a line of duty (LOD) determination for all major diseases or injuries that occur while at drill. Request a copy of that determination (or other supporting documentation) which is placed in the service personnel records and, in most cases, the member’s medical file.

Effective Date: November 1, 2000. 38 CFR 3.114 governs the effective date of entitlement in these cases (M21-1, Part IV, 25.18).

VAOPGCPREC 4-2002 (5/14/02) - If evidence establishes that an individual suffers from a disabling condition as a result of administration of an anthrax vaccination during inactive duty training, the individual may be considered disabled by an “injury” incurred during such training as the term is used in 38 U.S.C. 101 (24), which defines “active military, naval, or air service” to include any period of inactive duty training during which the individual was disabled or died from an injury incurred or aggravated in line of duty. Consequently, such an individual may be found to have incurred disability in active military, naval, or air service for purposes of disability compensation under 38 U.S.C. 1110 or 1131.

3.6 Duty periods – W. Rees 155 updated 7/25/18

Active Duty means: Full-time duty in the Armed Forces (not active duty for training) Full-time duty as a commissioned officer of the Regular or Reserve Corps of the Public Health service (not

for training purposes) - see reg for specifics on dates Full-time duty as a commissioned officer of the Coast and Geodetic Survey or of its successor agencies,

the Environmental Science Services Administration and the National Oceanic and Atmospheric Administration - see reg for specifics on dates

Service as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy

Attendance at the preparatory schools of the United States Air Force Academy, the United States Military Academy, or the United States Naval Academy for enlisted active-duty members – see reg for specifics, III.ii.6.A.1.h

Authorized travel to or from such duty or serviceAlso explains Active duty for training and Inactive duty training

Note to File: Veteran was a Midshipman in the US Naval Academy from {} to {}. Per 3.6, active duty means service "as a midshipman at the United States Naval Academy."

III.iii.2.K.3.a - On May 26, 2004, the Secretary of the Air Force denied “active duty” status for the U.S. Civilian Crewmembers of the Flotilla Alaska Barge and Transport Company who served overseas in Vietnam for the period of April 1966 through April 1975.

3.7 Individuals and groups considered to have performed active military, naval, or air service

3.654 Active service pay(b)(1) Where the veteran returns to active duty status, the award will be discontinued effective the day preceding reentrance into active duty status. If the exact date is not known, payments will be discontinued effective date of last payment and as of the correct date when the date of reentrance has been ascertained from the service department.

(b)(2) Payments, if otherwise in order, will be resumed effective the day following release from active duty if claim for recommencement of payments is received within 1 year from the date of such release: otherwise payments will be resumed effective 1 year prior to the date of receipt of a new claim. Prior determinations of service connection will not be disturbed except as provided in §3.105. Compensation will be authorized based on the degree of disability found to exist at the time the award is resumed. Disability will be evaluated on the basis of all facts, including records from the service department relating to the most recent period of active service. If a disability is incurred or aggravated in the second period of service, compensation for that disability cannot be paid unless a claim therefore is filed.

III.i.2.C - Once the Veteran is released from active duty, VA may resume benefits immediately for any service-connected disability that is considered static. (A disability is considered static unless the prior rating decision indicates a routine, future examination of the disability is necessary.) Note: Rating activity must re-evaluate any non-static disabilities.

III.iv.8.C.1.n – evaluation not protected while back on active duty

III.v.4.C.6.c – changed 6/13/16, Preparation of a rating decision that reflects loss of entitlement to benefits based on a Veteran’s return to active duty is not necessary. Discontinue benefits by award action, making the appropriate entries on the BASIC ELIGIBILITY tab in VETSNET or VBMS Awards.

Per VA Pulse, https://www.vapulse.net/thread/3254, a request to resume benefits is not considered a claim for benefits and therefore does not require any particular form, III.v.4.C.6.f & g, IV.ii.2.A.3.f

June 2016 Compensation Service Bulletin (CSB) & June 2016 Quality Call Notes–

First, return to active duty and return from active duty adjustments will be made in the Awards application (VBMS or VETSNET) only. Coding these types of adjustments into the rating decision using the Active Duty – Discontinue selection will no longer be authorized. This selection will be removed from VBMS-Rating as part of a future release. Field users will instead make the adjustment through the Basic Eligibility tab within the Awards application.

W. Rees 156 updated 7/25/18

Second, when the Veteran returns from active duty and requests reinstatement of benefits, the Veteran’s entire award (static and non-static conditions) will be reinstated. Historically, VA has only reinstated benefits for static conditions and has delayed resumption of benefits for non-static conditions pending a reevaluation of those conditions. Reevaluation of non-static conditions will continue to occur, however, resumption of benefits for those conditions will not require the re-evaluation to be completed prior to this action being taken.

Third, when determining which non-static conditions to reevaluate, field personnel should only request a reevaluation for non-static conditions that were subject to reevaluation during the Veteran’s period of active duty and through the date that the action to resume benefits is being taken. Historically, VA has reevaluated all non-static conditions, regardless of when the proposed reevaluation was scheduled to occur.

If a previous rating decision included an active duty adjustment (Active Duty – Discontinuance), the RVSR should remove those adjustments from the code sheet, and the active duty adjustment should be applied within the Awards application under the Basic Eligibility tab.

IV.ii.2.A.4 – changed 8/11/16, Evaluating Pending Claims When a Veteran Returns to Active Duty; if all issues require deferral, do not issue a rating decision, instead initiate deferral action in VBMS; if can grant at least one issue, but have to defer another/others (add to Reasons for Decision):

The issue of compensation for {} 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.

IV.ii.2.A.4.c – can defer ALL issues in a RD, do not do a deferral in VBMS (exception to partial rating policy); IV.ii.2.A.4.f – if claim abandoned & deferred issues remain on codesheet when get subsequent claim to reopen, deferred issues should be changed to denied

1151 –

HT1HT23.358 Compensation for disability or death from hospitalization, medical or surgical treatment, examinations or

vocational rehabilitation training (§3.800) – called 1151; eff 10/7/97, effective date is date injury or aggravation was suffered, if claim is received within 1 year after that date; otherwise, effective date is date of receipt of claim

3.400(i) 3.800 III.iv.3.A.7.g Instructions for Providing Medical Opinions – Claims Under 38 U.S.C. 1151

IV.ii.1.A IV.ii.2.G – IV.ii.2.G.1.e says no 1151 for medical procedure performed by a non-VA physician in a non-VA

facility even if a VA physician had rendered recommendation or advice concerning such procedure, with a few exceptions (under IV.ii.2.G.3.f-h). Ollis v. McDonald (10/15/15)

VAOPGCPREC 3-2004 (3/9/04) - A veteran's entitlement under section 1151(a) to compensation for a disability “as if” service connected does not satisfy 38 U.S.C. 3901(1)(A)'s requirement, for eligibility for automobile benefits under chapter 39 of title 38, United States Code, of entitlement to compensation under chapter 11 for a disability that “is the result of an injury incurred or disease contracted in or aggravated by active military, naval, or air service.”

Hornick v. Shinseki (2010) – protection of SC is applicable to disabilities compensated under 1151, III.iv.8.C.2.f

3.800 Disability or death due to hospitalization, etc.

1151 denial (need Long Form Narrative, per III.iv.6.C.7.a):

We have denied entitlement to compensation for incisional hernia. Compensation is payable for any disability which results from VA hospitalization, medical or surgical treatment, or vocational rehabilitation, or as the result of having submitted to a VA medical examination. The evidence must show that the veteran's additional disability is actually the result of the VA care. Specifically, carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination must be W. Rees 157 updated 7/25/18

shown; or the proximate cause of disability must be an event not reasonably foreseeable. For training and rehabilitation services or compensated work therapy program, it must be shown that the veteran's participation in an essential activity or function of the training, services, or CWT program provided or authorized by VA proximately caused the disability. Merely showing that a veteran has additional disability is not sufficient to establish causation.

The treatment records show that, prior to your laparoscopic nephrectomy in August 2000 you were "counseled regarding the possibility of conversion to open bleeding and bowel injury.” When a bowel injury occurred, surgery was performed to repair the injury. Complications arose and you had to undergo a left hemicolectomy and colostomy in September 2000. Your colostomy was removed in February 2001 and no incisional hernia was found. In August 2001 an incisional hernia was noted on your left flank and a repair was scheduled, but was never done.

Because the incisional hernia resulted from the surgery for the complications that you were informed of prior to your laparoscopic nephrectomy, and there is no evidence of carelessness, negligence or lack of proper care on VA's part, we cannot grant entitlement to compensation for incisional hernia.

ORlist what TRs show…

There is no evidence that the treatment you received in April 2002 involved carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part, as you were treated for foot pain that you directly associated with the callus you self-treated and there is no evidence that your treatment was the proximate cause of your disability. Therefore, we cannot grant entitlement to compensation for loss of left toes and left leg motor control with pain.

Asbestos -

Asbestos Exposure – 4.97 I.1.B.1.f – need to send additional notice, per IV.ii.1.l.3.d IV.ii.1.I.3 IV.ii.2.C.2IF IN NAVY BEFORE 1974, COULD HAVE BEEN EXPOSED (check Memo below)*not presumptive, but DIRECT *NEED MEDICAL NEXUS (entire file must be reviewed by MD), per VAOPGCPREC 4-00 (4/13/00)

Training documents are under “Asbestos Exposure Related Claims” at http://hvnc.gdit.com/lc/

Per IV.ii.2.C.2.b, VA recognizes the following conditions as associated with asbestos exposure:

fibrosis (most common is interstitial pulmonary fibrosis, or asbestosis) (6833)

tumors (6819 for respiratory, 7343 for digestive…)

pleural effusions and fibrosis (6845)

pleural plaques (scarring of the lining that surrounds the lungs) (6899-6833)

mesotheliomas of pleura (6899-6819) and peritoneum (7399-7343) [must be accompanied by asbestosis, per Bob Bogue 9/06, per IV.ii.2.C.2.c]

cancers of the lung [must originate in the lung parenchema rather than the bronchi AND develop after asbestosis, per IV.ii.2.C.2.c] (6819)

cancers of the bronchus (6819)

cancers of the gastrointestinal tract [must develop after asbestosis, per IV.ii.2.C.2.c] (7343)

cancers of the larynx (6819)

cancers of the pharynx (6819)

cancers of the urogenital system (except the prostate) [must develop after asbestosis, per IV.ii.2.C.2.c] (7528)

W. Rees 158 updated 7/25/18

Lung cancer resulting from exposure to asbestos can only be service-connected if it is lung cancer that originates in the lung parenchyma rather than the bronchi and eventually develops in about 50 percent of persons with asbestosis, so your lung cancer must be accompanied by asbestosis.

Gastrointestinal cancer resulting from exposure to asbestos can only be service-connected if it is gastrointestinal cancer that develops in 10 percent of persons with asbestosis, so your {colon/gastrointestinal} cancer must be accompanied by asbestosis.

Urogenital cancer resulting from exposure to asbestos can only be service-connected if it is urogenital cancer that develops in 10 percent of persons with asbestosis, so your urogenital cancer must be accompanied by asbestosis.

Mesothelioma resulting from exposure to asbestos can only be service-connected if it is mesothelioma that develops in 17 percent of persons with asbestosis, so your mesothelioma must be accompanied by asbestosis.

Asbestos MOS list published and referenced for VSRs/RVSRs to use is in two courses in the VA National Training Curriculum available through the VBA Learning Catalog: Special Issue Claims (TMS ID 610926) and Asbestos Exposure Related Claims (TMS ID 1306941).

The MOS details from the 5/13/02 Mary M. Parker Memo are now listed at IV.ii.1.I.3.d

W. Rees 159 updated 7/25/18

AGGRAVATION -

Note that the issue of aggravation is generally one requiring medical opinion. Unless the evidence clearly indicates that there was no change in the condition or if the progression was due to some event during service, it should require a medical opinion.

GR2

I.1.C.3.h –

Element 1 (current disability/sx)

Element 2 (evid the disability worsened – Davis v. Principi, Maxson v. Gober, Verdon v. Brown, Jensen v. Brown, Paulson v. Brown)

Element 3 (satisfied by Element 2)

has table for if do direct or aggravation opinion (still have to have all 3 Elements)

IV.ii.2.B.4

3.303 Principles relating to service connection – (c) Preservice disabilities noted in service. There are medical principles so universally recognized as to constitute fact (clear and unmistakable proof), and when in accordance with these principles existence of a disability prior to service is established, no additional or confirmatory evidence is necessary. Consequently with notation or discovery during service of such residual conditions (scars; fibrosis of the lungs; atrophies following disease of the central or peripheral nervous system; healed fractures; absent, displaced or resected parts of organs; supernumerary parts; congenital malformations or hemorrhoidal tags or tabs, etc.) with no evidence of the pertinent antecedent active disease or injury during service the conclusion must be that they preexisted service. Similarly, manifestation of lesions or symptoms of chronic disease from date of enlistment, or so close thereto that the disease could not have originated in so short a period will establish preservice existence thereof. Conditions of an infectious nature are to be considered with regard to the circumstances of the infection and if manifested in less than the respective incubation periods after reporting for duty, they will be held to have preexisted service. In the field of mental disorders, personality disorders which are characterized by developmental defects or pathological trends in the personality structure manifested by a lifelong pattern of action or behavior, chronic psychoneurosis of long duration or other psychiatric symptomatology shown to have existed prior to service with the same manifestations during service, which were the basis of the service diagnosis will be accepted as showing preservice origin. Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation.

residuals of conditions without the disease/injury in service – pre-existedsymptoms at, or close to, enlistment – pre-existedinfectious diseases manifested in less than incubation period – pre-existedchronic psych sx with same manifestations in service – pre-existedrefractive error, personality disorders and mental deficiency – not diseases/injuries

3.304(b) – Presumption of soundness. The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted,

3.306 Aggravation of pre-service disability – 1-EPTE & aggravated by service, 2-EPTE & not aggravated by service, 3-DNEPTE; used to use “US” following diagnosis when deducting the % at time of entrance (now indicate in VBMS-R); only give degree of disability over the degree existing at entrance, unless 100% now, if entrance degree cannot be determined, then do not deduct

(a) General. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. (Authority: 38 U.S.C. 1153)

(b) Wartime service; peacetime service after December 31, 1946. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to

W. Rees 160 updated 7/25/18

determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service.

(1) The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service.

(2) Due regard will be given the places, types, and circumstances of service and particular consideration will be accorded combat duty and other hardships of service. The development of symptomatic manifestations of a preexisting disease or injury during or proximately following action with the enemy or following a status as a prisoner of war will establish aggravation of a disability. (Authority: 38 U.S.C. 1154)

(c) Peacetime service prior to December 7, 1941. The specific finding requirement that an increase in disability is due to the natural progress of the condition will be met when the available evidence of a nature generally acceptable as competent shows that the increase in severity of a disease or injury or acceleration in progress was that normally to be expected by reason of the inherent character of the condition, aside from any extraneous or contributing cause or influence peculiar to military service. Consideration will be given to the circumstances, conditions, and hardships of service.

3.322 Rating of disabilities aggravated by service(a) Aggravation of preservice disability. In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service, whether the particular condition was noted at the time of entrance into active service, or whether it is determined upon the evidence of record to have existed at that time. It is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule except that if the disability is total (100 percent) no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule, no deduction will be made.

(b) Aggravation of service-connected disability. Where a disease or injury incurred in peacetime service is aggravated during service in a period of war, or conversely, where a disease or injury incurred in service during a period of war is aggravated during peacetime service, the entire disability flowing from the disease or injury will be service connected based on the war service.

4.22 Rating of disabilities aggravated by active serviceIn cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree existing at the time of entrance into the active service whether the particular condition was noted at the time of entrance into the active service, or it is determined upon the evidence of record to have existed at that time. It is necessary therefore, in all cases of this character to deduct from the present degree of disability the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule, except that if the disability is total (100 percent) no deduction will be made. The resulting difference will be recorded on the rating sheet. If the degree of disability at the time of entrance into the service is not ascertainable in terms of the schedule, no deduction will be made.

Cotant, 17/not published -pre-existing condition and aggravation; Clear and Unmistakable standard; Judicial notice; Absurd results

Hunt v. Derwinski (1991) – temporary or intermittent flare-ups are not aggravation unless the condition (not symptoms) is worsened

Monroe v Brown (1993) – defect vs disease

Crowe v. Brown (1994) – VA’s burden to show that a disability preexisted service and was not aggravated by service is a “formidable burden,” has to be recorded on examination and a history of preservice existence is not enough. AND Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service. Also see Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995)

Laposky v. Brown (1994) – The clear and unmistakable evidence standard is an “onerous one.”

Jensen v. Brown (Fed. Cir. 1994). The burden falls on the veteran to establish aggravation. If there is no evidence of injury, complaints, or treatment of the preexisting disability in service, the veteran’s burden of proof is not met. AND 38 U.S.C. 1153 requires some increase in the severity of the preexisting condition causally related to military service. AND 38 U.S.C. 1153 requires an increase in the severity of the preexisting

W. Rees 161 updated 7/25/18

condition, as distinguished from the mere recurrence of manifestations of the pre-service condition. ALSO see Davis v. Principi (Fed. Cir. 2002) and Hunt v. Derwinski (1991).

LeShore v. Brown (11/22/95) - the record of history without more is of no value; info (as reported by vet) recorded in treatment record or VAE is not competent medical evidence. [Court & General Counsel say need clear & unmistakable evidence that existed prior to enlistment if condition is not on entrance exam]

Bloom v. West (2/10/99), Mattern v. West (2/23/99) and Link v. West (11/18/98) - sets forth when a Doctor’s statement is speculative.

Splane v. West, 216 F. 3d 1058 (2000) - establishes SC for a condition that existed prior to enlistment but became aggravated to a compensable degree after service [during presumptive period]

Adams v. West (5/1/00) - MDs cannot weasel word- statements have to be definite (case specifically about presumption of soundness)

Davis v. Principi (1/11/02) - The Court held “that evidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone, is not sufficient for a non-combat veteran to show increased disability under 38 U.S.C. sec 1153 unless the underlying condition is worsened.”

Jordan v. Principi (9/24/03) - good discussion of issue of whether a condition existed prior to enlistment and aggravation; CUE “does not include the otherwise correct application of a statute or regulation where, subsequent to the Board decision challenged, there has been a change in the interpretation of the statute or regulation.”

VAOPGCPREC 3-2003 (7/16/03) - To rebut the presumption of sound condition VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The provisions of 38 CFR 3.304(b) are inconsistent with 38 U.S.C. 1111 insofar as Sec. 3.304(b) states that the presumption of sound condition may be rebutted solely by clear and unmistakable evidence that a disease or injury existed prior to service. Section 3.304(b) is therefore invalid and should not be followed. 3.306(b), which provides that aggravation may not be conceded unless the preexisting condition increased in severity during service, is not inconsistent with 38 U.S.C. 1111 and properly provides that a preexisting injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. The requirement of an increase in disability in 38 CFR 3.306(b) applies only to determinations concerning the presumption of aggravation and does not apply to determinations concerning the presumption of sound condition.

Wagner v. Principi (Fed. Cir 2004) – if consider it pre-existing, then have to consider aggravation (and will deduct the degree of disability existing at the time of entrance if aggravated)

Morris v. Shinseki (5/15/12) - the finding of a personality disorder in service does not implicate the presumption of soundness

Horn v. Shinseki (6/21/12) – indication that existed prior to service & not aggravated on MEB, without explanation does not constitute clear and unmistakable evidence of lack of aggravation

Gilbert v. Shinseki (10/24/12) – the inability to rebut the presumption of soundness does not result in a presumption of aggravation, as the in-service disease or injury is deemed to have been incurred in service. If the in-service injury or disease is deemed service-incurred under the presumption of soundness, disability compensation is only warranted for a current disability if the evidence is in equipoise that the current disability is related to the in-service disease or injury.

April 2013 IRR & Consistency Training (training conducted in May) – Per AVSCM, Mike Colby, if there is a pre-existing injury that is considered healed/resolved at enlistment, then the STRs show another injury, consider it a new injury/event and not an issue of aggravation. Grant direct SC if chronic. – not supported by regulations or manual. A disease (with waiver or not) is different and will most often need a medical opinion.

Notes from June 2014 Aggravation Training:

Lack of treatment in service is evidence of NO aggravation, Maxson v. Gober (Fed Cir 2000) -

If no evidence of injury, complaint, or treatment of pre-existing disability in service – burden of proof not met

Absence of evidence – There is nothing in service to show increase of preexisting disease or disability. Evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the veteran’s health and medical treatment during and after military service, as evidence of whether a preexisting condition was aggravated by military service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000)

W. Rees 162 updated 7/25/18

Affirmative evidence of no increase in severity includes normal clinical findings on separation examination, no complaints at separation examination, and where an evaluation of condition is shown to be the same as it was on entrance examination.

Medical opinion – Disease or disability was not aggravated during service.

May 2016 Quality Call Notes – confirms that “If a preexisting disability is noted upon entry into service… the Veteran may bring a claim for aggravation of that disability” but “The burden falls on the Veteran to establish aggravation. See Jensen v. Brown. If there is no evidence of injury, complaints, or treatment of the preexisting disability in service, the Veteran’s burden of proof is not met.” ALSO, if there is nothing noted on the enlistment exam & the examiner gives a negative opinion based on the veteran’s report of a pre-service injury, but we have no clear evidence it pre-existed, “… return to examiner with clear instruction to disregard the Veteran’s statement concerning an earlier injury. Without clear and unmistakable evidence the condition existed prior to service, the presumption of soundness has not been overcome. See M21-1, IV.ii.2.B.4.b; M21-1, IV.ii.2.B.4.d; and, Wagner v Principi.” If have clear evidence it pre-existed, “…return the opinion to the examiner to inquire whether the condition was aggravated beyond natural progression by military service.” (this is a change from local policy, but may have always been national policy)

Rating Note: The STRs clearly indicate the pre-existing, asymptomatic pes planus progressed to being symptomatic, and bilateral plantar fasciitis developed, during service.

W. Rees 163 updated 7/25/18

PRESUMPTIVE SERVICE CONNECTION -

Per May 2009 STAR errors - 3.400(b)(2)(ii) provides that effective date for presumptive service connection is date entitlement arose, if claim is received within 1 year after discharge from active duty (so, date of diagnosis). Law also provides that if the requirements for service connection were met during service, effective date will be date following discharge, if claim received within 1 year. If filed more than 1 year after discharge, but the TRs show to 10 percent within presumptive period, the effective date is the date of claim.

3.307 Presumptive service connection for chronic, tropical, or prisoner-of-war-related disease, or disease associated with exposure to certain herbicide agents; wartime and service on or after January 1, 1947 – need 90 days of service (either during a period of war or after 12/31/46); cannot use opinion to SC something diagnosed after presumptive period (need “characteristic manifestations” or symptoms during presumptive period)IV.ii.2.BPOWs - IV.ii.2.EHerbicides - IV.ii.2.CIV.ii.2.B.2.d – Burden of Proof Required to Rebut Presumptive SC

3.309 Disease subject to presumptive – effective date is date disability is first shown, if 21-526 rec’d w/i 1 year of RAD, otherwise it’s the date of claim

Notes from January 2014 Presumptive SC Training:

Chloracne, etc – if can’t tell when last exposed/in-country, use last day of service

“acute/subacute” means early-onset

Ch. 35 (from April 2013 Comp Bulletin)

3.310(d) change eff1/16/14 – 5 conditions automatically secondary to TBI – can SC without opinion, but depends on severity of TBI & onset of secondary conds

3.309(a) Chronic diseases – III.iv.5.C.4 - effective datesIV.ii.2.BOnly the following diseases shall be granted service connection although not otherwise established as incurred in service if manifested to 10% within 1 year from date of discharge, unless otherwise noted.Need 90 days svc (per 3.307(a)(1))

Anemia, primary 7700Arteriosclerosis 7005, 7006, 7017, 7020, 7114 (PVD)Arthritis*Dr. Nguyen says osteoarthrosis is arthritis.*Dr. Moyad, Orthopaedic Physician, says “narrowing” is arthritis.

III.iv.4.B.2.b shows degenerative arthritis includes: the presence of Heberden’s nodes or calcific deposits in the terminal joints of the

fingers with deformity ankylosis, in rare cases hyperostosis and irregular, notched articular surfaces of the joints destruction of cartilage bone eburnation, and the formation of osteophytes.

Per QRT/Carlos Rosario, use degenerative (5003) unless there is a traumatic event. Repetitive use is not considered trauma. 6/3/03 Musculoskeletal broadcast - http://vbaw.vba.va.gov/bl/21/Calendar/vbn/transcripts.htm

Rating Note: III.iv.4.A.5.a indicates that degenerative disc disease is IVDS & not degenerative arthritis, but the 7/22/03 x-ray findings show "degenerative changes" and "osteophytes,” which are forms of degenerative arthritis, per III.iv.4.B.2.b & fall under 3.309(a).

5002, 5003, 5004, 5005, 5006, 5007, 5008, 5009, 5010

W. Rees 164 updated 7/25/18

SPONDYLOLYSISIII.iv.4.A.8.h says spondylolysis is a congenital defect. *It appears this is not spondylosis.

orthoinfo.aaos.org & medicine.medscape.com say spondylolysis is a stressfracture from repeated microtrauma or heredity (possibly on a defect in the pars interarticularis of the neural arch ) *It appears this is not spondylosis.

SPONDYLOSISmedicine.medscape.com says spondylosis describes bony overgrowths (osteophytes) [and is not degenerative joint disease or osteoarthritis since not a joint]

Some VA examiners indicate that spondylosis is not arthritis since it involves osteophytes on the vertebrae (which is not a joint). Other VA examiners indicate it is arthritis. Still others indicate it’s DDD.

Local Narrative July 2013 says spondylosis should be 5242

Majority of information with rationale says spondylosis is NOT arthritis

SPONDYLOLISTHESISIII.iv.4.A.8.h says spondylolisthesis is not automatically a congential condition although is commonly associated with a congenital defect

orthoinfo.aaos.org says spondylolisthesis is when the vertebra shifts out of place after the stress fracture

medicine.medscape.com says spondylolisthesis (forward slippage of one vertebral body with respect to the one beneath it) can be congenital/dysplastic, isthmic, degenerative, traumatic or pathologic.Atrophy, Progressive muscular 8023Brain hemorrhage 8009Brain thrombosis 8008Bronchiectasis 6601

Calculi of the kidney, bladder, or gallbladder (aka kidney stones/renal calculi/nephrolithiasis/ureterolithiasis; bladder stones; gall stones/cholelithiasis)

7508, 7515, 7315

Cardiovascular-renal disease, including hypertension (combination involvement of arteriosclerosis, nephritis, and organic heart disease) *also see arteriosclerosis above, & myocarditis & nephritis below

7007, 7101

Cirrhosis of the liver 7312Coccidioidomycosis 6835Diabetes mellitus 7913Encephalitis lethargica residuals 8000Endocarditis (This term covers all forms of valvular heart disease.) 7000, 7001, 7002, 7016Endocrinopathies 7900, 7901, 7902, 7903, 7904, 7905,

7907, 7908, 7909, 7911, 7912, 7913, 7914, 7915, 7916, 7917, 7918, 7919

Epilepsies 8910, 8911, 8912, 8913, 8914Hansen’s disease (leprosy) (3 yr pres period per 3.307) 6302Hodgkin’s disease 7709Leukemia 7703Lupus erythematosus, systemic 6350Myasthenia gravis 8025Myelitis 8010Myocarditis 7006Nephritis 7502Other organic diseases of the nervous system, III.iv.4.N.1.dIncludes:

carpal tunnel syndrome (CTS) – organic per FAQ 10/4/00- carpal tunnel syndrome & December 2012 Compensation Service Bulletin (CSB) & III.iv.4.N.1.d

peripheral neuropathy - Local Narrative July 2013 confirms peripheral neuropathy is presumptive; April 2014 Compensation Service Bulletin (CSB) – confirms inclusion of disease of the central nervous system, as well as cranial and

6012/6013, 6100, 8003, 8007, 8011, 8012, 8013, 8014, 8015, 8019, 8020, 8022, 8045, 8046, 8100, 8205/8305/8405, 8207/8307/8407, 8209/8309/8409, 8210/8310/8410, 8211/8311/8411, 8212/8312/8412, 8510/8610/8710, 8511/8611/8711, 8512/8612/8712, 8513/8613/8713, 8514/8614/8714, 8515/8615/8715,

W. Rees 165 updated 7/25/18

peripheral nerve conditions; III.iv.4.N.1.d

migraine headaches - FAQ 12/4/00- Migraine Headaches/New Claim during VA Exam said no to migraines, rescinded by July 2013 Compensation Service Bulletin (CSB) - clarif, not liberalizing; III.iv.4.N.1.d

sensorineural hearing loss – III.iv.4.N.1.d

glaucoma - III.iv.4.N.1.d

progressive spinal muscle atrophy - III.iv.4.N.1.d

disease of the cranial nervous system- III.iv.4.N.1.d

cranial nerve conditions - III.iv.4.N.1.d

peripheral nerve conditions - III.iv.4.N.1.d

tinnitus associated with acoustic trauma - see below clarification provided 1/30/18 - III.iv.4.N.1.d & IV.ii.2.B.2.a, Fountain v. McDonald (2/9/15)

January 2017 Quality Call Notes – If there is uncertainty as to whether a claimed disability may be considered as an organic disease of the nervous system for purposes of 38 CFR 3.309(a), send the case to CS’s Advisory Review Staff for guidance. See M21-1, III.vi.1.A for more information on requesting advisory opinions.

Question: Is military noise exposure equivalent to acoustic trauma for the purposes of establishing SC for tinnitus? See VA Pulse post # 1 and VA Pulse post # 2.

Answer: As noted in the VA Pulse inquiries, this matter is being investigated. As soon as the appropriate policy determinations are made, the manual will be updated with corresponding procedures.

January 2018 Quality Call Notes – We have received several inquiries from the field requesting clarification regarding acoustic trauma versus noise exposure – who determines the acoustic trauma occurred, and when to consider tinnitus on a presumptive basis? A claims processor cannot concede acoustic trauma, only noise exposure. Acoustic trauma is damage to the hearing mechanisms within the ear and therefore can only be made by a clinician such as an audiologist. Again, acoustic trauma is a medical determination.

Tinnitus is a presumptive condition under 38 CFR 3.309a and should be granted service connection if a diagnosis appears and manifests to a compensable degree within one year of discharge. A medical opinion is not needed unless there is medical and/or lay evidence showing the condition may have been caused from post-service event, injury or illness. – This does not speak to the issue that Fountain v. McDonald says “tinnitus is considered an organic disease of the nervous system when there is evidence of acoustic trauma.”3 questions requested clarification

Q: The Quality Call directed that tinnitus would be considered a presumptive condition and the manual will be updated. However, it was my understanding that tinnitus is a presumptive condition (i.e. considered an organic disease of the nervous system) when there is evidence of acoustic trauma. M21-1 III.iv.4.G.1.d: “The court holding in Fountain v. McDonald, 27 Vet.App. 258 (2015) established that tinnitus is considered an organic disease of the nervous system when there is evidence of acoustic trauma.” We are curious about the information provided in the Call because it appears that the presenter is saying that as long as tinnitus is diagnosed within 1 year following separation from AD that the decision maker should grant SC. But, the Court case appears to have said that there must be acoustic trauma before tinnitus can be considered a presumptive condition. Can you please provide clarification of this?

Q: Can you please clarify the issue of tinnitus as a presumptive condition? The MR and Fountain v. McDonald decision instruct that tinnitus is an organic disease of the nervous system when there is evidence of acoustic trauma; however, the presenter mentioned that only a medical provider can determine if there was acoustic trauma. The slides indicated that we are to grant presumptively WITHOUT a medical opinion. How is this possible if acoustic trauma is a medical determination?

Q: On today’s Quality Call, the presenter discussed the issue of tinnitus being a presumptive condition, advising us that service connection should be granted if it manifested to a compensable degree in the applicable period as long as there are no intercurrent causes. However, M21-1 IV.ii.2.B.2.a, in citing the Fountain decision, states that we may only treat tinnitus as an organic disease of the nervous system

8516/8616/8716, 8517/8617/8717, 8518/8618/8718, 8519/8619/8719, 8520/8620/8720, 8521/8621/8721, 8522/8622/8722, 8523/8623/8723, 8524/8624/8724, 8525/8625/8725, 8526/8626/8726, 8527/8627/8727, 8528/8628/8728, 8529/8620/8729, 8530/8630/8730

W. Rees 166 updated 7/25/18

when there is evidence of acoustic trauma. As the presentation also cautioned us that acoustic trauma is medical rather than adjudicative determination, would we not need to pursue medical opinions in these cases where acoustic trauma is not medically shown?

Clarification finally provided 1/30/18: The statement in the manual (referenced above) is incorrect; tinnitus should be considered a chronic disease for purposes of 38 CFR 3.309(a) regardless of whether there is evidence of acoustic trauma of record. This includes treating tinnitus as a chronic disease when applying the principles of presumptive service connection under 38 CFR 3.307(a)(3). It also includes the situation at issue in Fountain, which is considering tinnitus a chronic disease when applying the holding in Walker v. Shinseki to determine whether service connection is established on the basis of continuity of symptomatology. See also 38 CFR 3.303(b).

The court, in Fountain, stated that 38 CFR 3.309(a) “includes tinnitus, at a minimum where there is evidence of acoustic trauma, as an ‘organic disease [ ] of the nervous system.’” [emphasis added] Because Mr. Fountain claimed service connection should be granted for tinnitus on the basis of continuity of symptomatology, and there was direct evidence of acoustic trauma in the record (e.g., audiograms meeting the criteria in 38 CFR 3.385 and an in-service diagnosis of hearing loss), the court’s qualifying statement made sense.

To require direct evidence of acoustic trauma in every case, however, does not make sense. In that regard, a Veteran’s records may show exposure to hazardous noise, as well as show tinnitus clinically diagnosed within one year of separation, but may not contain evidence of acoustic trauma. Absent a medical opinion as to whether the hazardous noise exposure resulted in acoustic trauma, the prior manual reference could not be applied. Generally, in that fact pattern, a medical opinion is not needed unless there is evidence (lay or medical) showing the condition may have been caused from a post service event, injury, or illness.

When tinnitus is NOT diagnosed and manifested to a compensable degree within a year from discharge, either direct or indirect evidence is needed to award service connection. Direct evidence is clear, undisputable proof of an event, injury, or disease. Such evidence includes, but is not limited to, in-service treatment, symptoms, or a diagnosis. Indirect evidence is evidence that relies on an inference to connect it to a conclusion. Such evidence includes, but is not limited to, noise exposure. When the service record does not contain direct evidence but does contain indirect evidence, the claims processor must concede the in-service event, injury, or illness. The threshold for concession is very low. Unless the medical evidence of record shows a formal diagnosis and competent medical nexus, an examination and medical opinion is needed. The current manual entries contradict the principle of service connection on a presumptive basis by requiring direct evidence of acoustic trauma; presumptive conditions do not require direct evidence during service. The relevant manual references are being processed for revision.

February 2018 Quality Call Notes – Q # 1: Under DC 6260, a 10% evaluation is warranted for recurrent tinnitus. For presumptive effective date purposes, at what point is tinnitus considered recurrent to establish a 10% evaluation? When claimed by the Veteran within a year of discharge (with no complaints in STRs and no post service treatment records) or the date of the Audio DBQ showing recurrent tinnitus (also with negative medical opinions about etiology of tinnitus)?

This is asked because this following scenario was asked by a RVSR: “A Veteran claims tinnitus within one year of discharge. It is not noted during service and there are no post service treatment records. The Audio VAE diagnoses tinnitus and notes it is recurrent but provides a negative opinion.” For presumptive purposes, is the effective date the date of claim (because a layperson can establish a diagnosis) or the date of Audio VAE (because it is identified as recurrent on that date)?

The RVSR and I discussed III.iv.4.D.3.b; III.iv.4.D.1.a; III.iv.4.N.1.d; CFRs 3.307, 3.309(a); and, 4.87 DC 6260. We decided date of claim would be appropriate. Since this topic was raised on the Quality Call, I would be interested in an official response.

A # 1: The Veteran is competent to report the frequency of the tinnitus symptoms; however, a Veteran is not competent to self-diagnose in a formal capacity. Therefore, the basic service-connection requirement of having a current, formal diagnosis was not met in this particular example until the VA examination (VAE). Thus, the date of the VAE, which is the “date entitlement arose,” is the appropriate effective date for presumptive service connection of tinnitus.

W. Rees 167 updated 7/25/18

Please refer to 38 CFR 3.400 (b)(2), which states the following: “(ii) Presumptive service connection (§§3.307, 3.308, 3.309). Date entitlement arose, if claim is received within 1 year after separation from active duty [emphasis added]; otherwise date of receipt of claim, or date entitlement arose, whichever is later. Where the requirements for service connection are met during service, the effective date will be the day following separation from service if there was continuous active service following the period of service on which the presumption is based and a claim is received within 1 year after separation from active duty.”

Another applicable reference is M21-1 III.iv.5.C.4.a - Effective Dates for Presumptive SC, which states the following: “The effective date will be the date entitlement arose [emphasis added] when all of the following criteria are met: the claim is received within one year of separation from active duty, and the requirements for SC are not met during service.” The example in III.iv.5.C.4.b parallels this scenario (see Appendix A). The date entitlement arose means the date the condition was shown to exist by medical evidence; for the definition reference, please refer to the Direct Service Connection section (click HERE) or III.iv.5.C.1.c, which states that it is the date on which the facts in the case demonstrate that the entitling criteria are first met. For clarity on the phrase, “whichever is later,” please review Example 2 of III.iv.5.C.1.d (see Appendix B).

Q # 2: The Veteran simply claims tinnitus within one year of discharge (no lay testimony that the condition is recurrent) and STRs are silent for tinnitus. There are no VA treatment records regarding tinnitus. The VAE is conducted more than one year from discharge and recurrent tinnitus is noted, but the opinion is negative for a direct basis to service. Although we have tinnitus shown within one year of discharge, the evidence shows it was first compensable (recurrent) after one year from discharge. Based on this fact pattern, can service connection still be granted on a presumptive basis?

A # 2: The Veteran submitted his/her claim within a year of discharge. It is not their fault that the VAE occurred passed the one-year mark. Since the VAE occurred in connection with the claim that was submitted within a year of discharge, it falls under the presumptive purview. Since the VAE established a formal diagnosis and showed that the condition was recurrent, the decision maker must grant the condition as a presumptive disability.

Q # 3: We and other ROs are trying to make sure that we get this tinnitus issue right. Tinnitus appears to be one of our most claimed conditions. And, it is also one of our more unusual claims since it is a totally subjective condition for which we grant SC. Now that it is considered a presumptive condition in all situations, we are hoping to get this guidance as clear as possible. The guidance provided in the January 2018 Quality Call Transcript seems to only view 3 scenarios. The 1st is where there is an in-service diagnosis of tinnitus. In that case the decision maker grants service connection (this would not involve presumptive service connection under 38 CFR 3.307, but would involve direct service connection under 38 CFR 3.303. The 2nd involves an after service diagnosis of tinnitus within 1 year of discharge. In that case, the decision maker grants service connection. The 3rd scenario involves no diagnosis of tinnitus within 1 year of discharge.

Today’s question is what if there isn’t a diagnosis of tinnitus within 1 year of discharge and, to make it clearer, there isn’t direct or indirect evidence (e.g. Veteran’s MOS has a low probability of noise exposure). Would the Veteran’s lay evidence, in a claim received more than 1 year after discharge from service, overcome the need for an opinion and support a grant of service connection for tinnitus on the basis of presumption? Since there is no way to prove the existence of tinnitus other than by subjective complaints of the condition, and the Veteran is competent to describe what he/she is personally experiencing [38 CFR 3.159(a)(2)], then would presumptive service connection for this organic disease of the nervous system be warranted without a medical opinion?

Note that for any other claim involving a presumptive condition [3.309(a)], there has to be objective evidence that the condition manifested to a compensable degree within the applicable time period. For example, a Veteran couldn’t say that his diabetes mellitus Type II was either diagnosed within 1 year following discharge from service or that it manifested to a compensable degree within 1 year of discharge from service and, based upon that statement, VA would grant SC on a presumptive basis.

W. Rees 168 updated 7/25/18

We would be required to develop for the medical records showing that the condition was diagnosed within 1 year following discharge from service or for the medical records showing symptoms developed within 1 year following discharge from service and a medical opinion relating a diagnosis of diabetes to those symptoms. However, if there are no medical or other records showing tinnitus symptoms within 1 year following discharge from service, do we still require a medical opinion?

A # 3: If the Veteran submitted his/her claim for tinnitus more than a year after discharge, a medical opinion is needed. For example, the Veteran was discharged on 01/01/2017. He submitted a claim for tinnitus on 03/13/2018. The service records, private medical records, and VA medical records are negative for a diagnosis, symptoms, and complaints. The only indirect evidence is a low probability MOS. Though the MOS concedes the in-service event, the other two criteria (diagnosis and link) are still needed. The claims processor must order an examination and medical opinion. If the examiner reports a current, formal diagnosis of tinnitus and provides a positive link between the diagnosis and the MOS, the decision maker must grant service connection on a direct basis.

Appendix A:

III.iv.5.C.4.b - Facts: The Veteran was discharged June 22, 2016. He submitted a claim for SC for hypertension on May 12, 2017. STRs show no evidence of treatment for or diagnosis of hypertension during service. Private treatment records show that the hypertension first manifested to a compensable degree on March 19, 2017.

Analysis: The claim for SC was received within one year of release from active duty, but the requirements for SC were not met during service. Thus, the effective date is the date entitlement arose, which is the date hypertension was first diagnosed, March 19, 2017.

Appendix B:

III.iv.5.C.1.d - Example 2: A Veteran claims SC for elevated blood sugar due to possible diabetes on October 8, 2014, associated with confirmed Vietnam service. Private treatment records are requested and received showing that his blood sugars were first slightly elevated in June 2013, and the records document continued monitoring thereafter. A VA examination dated January 3, 2015, indicates a diagnosis of type 2 diabetes mellitus, and the physician notes that the diagnostic criteria for diabetes were first met as shown in the private treatment records on November 13, 2014, when blood sugars and other testing met the American Diabetes Association criteria for a diabetes diagnosis, as the documented symptoms prior to that time were not sufficient for a diagnosis.

Osteitis deformans (Paget’s disease) 5016Osteomalacia 5014Palsy, bulbar 8005Paralysis agitans 8004Psychoses 9201, 9208, 9210, 9211Purpura idiopathic, hemorrhagic 7705Raynaud’s disease 7117Sarcoidosis 6846Scleroderma 7821-7806Sclerosis, amyotrophic lateral (eff 9/23/08 anytime after service if had at least 90 days of service), III.iv.4.N.6.b confirms that 3.114 applies 3.318 III.iv.4.N.6.b – primary lateral sclerosis (PLS) excluded

8017

Sclerosis, multiple (7 yr pres period, per 3.307) 8018Syringomyelia 8024Thromboangiitis obliterans (Buerger’s disease) 7115Tuberculosis, active (3 yr pres period per 3.307) 6701, 6702, 6703, 6704, 6730Tumors, malignant, or of the brain or spinal cord or peripheral nerves 5012, 5327, 6014, 6208, 6819, 7343,

7528, 7627, 7818, 7833, 7914, 8002, 8021, 9918

Ulcers, peptic (gastric or duodenal)(A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data.)

7304, 7305, 7306

Walker v. Shinseki (2/21/13) - says 3.303(b) provisions apply only to chronic diseases identified in 3.309(a); “Service W. Rees 169 updated 7/25/18

connection for a disease not listed under 3.309(a) may not be established on the basis of chronicity provisions of 3.303(b), but would have to satisfy the typical three-element nexus of 3.303(a). The provisions of § 3.303(b) also provide that if a chronic disease is shown in service or within the presumptive period, subsequent manifestations of the same chronic disease at any later date will be service connected unless clearly attributed to intercurrent causes. The regulation provides that if a condition noted in service or in a presumptive period is not clearly identified as a chronic disease during such periods, a showing of continuity of symptomatology is necessary to establish service connection for the disease under § 3.303(b).”

Subordinate Issues handout says hiatal hernia (7346) is a chronic disability.

April 2014 Compensation Service Bulletin (CSB) - Walker v. Shinseki (2013) says that continuity of symptomatology under 3.303(b) may only be used to establish service connection for a chronic disease listed under 3.309(a). For all other disabilities, service connection must be established through 3.303(a), which requires a medical nexus between the condition in service and the current disability as part of the standard three-element test for entitlement to disability compensation… but, evidence of continuous symptoms may be used to support a nexus under the three-element test of 3.303(a), as all evidence bearing upon service connection should be evaluated under the three-part nexus test and evidence of continuous symptoms following service may be relevant to determinations of service connection under the nexus standard. Evidence of continuous symptoms alone may also be sufficient to satisfy the nexus requirement under 3.303(a) and warrant a grant of entitlement to service connection under that regulation. Use “continuity of symptomatology” for 3.303(b) and “evidence of continuous symptoms” for 3.303(a)

April 2017 Quality Call Notes –

Question: Can you provide clarification on granting service connection for chronic disabilities (listed under 38 CFR 3.309 a)? It was noted that these condition would generally be granted service connection at 0% if the condition was diagnosed in service and the Veteran then failed to report to an examination. Would you be able to clarify when service connection would not be granted for a chronic condition when diagnosed during service? Or is more appropriate to state that chronic condition listed under 3.309a should always be granted?Answer: Service connection is not appropriate in every case that demonstrates this fact pattern – rebuttal of the idea that a set of circumstances exists that always results in an “automatic” grant or denial without consideration of the totality of the evidence is the central theme of this training. For this particular point, service connection would not be appropriate for a 38 CFR 3.309(a) chronic disease under 38 CFR 3.303(b) if the totality of the evidence demonstrates an intercurrent cause to rebut the presumption between in-service occurrence and the claim. See also 38 CFR 3.307(b), Groves v. Peake, May 1, 2008, 524 F.3d 1306, and Walker v. Shinseki, Feb 21, 2013, 708 F.3d 1331.

…

III.iii.1.B.1.c – clarifying issues

As of 3/24/15, IV.ii.2.A.1.f:VSR, solicitation is needed, so please include this in the notification letter to the Veteran: “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.”

VSR, clarification* is needed, so please include this in the notification letter to the Veteran: “It is unclear whether you are seeking service connection for {} based on {list evidence that is unclear} received on {}. If you want to file a claim for {}, 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.”*this a clarification, not a solicitation

VSR, clarification* is needed, so please include this in the notification letter to the Veteran: “It is unclear whether you are seeking an increased evaluation for your service-connected {} based on the {list evidence that is unclear} received on {}. We recommend you clarify your intent as soon as you can, in order to ensure the earliest possible payment date, if an award is authorized.”*this a clarification, not a solicitation

W. Rees 170 updated 7/25/18

QRT FY13 Local Narratives – if claimed left eye, but VAE diagnoses right eye, should deny left eye and invite right eye

March 2016 Quality Call Notes – Solicitation of a claim for increase is only required for diabetes mellitus & it’s complications (if DM &/or that specific complication(s) NOT claimed, but another complication was claimed; my example: eyes claimed, but TRs show nephropathy diagnosed/worsened), per III.iv.4.M.1.g; otherwise solicitation of a claim for SC for chronic, unclaimed disabilities notes in STRs is just encouraged, per IV.ii.2.A.1.a (says it is not an error NOT to solicit) (also says, in Q&A, if claimed PTSD & increase in DM shown in TRs, could consider soliciting CFI, seems not to be required in this case) [per QRT/GiaBao Nguyen, 5/25/17, if see worsening in SC cond in DBQ, can solicit claim & if claim within one year, can use date of DBQ for effective date]

August 2016 Quality Call Notes – Claim for “exposure to Agent Orange” on 526 with subsequent 4138 claiming SC for diabetes cannot be considered the same claim unless we call veteran & clarify, per IV.ii.1.H.1.j

3.309(b) Tropical diseases – 3.307 3.308IV.ii.1.HIV.ii.2.BIII.iv.4.EOnly the following diseases shall be granted service connection as a result of tropical service, although not otherwise established as incurred in service if manifested to 10% within 1 year from date discharge or at a time when standard accepted treatises indicate that the incubation period commenced during such service.Need 90 days svc (per 3.307(a)(1))

Amebiasis (digestive)Blackwater feverCholeraDracontiasisDysentery (7322)FilariasisLeishmaniasis, including kala-azar [oriental sore and espundia (old world cutaneous and American mucocutaneous leishmaniasis)], up to 1 yr incubation (skin)LoiasisMalaria Onchocerciasis (skin)Oroya fever [verruga peruana is a late residual] (skin)Pinta (skin)Plague Schistosomiasis (digestive)YawsYellow feverResultant disorders or diseases originating because of therapy administered in connection with such diseases or as a preventative thereof.

3.309(c) Prisoners of War –

3.1(y) 3.22 3.304(e) 3.307 3.309(c) III.iii.2.G – Former Prisoner of War Service Records

III.iv.3 – Exams

III.v.1.C – Former Prisoner of War Status

IV.ii.1.G – Claims Based on Former Prisoner of War Status

W. Rees 171 updated 7/25/18

IV.ii.2.E – Service Connection for Disabilities Incurred as a Prisoner of War

IV.ii.2.F.4.e – IU

Diseases specific as to former prisoners of war. If a veteran is: (1) A former prisoner of war and; (2) as such was interned or detained for not less than 30 days, only the following diseases shall be service-connected if manifest to a degree of 10% or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service (or if at 0% now). No requirement for 90 days svc (per 3.307(a)(1))

Avitaminosis 6313 8/12/70Beriberi (including beriberi heart disease*) lack of thiamine (peripheral neuro, cerebral & cardio abnormalities)

6314 or 7005 8/12/70

Chronic dysentery 7322 8/12/70Helminthiasis (worms) 7399-7324 8/12/70Malnutrition (including optic atrophy associated with malnutrition)

6399-6313 8/12/70

Pellagra (niacin deficiency; skin-dermatitis where there was trauma or exposure to light, gastro, mucosal, neuro disturbances & mental)

6315 8/12/70

Any other nutritional deficiency ??? 8/12/70*Psychosis III.iv.4.O.1.g 9201 thru 9211 8/12/70*Any of the anxiety states (incl. PTSD) 9400 thru 9413 10/1/81*Dysthymic disorder (or depressive neurosis) 9433 thru 9435 10/1/83*Organic residuals of frostbite, if it is determined that the veteran was interned in climatic conditions

7122 10/1/86

*Post-traumatic osteoarthritis (need report of trauma & MD's opinion that it is traumatic from the POW experience (as opposed to from aging))

5010-DC for location 10/1/86

Irritable bowel syndrome 7319 5/20/88Peptic ulcer disease 7304 thru 7306 5/20/88Peripheral neuropathy except where directly related to infectious causes

8510 thru 8730 5/20/88

Cirrhosis of the liver 7312 7/18/03*Atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia)

7005-ASHD/CAD, 7006-MI, 7007-hypertensive heart dz, 7010 & 7011-arrhythmias, 7017-CABG, 7018-pacemaker, 7019-transplant, 7020-cardiomyopathy, 7101-hypertensive vascular disease/htn

10/7/04

*Stroke and its complications 8008-thrombosis of brain vessels, 8009-hemorrhage from brain vessels

10/7/04

Osteoporosis 5013 9/28/09& any condition secondary to those above.

Note: For purposes of this section, the term beriberi heart disease includes ischemic heart disease in a former prisoner of war who had experienced localized edema during captivity. Don't need beriberi diagnosis. 8/24/93 (includes arteriosclerotic heart disease, CAD, MI, secondary conds, aneurysm of the heart wall, aneurysm of the coronary artery, & arrhythmias w/medical opinion; excludes hypertension, arteriosclerosis, aortic stenosis, PVD, stroke, aortic aneurysm (7110), and renal nephrosclerosis-even if any are secondary to the heart cond.) (Authority: 38 U.S.C. 1112)

*30 days not required, effective 12/16/03 (subject to 3.114)

3.309(e) herbicide (Agent Orange) exposure –January 9, 1962, to May 7, 1975- per 3.307 & IV.ii.1.H2, 4-D or 2, 4, 5-T; TCDD; cacodylic acid; picloram- per 3.307If a veteran was exposed to an herbicide agent during active military, naval, or air service, only the following diseases shall be service-connected if manifested to 10% at any time after exposure, unless otherwise noted. No requirement for 90 days svc (per 3.307(a)(1))

Polovick v. Shinseki (4/22/09) - VA is not required to grant presumptive service connection for disabilities not on VA’s presumptive Agent Orange list on the basis of the opinions of individual doctors that there is a statistical correlation between Agent Orange exposure and such disabilities.

I.1.B.1.f – need to send additional notice, per IV.ii.1.H.1.f, IV.ii.1.H.1.k

Date Disabilities Became Subject to Presumptive Service Connection – IV.ii.2.C.3.i

Chloracne or other acneform disease consistent with chloracne (1 year presumptive period from date of exposure, per 3.307), 3.813

7829 2/6/91

W. Rees 172 updated 7/25/18

Non-Hodgkin’s lymphoma (NHL)

Rec’d via email on 1/9/13:Subtypes of Non-Hodgkins Lymphoma (WHO Classification) Cell Origin Tumor Precursor B-cell tumor Precursor B-lymphoblastic leukemia/lymphoma* Mature B-cell tumors B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma† B-cell prolymphocytic leukemia† Lymphoplasmacytic lymphoma† Splenic marginal zone B-cell lymphoma (± villous lymphocytes) † Hairy cell leukemia† Plasma cell myeloma/plasmacytoma† Extranodal marginal zone B-cell lymphoma of the MALT type† Nodal marginal zone B-cell lymphoma (± monocytoid B cells)† Follicular lymphoma† Mantle cell lymphoma‡ Diffuse large B-cell lymphomas* (including mediastinal large B-cell lymphoma and primary effusion lymphoma) Burkitt's lymphoma* Precursor T-cell tumor Precursor T-lymphoblastic lymphoma/leukemia* Mature T-cell tumors T-cell prolymphocytic leukemia† T-cell granular lymphocytic leukemia* Aggressive NK cell leukemia* Adult T-cell lymphoma/leukemia* (HTLV 1-positive) Extranodal NK/T-cell lymphoma, nasal type* Enteropathy-type T-cell lymphoma* Hepatosplenic γ-δ T-cell lymphoma* Subcutaneous panniculitis-like T-cell lymphoma* Mycosis fungoides/Sézary syndrome† Anaplastic large cell lymphoma, T/null cell, primary cutaneous type* Anaplastic large cell lymphoma, T-/null-cell, primary systemic type* Peripheral T-cell lymphoma, not otherwise characterized* Angioimmunoblastic T-cell lymphoma*

*Aggressive. †Indolent. ‡Indolent but more rapidly progressive.HTLV = human T-cell leukemia virus 1; MALT = mucosa-associated lymphoid tissue; NK = natural killer; ± = with or without.

October 2013 Compensation Service Bulletin (CSB) – NHL includes mycosis fungoides (a cutaneous T-cell lymphoma, which is manifested by skin symptoms that can appear as patches, plaques, or tumors). See full write-up under 3.313 below, III.iv.4.K.2.e – 7715-7818 or just 7715

7715 2/6/91 (or 8/5/64 under 3.313) (Nehmer)

Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma)including:

Adult fibrosarcoma Angiosarcoma (hemangiosarcoma and lymphangiosarcoma) Alveolar soft part sarcoma Clear cell sarcoma of tendons and aponeuroses Congenital and infantile fibrosarcoma Dermatofibrosarcoma protuberans Ectomesenchymoma Epithelioid leiomyosarcoma (malignant leiomyoblastoma) Epithelioid sarcoma Extraskeletal Ewing’s sarcoma Leiomyosarcoma Liposarcoma Malignant fibrous histiocytoma, ganglioneuroma, giant cell tumor of tendon sheath, granular cell tumor, glomus tumor, hemangiopericytoma, mesenchymoma or schwannoma (including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas)Proliferating (systemic) angioendotheliomatosis Rhabdomyosarcoma Synovial sarcoma (malignant synovioma)

5329 or 8540 2/6/91 (Nehmer)

Hodgkin’s disease 7709 2/3/94 (Nehmer)Porphyria cutanea tarda (1 year presumptive period from date of exposure, per 3.307), 3.813 7815 2/3/94 (Nehmer)Multiple myeloma*generally multiple myeloma is 100% P&T (rare exceptions), per III.iv.4.K.2.a

7799-7709 6/9/94 (Nehmer)

Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) 6819 6/9/94 (Nehmer)Prostate cancer 7528 11/7/96 (Nehmer)

W. Rees 173 updated 7/25/18

Early-onset peripheral neuropathy (previously acute and subacute, changed 9/6/13) (per Note 2 - means transient peripheral neuropathy that appears w/i weeks or months of exposure and resolves w/i 2 years of date of onset; per 3.307 - 1 year presumptive period from date of last exposure to herbicides)

8510 thru 8730 11/7/96 (Nehmer)

Type 2 diabetes (also known as adult-onset diabetes) 7913 5/8/01 (Nehmer & Liesegang; previously 7/9/01)

Chronic Lymphocytic Leukemia (CLL) - *should be 100% P&T, per III.iv.4.K.2.c

7799-7703 10/16/03 (Nehmer)

AL Amyloidosis (“amyloid light chain” primary amyloidosis, ALA)*should be 100% P&T, per III.iv.4.K.2.b

7717, per III.iv.4.K.2.b

5/7/09 (Nehmer)

All chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia (CLL))

(also including hairy cell leukemia, acute lymphoblastic leukemia/lymphoma (ALL), mantle cell lymphoma (MCL), Burkitt lymphoma, mucosa associated lymphoid tissue (MALT), B-cell chronic lymphocytic leukemia/small cell lymphocytic lymphoma, acute lymphoblastic leukemia mature B-cell type, B-cell prolymphocytic leukemia, pre-cursor B lymphoblastic leukemia, diffuse large B-cell lymphoma, follicular lymphoma, mediastinal large B-cell lymphoma, Waldenstrom Macroglobulinemia, nodular marginal zone B-cell lymphoma (NMZL), splenic marginal zone lymphoma (SMZL), nodal marginal zone b-cell lymphoma (NMZL), extranodal marginal zone B-cell lymphoma, intravascular large B-cell lymphoma, primary effusion lymphoma, lymphomatoid granulomatosis)

(excluding myeloid stem cells, myeloblasts, granulocytes, red blood cells, platelets, T lymphocytes, natural killer cells, precursor T acute lymphoblastic leukemia/lymphoma, prolymphocyte or prolymphocytic, anaplastic large cell or lymphomatoid papulosis, cutaneous [mycosis fungoides, Sezary’s disease, hepatosplenic, angioimmunoblastic], enteropathic associated with T-cell lymphoma, adult T-cell leukemia/lymphoma, blastic NK lymphoma, extra nodal NK-T cell lymphoma, large granular lymphocytic leukemia, acute biphenotypic leukemia, lymphoproliferative disorder, x-linked lymphoproliferative disease, autoimmune lymphoproliferative syndrome, leukemoid reaction, pseudolymphoma) However, consider service connection under Non-Hodgkin’s lymphoma for T-cell or any lymphoma that is not B-cell.

Leukemias are classified in two important ways. The first is as either Acute or Chronic. Long story short, the Chronic leukemias have the more favorable diagnoses because they're indolent, or slow-growing, and sometimes don't require treatment for years. The Acute leukemias are aggressive and life-threatening; they come on very quickly, and patients can sometimes die within weeks of being diagnosed. The second is as either Myeloid or Lymphoid. If Myeloid, it means the cancer involves the myeloid cells, which are the white blood cells that create neutrophils, which our bodies need to fight foreign bacteria. If Lymphoid, it means the cancer involves the lymphoid cells, the white blood cells that create lymphocytes, which our bodies need to fight off anything non-bacterial.

Myeloid is NOT associated with AO. Lymphoid is associated with AO.

7703

(in the past, may also have used 7799-7700 and 7799-7716)

8/31/10 (Nehmer)

W. Rees 174 updated 7/25/18

Parkinson’s disease

(excluding other motor system disorders like Parkinsonism, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, dementia with Lewy bodies)

Per IV.ii.2.A.2.a – Parkinson-like tremor is a subthreshold diagnosis

Per IV.ii.2.C.3.i – excludes Parkinsonism and/or Parkinsonian syndromes

From Rating Team 2/24/11 POD: Evaluating disabilities using Disability Benefit Questionnaires (DBQ): a. RVSRs should use the information provided by the DBQ to identify Veteran

disabilities.  RVSRs should never "diagnose" disabilities on their own.  For example, the Parkinson's DBQ provides information on SPEECH CHANGES (none, mild, mod, severe).  The RVSR should rate this condition as SPEECH CHANGES secondary to Parkinson's disease.  Describing this condition as APHONIA would be incorrect, unless there is an actual medical diagnoses APHONIA due to Parkinson's disease somewhere in the evidence. 

b. The same rule applies for DIFFICULTY CHEWING/SWALLOWING.  If a diagnosis of DYSPHAGIA is not provided, identify this disability as DIFFICULTY CHEWING/SWALLOWING secondary to Parkinson's disease.

c. RVSR should not assign an evaluation for STOOPED POSTURE, BALANCE IMPAIRMENT, or SLEEP DISTURBANCE unless an associated disability is identified.  If clarification is needed, request appropriate VAE.

d. RVSR should not assign an evaluation for DEPRESSION and/or COGNITIVE DISORDER without appropriate medical evidence.  If the only available evidence is the DBQ, an examination will be required.

*as of before 3/17, no one is following c or d, see below VA Pulse info

March 2015 Quality Call Notes – steps to properly evaluate Parkinson’s using VBMS-R (to avoid override) – “Neurological Other System,” then “Paralysis agitans,” then “Minimum” or “Rate Residuals,” use other Calculators to evaluate each residual, one-at-a-time

https://www.vapulse.net/docs/DOC-78794

Parkinsons_Tool (from VA Pulse).xlsm and Parkinsons DBQ Rating Help (from VA Pulse) are saved at H:\VSC\Rating ReferencePeripheral Nerve Evaluation Matrix on Rating Job Aids page also has some notes under “Top 10 Highlights” tab

My list (complied from above & other info):Impairment Diagnostic Code Optionsstooped posture 5327 I 8211 I 5320balance impairment 6204 I 8211 I 8209bradykinesia or slowed motion Rate with extremity under nerves I 5307 I 5310loss of automatic movements 8207 I 8205speech changes 6519 I 6516 I 8210 I 82XXtremors – UEs 8514 I 8513 I nerve indicated I 5215/5109tremors – LEs 8521 I 8520 I nerve indicated I 5167/5010muscle rigidity – UEs 8514 I 8513 I nerve indicated I 5307 I

5215/5109muscle rigidity – LEs 8521 I 8520 I nerve indicated I 5310 I

5167/5010depression 9434cognitive impairment or dementia

9310 I 9326

loss of sense of smell 6275sleep disturbance Combined w/mental I 9400 I 6847difficulty chewing 6521 I 7203 I 8205 I 82XXconstipation 7332 I 7319 I 8210sexual dysfunction 7522urinary problems 7541 I 7542loss of taste 6276

8004

*speech changes or dysarthria8212 (twelfth/hypoglossal cranial nerve) [Audrey Reid uses 6516]

*difficulty chewing/swallowing 7299-7203 (analogous to esophageal stricture)

*loss of smell 6275

*UE 8516 (ulnar nerve) [Audrey Reid uses 8510 (upper radicular group/fifth & sixth cervical)]

*LE 8521 (external popliteal nerve/common peroneal) [Camp Lejeune training uses 8520 (sciatic nerve)]

8/31/10 (Nehmer)

W. Rees 175 updated 7/25/18

Ischemic heart disease

III.iv.4.G.1 - Arteriosclerotic heart disease, also diagnosed as ischemic heart disease (IHD) and coronary artery disease (CAD), is a disease of the heart caused by the diminution of blood supply to the heart muscle due to narrowing of the cavity of one or both coronary arteries due to the accumulation of fatty material on the inner lining of the arterial wall.

IV.ii.2.C.4.c - IHD (including, but not limited to, acute, subacute, and old myocardial infarction (MI); atherosclerotic cardiovascular disease (ASCVD) including coronary artery disease (CAD) (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal’s angina

(also including coronary atherosclerosis, arteriosclerotic heart disease, atherosclerotic cardiovascular disease, acute coronary syndrome, coronary heart disease, angina pectoris, anginal syndrome, coronary insufficiency, ischemic cardiomyopathy, cardiomyopathy, variant angina (indicates a rapid progression of CAD), atherosclerosis, heart failure/congestive heart failure, heart transplant, silent ischemia, status post angioplasty (PTCA))

(excluding hypertension, PVD/PAD, stroke/TIA, valvular heart disease)

Per Carlos Rosario:

Must involve the coronary arteries (right coronary artery, RCA and left coronary artery/left anterior descending artery, LAD), not the aorta or carotids (“plumbing”), not the valves (“electrical”) and not the arteries in the legs.

Excludes arrhythmias, endocarditis, pacemakers for non-IHD/CAD, lower extremity arteriosclerosis/atherosclerosis/PVD, thrombosis, embolus, WPW syndrome, heart block, sick sinus syndrome, BBB, MVP, hypertensive heart disease.

Ensure “cardiomegaly,” “cardiomyopathy” and “congestive heart failure” are a result of IHD/CAD.

Percutaneous coronary intervention (PCI) is commonly known as angioplasty

Per VA Pulse, https://www.vapulse.net/thread/7792, do not grant SC for underlying atherosclerosis (disease process characterized by hardening and narrowing of the arteries and can occur throughout the entire body (including the heart, brain and carotids))

IHD

7005, 7006, 7017, 7019, 7020

8/31/10 (Nehmer)

Conditions having No Positive Association with Herbicide exposure (from IV.ii.2.C.3.k):

Cancers o bone and jointo brain and nervous system (including eye)o breast (7627)o digestive (including esophagus, stomach, colon-rectum, small intestine, and anus)o endocrine (including thyroid and thymus)o hepatobiliary (liver, gallbladder, and bile ducts) and pancreatico leukemia (excluding chronic B-cell leukemias such as CLL and hairy cell)o nasal cavity (including ears and sinuses)o oral cavity (including lips and tongue)o pharynx (including tonsils)o pleura, mediastinum, and other unspecified sites within the respiratory system and intrathoracic organso renal (kidney and renal pelvis)o skin (including melanoma, basal cell carcinoma, and squamous cell carcinoma) (7818, 7833)o reproductive (including the cervix, uterus, ovary, testes, and penis, but excluding prostate)o urinary bladder (7528)o any cancers for which the Secretary has not already established a presumption.

Othero bone conditionso circulatory disorders (but excluding IHD)o cognitive and neuropsychiatric effectso endometriosiso eye problems

W. Rees 176 updated 7/25/18

o gastrointestinal, metabolic, and digestive disorders (including changes in liver enzymes, lipid abnormalities, and ulcers)

o hearing losso immune system disorders (immune suppression, allergy, and autoimmunity)o neurobehavioral (cognitive and neuropsychiatric) disorderso neurodegenerative diseases (including amyotrophic lateral sclerosis (ALS), but excluding Parkinson's

disease)o conditions affecting offspring of exposed persons (including neonatal death, infant death, stillborn, low birth

weight, birth defects other than spina bifida, and childhood cancer such as acute myeloid leukemia)o chronic peripheral nervous system disorders such as late-onset PN (but excluding early-onset PN)o reproductive effects, such as abnormal sperm parameters and infertilityo respiratory disorders(but excluding covered respiratory cancers) such as asthma and chronic obstructive

pulmonary disease (COPD), ando effects on thyroid homeostasis.

*hypertension (added 6/10/08, not listed at IV.ii.2.C.3.k , but have AO2)

IV.ii.2.C.3.k Note: No positive association means that the evidence for an association does not equal or outweigh the evidence against association.

I asked a question on VA Pulse about soliciting medical evidence for claims for the above disabilities & was told VSRs are still to include those paragraphs, https://www.vapulse.net/message/41806

Manual & in-country References:

2/28/61-5/7/75, My Notes: USARV on DD214 usually means RVN (but it’s not enough on it’ sown), USARPAC in SPRs usually means RVN (but it’s not enough on it’s own)

USED USARPAC FOR RVN:

for deferral: We need to request the SPRs. *See Claim Notes for more details.

for Claim Note: Claim is not RFD. We need to request the SPRs. The notes on the DD214 say USARPAC means RVN service, but that is not VA policy. IV.ii.1.H.1.g says the DD214 needs to show “Republic of Vietnam” or “RVN” & that receipt of the Vietnam Service Medal is not acceptable proof of RVN service for the purpose of proving herbicide exposure. Deferral done.

IV.ii.1.H – inland waterways, offshore waters, duty, visitation

IV.ii.1.H.1.d – development steps for verifying RVN service

IV.ii.1.H.1.g – Receipt of the Vietnam Service Medal, Vietnam Campaign Medal, Armed Forces Expeditionary Medal and/or the Vietnam Cross of Gallantry is not acceptable proof of RVN service for the purpose of proving herbicide exposure. IV.ii.1.H.1.i – mark “RVN service, pg {#}” in Subject line of document (updated 6/23/17)

IV.ii.1.H.2IV.ii.2.C.3.m – Da Nang, Vung Tau, Qui Nhon, Ganh Rai Bay and Cam Ranh Bay are deep-water coastal harbors, not inland waterways or shore dock, need confirmation that went ashore during anchorage

IV.ii.2.C.3 – IV.ii.2.C.3.n apply 3.156(c) if previously denied & now have ship/Thailand/DMZ evidence

IV.ii.1.H.9.b & IV.ii.2.C.4 – Nehmer info; can’t go prior to 9/25/85, the date the regulation was effective

AO outside RVN:

AO3 for secondary or remote contact with an aircraft or equipment previously used in Vietnam, IV.ii.1.H.2.m

DMZ (KOREA) – IV.ii.1.H.4.b - list of units in DMZ (Korea) when AO was used [April 1968 to August 1971], per IV.ii.1.H.4.c, if not

during those dates or in one of the units/entities from IV.ii.1.H.4.b, send a JSRRC request (need dates, location(s) & nature of exposure)

W. Rees 177 updated 7/25/18

OTHER LOCATIONS THAN RVN OR DMZ – email Compensation Service and request a review of DoD’s inventory of herbicide operations to determine whether herbicides were used as alleged (if have dates, location and nature of alleged exposure), if not need formal finding that sufficient information required to verify herbicide exposure does not exist, per IV.ii.1.H.7.a, as of 3/27/18, formal finding no longer needed (except for Thailand)

https://www.publichealth.va.gov/exposures/agentorange/locations/tests-storage/index.asp

IV.ii.1.H.2.l & m – Use of JSRRC's Memorandum in Claims of Exposure From Herbicides Being Stored or Transported on Veteran's Ship May 2009 Compensation Service Bulletin (CSB) & 5/1/09 Memorandum for Record from the Department of the

Army, U.S. Army & Joint Services Records Research Center – “the JSRRC has found no evidence that indicates Navy or Coast Guard ships transported tactical herbicides from the United States to the Republic of Vietnam or that ships operating off the coast of Vietnam used, stored, tested, or transported tactical herbicides. Additionally, the JSRRC cannot document or verify that a shipboard veteran was exposed to tactical herbicides based on contact with aircraft that flew over Vietnam or equipment that was used in Vietnam.”

JOHNSTON ISLAND – IV.ii.1.H.6

THAILAND – IV.ii.1.H.5 – (1) Royal Thai Air Force Bases (RTAFBs) as security policeman, security patrol dog handler, member of

security police squadron, or otherwise near the air base perimeter, can concede herbicide exposure; (2) on U.S. Army Base in Thailand as MP or with a MP occupational specialty, concede herbicide exposure; (3) if neither of the first two, follow chart at IV.ii.1.H.5.b

IV.ii.1.H.10.c - Formal finding that the Department of Veterans Affairs (VA) lacks the information the U.S. Army and Joint Services Records Research Center (JSRRC) requires to verify herbicide exposure in [LOCATION(S)]. – as of 3/27/18, only for Thailand

W. Rees 178 updated 7/25/18

W. Rees 179 updated 7/25/18

APO NUMBER GEOGRAPHICAL LOCATION

DATE APO OPENED

DATE APO CLOSED

APO NUMBER GEOGRAPHICAL LOCATION

DATE APO OPENED

DATE APO CLOSED

96201 Tan Son Nhut AB, Saigon, RVN 11/15/66 3/13/73 96262 Camp Redcliff, An Khe 3/1/70 12/15/7096203 Monkey Mnt., Quang Nam, RVN 11/10/66 3/6/73 96265 Tuy Hoa, RVN 9/10/66 4/9/6796204 Dalat, RVN 11/10/66 10/1/72 Pleiku 4/10/67 12/15/7096205 Nha Trang AB, RVN 12/1/66 3/28/73 96266 Long Binh, RVN 6/1/66 3/28/7396214 Nhe Be, RVN 11/1/66 5/11/68 96268 Ban Me Thuot, RVN ? 10/9/6696215 Can Tho, RVN 1/1/65 9/ /73 Bear Cat, RVN 10/10/66 7/13/6796216 Tay Ninh, RVN 4/11/67 2/28/71 Dau Tieng 7/14/67 10/1/7296217 Duc Phu, RVN 12/28/67 12/28/71 96269 Dong Ha, RVN 11/5/66 4/16/7296219 Chu Lai, RVN 10/17/67 4/7/71 96278 Pleiku 7/16/66 12/15/7096221 Phuoc Vinh, RVN 12/31/67 5/9/71 96279 Long Binh, RVN 12/1/66 2/15/71

Phan Thiet 5/10/71 10/1/72 96289 Saigon (Di An), RVN 3/4/66 4/15/7296222 Cholon, Saigon, RVN 11/1/66 2/12/68 96291 Vung Tau, RVN 1/1/65 3/25/73

Tan Son Nhut AB, Saigon, RVN 2/13/68 3/28/73 96294 An Khe, RVN 3/4/66 7/24/7296223 Phu Bai, RVN 1/26/68 10/20/68 Cheo Reo 7/25/72 10/1/72

Long Binh 10/21/68 11/19/69 96295 Pleiku Airport, RVN 1/1/65 4/18/7296225 Cu Chi, RVN 3/ /66 4/20/71 96296 Soc Trang, RVN 1/1/65 10/1/7296226 Phu Tai Valley, Bin Dinh, RVN 10/1/68 4/25/72 96297 Ban Me Thuot, RVN 1/1/65 3/15/7396227 Bien Hoa AB, RVN 1/1/65 3/14/73 96307 Tan Son Nhut AB, RVN 1/1/65 3/13/7396228 Bear Cat, RVN 2/15/68 2/16/68 96308 Phu Bai Airport, RVN 3/25/65 2/10/73

Chu Lai, RVN 2/17/68 3/10/68 96309 Cholon, RVN 5/1/65 2/ /68Phu Bai, RVN 3/11/68 9/24/68 Tan Son Nhut 2/ /68 3/28/73Bien Hoa AB, RVN 9/25/68 10/27/68 96312 Cam Ranh Bay, RVN 5/1/65 6/21/72Tan Son Nhut AB, Saigon, RVN 10/28/68 12/10/69 96314 Tan Son Nhut Afld., RVN 1/1/65 4/20/72

96230 Da Nang AB (west), RVN 11/1/71 11/30/71 96316 Tuy Hoa AB, RVN 5/1/65 2/22/7296234 Bien Hoa AB, RVN 12/10/71 2/28/72 96317 Phan Thiet, RVN 5/1/65 12/26/70

Tan Son Nhut AB, Saigon, RVN 3/1/72 5/2/75 Da Nang 12/27/70 4/27/7296236 Duong Dong, RVN 7/13/67 1/6/69 96318 Camp Holloway, Pleiku, RVN 5/1/65 6/6/7196238 Qui Nhon, RVN 1/1/65 4/25/72 Camp Schmidt, Pleiku 6/7/71 3/28/7396240 Nha Trang AB, RVN 1/1/65 9/ /73 96320 Binh Thuy, RVN 8/6/65 4/16/7296243 Saigon, RVN 1/1/65 9/3/73 96321 Phan Rang AB, RVN 8/20/65 3/25/72

Tan Son Nhut AB, Saigon, RVN 9/4/73 5/2/75 96322 Tan Son Nhut Afld., RVN 10/1/65 6/15/6996256 Tay Ninh, RVN 8/1/66 4/15/67 96325 Chu Lai, RVN 10/1/65 12/28/71

Chu Lai, RVN 4/16/67 4/30/69 96326 Cam Ranh Bay AB, RVN 10/29/65 5/17/72Moc Bai, Quang Tin Province (LZ Baldy) 5/1/69 6/6/71 96327 Phu Quoc I, RVN 11/5/65 3/1/67Da Nang 6/7/71 6/22/72 96332 Camp Davies, Saigon, RVN 10/15/67 10/9/68

96257 Xuan Loc (Long Giow), RVN 7/8/66 9/25/69 Long Binh 10/10/68 10/25/72Bien Hoa 9/26/69 4/4/70 96337 Da Nang Airport, RVN 1/1/65 3/9/73Di An 4/5/70 5/ /71 96345 Qui Nhon, RVN 7/1/65 7/26/65Long Binh 5/ /71 12/6/71 Bien Hoa 7/27/65 11/11/65Pho Loi 12/7/71 12/28/72 Saigon 11/12/65 4/2/70

96258 Hue, RVN 1/1/65 2/10/73 96347 Bien Hoa or Cam Ranh Bay, RVN 7/8/65 7/31/6596260 Quang Ngai, RVN 1/1/65 2/10/73 An Khe 8/1/65 11/13/6596262 Saigon, RVN ? 8/5/66 Phan Rang 11/14/65 6/ /68

Pleiku 8/6/66 2/28/70 Bien Hoa 6/ /68 9/14/6896347 Long Binh 9/15/68 3/28/73 96393 Saigon, RVN 3/1/73 5/2/7596348 Tan Son Nhut AB, RVN 9/20/67 2/28/72 96395 Quang Tri, RVN 8/9/71 3/30/72

Long Binh 3/1/72 2/20/73 96398 Di An, RVN 11/15/70 2/25/7196349 Da Nang 5/1/68 3/28/73 Phu Loi 2/26/71 10/31/7296350 Nha Trang, RVN 10/25/66 4/5/72 96399 Saigon, RVN 10/26/70 3/28/7396355 Pleiku, RVN 1/1/66 7/31/67 96402 Bac Lieu, RVN 1/1/65 10/1/72

Doc Pho 8/1/67 1/27/68 96477 Quang Tri, RVN 7/15/68 8/15/71LZ Baldy 1/28/68 3/1/68 96485 Phu Cat, RVN 1/1/72 5/ /72LZ English, Bong Son 3/2/68 3/29/68 Qui Nhon 5/ /72 3/20/73Pleiku 3/30/68 12/15/70 96490 An Khe, RVN 9/30/65 1/31/68

96357 Vinh Long, RVN 1/1/65 10/1/72 Phu Bai 2/1/68 9/30/6896359 My Tho, RVN 1/5/66 10/1/72 Camp Evans, Phuoc Vinh 10/1/68 7/11/6996361 Tan Son Nhut AB, RVN 10/25/67 10/29/70 Bien Hoa 7/12/69 8/16/7296362 Dong Ha, RVN 2/15/66 10/31/69 96491 Qui Nhon, RVN 10/1/65 3/27/6696363 Ca Mau, RVN 4/1/66 10/1/72 Tan Son Nhut AB 3/28/66 5/14/6696368 Phu Cat AB, Binh Dinh, RVN 7/11/66 7/ /70 Long Binh 5/15/66 2/23/73

Cam Ranh Bay 7/ /70 2/28/72 96492 Charang Valley, Qui Nhon, RVN 10/5/68 4/25/72Tan Son Nhut 3/1/72 3/15/73 96493 Bao Loc, RVN 11/18/68 4/15/72

96370 Bear Cat, RVN 10/1/66 7/26/68 96494 Camp Holloway, Pleiku, RVN 6/18/69 5/1/72Dong Tam 7/27/68 8/18/69 96495 Quang Tri, RVN 5/1/68 7/ /70

96371 Phu My, RVN 12/20/66 1/14/67 96496 Long Binh, RVN 3/20/68 3/25/73Bear Cat 1/15/67 7/26/68 96499 Kontum. RVN 1/1/65 10/1/72Dong Tam 7/27/68 8/ /69 96530 Bear Cat, RVN 3/28/68 12/2/72Tan An 8/ /69 10/5/70 96599 Long Binh, RVN 7/1/66 1/31/68

96372 Phu My, RVN 1/15/67 4/18/67 An Khe 2/1/68 7/4/69Bear Cat 4/19/67 7/26/68Dong Tam 7/27/68 8/18/69

96373 Bear Cat, RVN 12/8/66 7/26/68

Training documents are under “Agent Orange” at http://hvnc.gdit.com/lc/

The following APOs have been verified by the Military Postal Service Agency (MPSA) as having been used for delivery to Vietnam.

 15 27 38 40 91 95 96 97137 143 157 158 299 300 307 9649596496 96499 96208 96214 96215 96216 96217 9621996221 96222 96223 96225 96226 96227 96228 9623096234 96236 96238 96240 96243 96250 96256 9625796258 96260 96262 96265 96266 96268 96269 9627896279 96289 96291 96294 96295 96296 96297 9630796308 96309 96312 96314 96316 96317 96318 9632096321 96322 96325 96326 96327 96332 96337 9634596347 96348 96349 96350 96353 96355 96357 9635996361 96362 96363 96368 96370 96371 96372 9637396374 96375 96376 96377 96379 96381 96383 9638496385 96388 96393 96392 96395 96398 96494 9639996402 96477 96485 96490 96491 96492 96493

MPSA was created in 1980 and date prior to its creation was maintained by the individual services. The data received by MPSA from the branches was not always complete; therefore, additional addresses may exist. Military Postal History Society, a private organization, as being located in Vietnam, has identified the following Navy addresses. These addresses cannot by verified by MPSA, however, MPSA cannot state that they were not in Vietnam. These will most likely appear as FPO (Fleet Post Office) or “Navy Br.,” rather than APO.

 150 955 17041 17090 17095 17115 9622096621 96622 96623 96624 96625 96626 9662796628 96629 96638 96639 96641 96647 9664896694 96695 96696

Agent Orange and other herbicides used in Vietnam were tested or stored elsewhere, including many military bases in the United States. Below is information from the Department of Defense (DoD) on projects to test, dispose of, or store herbicides in the U.S.

In the U.S.: Alaska| Arizona | California | Florida | Georgia| Hawaii| Indiana | Kansas | Kentucky |Maryland | Mississippi | Montana | New York | North Dakota | Pennsylvania | Rhode Island | Tennessee | Texas | Utah | Washington | Wisconsin

Many Veterans have submitted claims alleging exposure to Agent Orange in Thailand. The Air force operated a number of large bases in Thailand during the Vietnam War, and veterans who were stationed there are not eligible for presumption on “in-country” Vietnam status unless they can establish that they actually set foot in Vietnam. See FL 09-20.

If a veteran claims exposure based on their occupation, then the important thing to remember regarding these type claims is that they are currently being verified by submitting inquires to the C&P Agent Orange Mailbox. However, Regional office can also use their JRRSC coordinators to verify claims of this nature.

NOTE: No aircraft based in Thailand sprayed herbicide in Thailand or Vietnam IV.ii.1.H.2.e - changed 4/29/16, add “Blue Water Navy” flash & establish EP 409 for claims based on service aboard

ships on the RVN’s offshore waters or inland waterways

Vietnam Era Navy Ship Agent Orange Exposure Development Site , updated 6/1/18 [see Rating References ARCHIVE for lists of Navy and Coast Guard Ships Associated with Service in Vietnam and Exposure to Herbicide Agents (I’m keeping ALL of the lists there with the most recent list highlighted)] *See III.iv.5.C.6.g for effective dates under 3.156(c) (can use this list like supplemental STRs if had everything but verification that ship docked while veteran as aboard)

3.309(f) Camp Lejeune, NC –

W. Rees 180 updated 7/25/18

3.307(a)(7) I.1.B.1.f III.ii.6.A.2.i III.iii.2.E.8.d IV.ii.1.I.6 – Developing Claims IV.ii.1.I.7 – Developing Claims – SPRs should be marked with “CLNC” & the page & dates served, has chart for who

works claims

IV.ii.2.C.6 – rating info, per QRT/Konane Stradling, handle previously denied claims same as claims filed prior to 3/14/17, per IV.ii.2.C.6.k

Entitlement to an effective date prior to March 14, 2017, for service connection of {}.

Entitlement to an effective date prior to March 14, 2017, for service connection of {}, is deferred.

Entitlement to an effective date prior to March 14, 2017, for service connection of {}, is deferred for a review of your previously denied claim.

VSR: Please continue the end product (EP) for assignment of the claim to the Louisville RO to address the issue of entitlement to an effective date prior to March 14, 2017.

30 days service (consecutive or nonconsecutive) from 8/1/53-12/31/87 at US Marine Corps Base Camp Lejeune & Marine Corps Air Station New River (MCAS) [IV.ii.2.C.6.b has borders of base, excludes MCAS Cherry Point]

Per IV.ii.2.C.6.k & IV.ii.1.I.7.c, any claim filed prior to 3/14/17 MUST be referred to Louisville (do partial grant first)

eff 3/14/17, some worked by Louisville RO (327), IV.ii.1.I.7.c has chart for if claim stays with ROJ or goes to Louisville

adult leukemia 7703 *CLL should be 100% P&T, per III.iv.4.K.2.c

3/14/17

aplastic anemia & other myelodysplastic syndromes

7716 3/14/17

bladder cancer 7528 (or 7516 if have suprapubic cystostomy) 3/14/17kidney cancer 7528 (or 7500 if removed, or 7530 if on dialysis) 3/14/17liver cancer 7343 (or 7311, or 7351 with transplant [might need

4.29 while in hospital waiting for transplant])*remember 4.114 if rate residuals of liver cancer under 7311, 7345

3/14/17

multiple myeloma 7799-7709*generally multiple myeloma is 100% P&T (rare exceptions), per III.iv.4.K.2.a

3/14/17

Non-Hodgkin’s lymphoma (NHL) 7715 3/14/17Parkinson’s disease 8004 3/14/17

use Environmental Hazard-Camp Lejeune OR Environmental Hazard – Camp Lejeune – Louisville special issues in VBMS-R IV.ii.2.C.6.i - Add this to Reasons for Decision if granting presumptively:

Service connection may be granted for specific diseases or conditions which are presumed to have been caused by exposure to contaminants in the water supply at Camp Lejeune. Although not shown in service, service connection for [insert condition] has been granted on the basis of presumption due to exposure to contaminants in the water supply at Camp Lejeune.

IV.ii.2.C.6.j - Add this to Reasons for Decision if denying presumptively:

VA has acknowledged a relationship between exposure to contaminants in the water supply at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, and the subsequent development of the following conditions:  kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. Service at Camp Lejeune for Veterans, Reservists, and former National Guard members must have been for at least 30 days (cumulative) during the specified time frame. A presumption of service connection based on exposure to contaminants in the water supply at Camp Lejeune is not warranted for any other condition.

*plus add relevant text from table at IV.ii.2.C.6.j in Reasons for DecisionW. Rees 181 updated 7/25/18

April 2017 Quality Call Notes –

Question: A Veteran with qualifying Camp Lejeune service claims Parkinson’s disease, but medical evidence shows only Parkinsonism. This looks like it will be the ROJ’s jurisdiction per M21-1 IV.ii.1.I.7.c and a possible denial since there is no diagnosis of the claimed condition. However, if the same Veteran claimed Parkinsonism, then per the same table, it would be referred to Louisville and a SME medical opinion may be requested by Louisville. Are we reading that table and those following blocks correctly?Answer: Parkinsonism should be considered a neurobehavioral effect under the healthcare law (38 CFR 17.400). So if you see the diagnosis, or if Parkinsonism is claimed, it should be sent to Louisville.

From: VAVBASDC/RO/VSC Sent: Wednesday, April 04, 2018 3:10 PMSubject: Q-Tip: Camp Lejeune Contaminated Water Rating decisions and Liberalizing Legislation (3.114)

Recent communication from the Louisville RO has identified a jurisdictional issue with regard to Camp Lejeune contaminated drinking water claims where an earlier effective date pursuant to 38 CFR 3.114 (Change in Law) is involved. Accordingly, this Q-Tip is being sent out with the intent of clarifying the action to take on claims associated with drinking water contamination at Camp Lejeune, received prior to the change in law. 

Background:

On March 14, 2017, 38 CFR 3.307(a)(7) effectuated a presumption of SC for specific disabilities for Veterans who served no less than 30 days (consecutive or nonconsecutive) at the U.S. Marine Corps Base Camp Lejeune, North Carolina between August 1, 1953, and December 31, 1987, based on exposure to contaminants present in the base’s water supply.

M21-1, IV.ii.1.l.7.c  provides a table which lists the RO having jurisdiction over the claim dependent upon several factors including whether the condition claimed is recognized under 38 CFR 3.309(f), whether a diagnosis actually exists, and also taking into consideration the amount of time the Veteran is of record as having served onboard Camp Lejeune. RVSR’s are encouraged to consult this section of the Manual prior to rating and evaluating a claim stemming from duty onboard Camp Lejeune.

Additionally, please note that the Louisville RO has jurisdiction for any appeals received on Camp Lejeune claims and all other inextricably intertwined non-Camp Lejeune appeals.

Effective date consideration:

Of specific importance are the effective date considerations. The presumption established in 38 CFR 3.307(a)(7) became effective on March 14, 2017. Decision makers must evaluate the facts of each claim to determine the most advantageous effective date allowed.

If awarding a claim based on exposure to contaminants in the Camp Lejeune water supply on a direct basis under 38 CFR 3.303, apply the regular effective date provisions of 38 CFR 3.400, General.

If awarding a claim presumptively under 38 CFR 3.307(a)(7), consider the provisions of 38 CFR 3.114(a), i.e. Change of law or Department of Veterans Affairs issue.

Please be aware that if you are processing a Camp Lejeune claim which was filed prior to March 14, 2017 (the date of the change in law), please refer to M21-1, IV.ii.2.C.6.k. The provisions of 38 CFR 3.114 may apply. This section of the Manual states all Camp Lejeune claims filed PRIOR to March 14, 2017, must be referred to the Louisville RO.

/s/VSC Front Office

This reference further provides a table describing the process of handling claims filed prior to the change in law. (M21-1 IV.ii.2.C.6.k.)

1 Rating activity Creates a free text issue for entitlement to an earlier effective date for the Camp LeJeune presumptive condition. 

W. Rees 182 updated 7/25/18

Example:  Entitlement to an effective date prior to March 14, 2017, for service connection of bladder cancer.

2 Rating Activity

Creates a note in the SPECIAL NOTATION field, instructing the authorization activity to continue the end product (EP) for assignment of the claim to the Louisville RO.

2 Rating Activity

Completes a rating decision

awarding SC for the presumptive disability

deferring the earlier effective date issue

providing an explanation of the reason for deferral, and

addressing any other issues that can be decided.

3 Authorization Activity Designates the EP to continue at authorization.

4 Authorization Activity Authorizes the award.

5 Authorization ActivityAffixes the Environmental Hazard – Camp Lejeune – Louisville special issue indicator to the relevant contention(s).

Assistance in deferral of the earlier effective date can be located in the VBMS Deferral Job Aids, under Deferral Job Aids, Initiating and Finalizing Draft Deferrals.

https://vbaw.vba.va.gov/VBMS/docs/Desktop/Job_Aids/VBMS_Initiating_and_Finalizing_Draft_Deferrals_Job_Aid_20170816_final.pdf

3.31 Commencement of the period of payment – “first day of the calendar month following the month in which the award became effective”

3.313 Claims based on service in Vietnam – non-Hodgkin’s lymphoma (NHL), 7715, do not need in-country service, just service in RVN during the Vietnam Era, & does not have to be 10% (incl. Waldenstrom Macroglobulinemia, T-cell lymphomas & B-cell lymphomas; when B-cell leukemias added to AO list, 7703, Waldenstrom listed there; MEPSS shows it’s a lymphoma)

GC Opinion 9/13/96- broader interpretation than 3.307 IV.ii.1.H

IV.ii.2.C.3

May 2011 Compensation Service Bulletin (CSB) Addendum and the September 2011 Compensation Service Bulletin (CSB)) - 3.313 includes B-cell type (not T-cell) chronic lymphocytic leukemia (CLL) & small-cell lymphocytic leukemia (SLL) [interpretive change & not subject to 3.114, so effective date is DOC or date disability arose]

November 2012 Compensation Service Bulletin (CSB) – if have enough info to grant SC & evaluate NHL, do so (even if have to defer other decisions)

IV.ii.2.C.3.o has full list of low, intermediate and high grade lymphomas qualifying as NHL

October 2013 Compensation Service Bulletin (CSB) – Mycosis fungoides is a cutaneous T-cell lymphoma, which is manifested by skin symptoms that can appear as patches, plaques, or tumors. In 1993, The Institute of Medicine identified mycosis fungoides as a form of non-Hodgkin’s lymphoma (NHL). The disease should be

W. Rees 183 updated 7/25/18

considered the same as NHL and subject to presumptive service connection under the provisions of 38 C.F.R. 3.309. Service connection for NHL is also warranted under 38 C.F.R. 3.313 (which also includes service in the offshore waters of Vietnam (MR IV .ii.2.C.10.v). If service connection for mycosis fungoides was previously denied and the evidence shows a diagnosis of mycosis fungoides at the time of the previous denial and confirms the Veteran’s service in Vietnam, please refer these cases to Compensation Service for an advisory opinion in accordance with M21-1Manual Rewrite (MR), Part III, Subpart iv, Chapter 1, Section A, Topic 2, Block a (MR III.vi.1.A.2.a). III.iv.4.K.2.e

3.814 Monetary allowance under 38 U.S.C. 1805 for a child suffering from spina bifida who is a child of a Vietnam veteran – claims processed by the Denver Regional Office per VI.1.1, also includes multiple other birth defects, see VI.2 or 3.814

3.815 Monetary allowance under 38 U.S.C. chapter 18 for an individual with disability from covered birth defects whose biological mother is or was a Vietnam veteran; identification of covered birth defects.

3.816 Awards under the Nehmer Court Orders for disability or death caused by a condition presumptively associated with herbicide exposure. – 9/25/85 (the date 38 CFR 3.311(a) was effective)

III.iv.6.B.1.f – entitlement to an earlier effective date under Nehmer does not have to be expressly claimed; if records support an EED, can grant even if not making a decision on that issue

IV.ii.2.C.4 Nehmer Training Guide If there is evidence in the file that secondary conditions existed prior to change in the law, we can grant prior to the date of the change.

For Nehmer, the veteran has to have been in-country RVN. Nehmer does not include AO exposure outside RVN.

TBI, Case Law and Nehmer Timeline [spreadsheet with Nehmer Timeline] is saved at H:\VSC\Rating Reference

Gulf War –

GW1

3.317 - Compensation for certain disabilities due to (1) undiagnosed illnesses or (2) medically unexplained chronic multi-symptom illness (MUCMI) –

3.2 I.1.B.1.f – need to send additional notice, per IV.ii.1.l.6.c DBQ is for internal VA use only, see DBQ at http://vbacodmoint1.vba.va.gov/bl/21/dbq/default.asp

IV.ii.1.E –

IV.ii.1.E.1.c – using DD214 to verify Southwest Asia theater of operations / SWA service = service in SWA with dates, Iraq Campaign Medal, Kuwait Liberation Medal are ALL good; Southwest Asia Service Medal (check that not for Israel, Egypt, Turkey, Syria or Jordan); GWOT Medal not sufficient

IV.ii.1.E.2.a - The threshold for requiring an examination is low, just need service in Southwest Asia Theater of Operations / SWA & medical/lay evid documenting chronic/recurrent sx lasting at least 6 months that fit the description of conditions; To be sufficient, the examiner must provide a medical opinion 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 theater of operations / SWA

Do not prepare a separate medical opinion DBQ. The Notice to Examiners in Southwest Asia Claims directs the examiner to provide the required opinion.

IV.ii.1.E.2.b – examples; a Gulf War General Medical Examination should not be requested if one has already been completed for a claim that has not yet become final.

W. Rees 184 updated 7/25/18

IV.ii.1.E.2 – examples for no exams warranted:

IV.ii.1.E.2.f known clinical diagnosis [sleep apnea]

IV.ii.1.E.2.k no potential entitlement [multiple sclerosis, diabetes, single joint injury w/trauma (in service or thereafter) & known clinical diagnosis indicating injury etiology]

IV.ii.1.E.2.l no potential entitlement [single joint injury w/trauma (in service or thereafter) & known clinical diagnosis indicating injury]

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

IV.ii.1.E.3 – brain cancer, need SWA service 1/17/91-4/11/91 (GW I only) & diagnosis, request medical opinion if no nexus with “rational, scientific explanation” yet on file [only do VHA exams, ACE is okay; use SWA Brain Cancer (MO) & add SWA Brain Cancer Fact Sheet (which loads to desktop after create ERB)]

IV.ii.1.I.10 & IV.ii.2.C.5 – burn pits, Sulfur mine, Chromium VI, waste incinerator, 3.317, Camp Lejeune

Burn pits in Iraq (Joint Base Balad Logistical Support Area (LSA) Anaconda in Northern Iraq is a 10 acre area), Afghanistan & Djibouti on the Horn of Africa – VBMS-R has Special Issue for Burn Pit Exposure as of 10/15 [The Fact Sheet under IV.ii.1.I.10.a shows burn pits can affect respiratory, skin, eyes, liver, kidneys, central nervous system, cardiovascular, reproductive, peripheral nervous system, & GI tract.]

“Particulate Matter” in Iraq & Afghanistan

sulfur fire at Misraq State Sulfur Mine near Mosul, Iraq (4-week fire, started 6/24/03 (go to one week after fire, so 4 weeks), affected Mosul Airfield and Qayyarah Airfield West (Camp Q West) which is the primary deployment area for the 101st airborne division; causes skin conditions, and respiratory conditions to include shortness of breath and “constrictive bronchiolitis”)

NG & Chromium VI at Qarmat Ali Water Treatment Plant in Bashrah, Iraq (4/03-9/03, Army National Guard personnel from West Virgina, South Carolina and Oregon), IV.ii.1.I.6.f

Emissions from waste incinerator near naval air facility in Atsugi, Japan (1985-2001)

IV.ii.2.C.5.n & IV.ii.1.I.6.h - What to Include in VA Examination and/or Medical Opinion Requests  in Environmental Hazard Claims

IV.ii.2.D –

medically unexplained chronic multi-symptom illnesses (MUCMIs) are only for veterans with service in Southwest Asia theater of operations / SWA; “military, naval, or air service”

IV.ii.2.D.1.f - Iraq, Kuwait, Saudi Arabia, neutral zone between Iraq & Saudi Arabia, United Arab Emirates, Bahrain, Qatar, Oman, Gulf of Aden, Gulf of Oman, Persian Gulf, Arabian Sea, Red Sea AND the airspace above these locations after 8/2/90; NOT for Afghanistan veterans; infectious diseases are for both veterans with service in SWA theater of operations and Afghanistan veterans with service on or after 9/19/01

IV.ii.2.D.1.j – functional gastrointestinal disorders (FGIDs) – type of MUCMI (list of characteristic symptoms & diagnoses; includes irritable bowel syndrome (IBS), functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, functional dysphagia); EXCLUDES structural gastrointestinaldiseases like inflammatory bowel disease (ulcerative colitis, Crohn’s diease) & gastroesophageal reflux disease/GERD

IV.ii.2.D.1.m – thru 12/31/2021

IV.ii.2.D.1.n - signs/symptoms of undiagnosed illness or MUCMI: joint pain (IV.ii.1.E.1.b says call to get specific joint, but even if can’t clarify can still get exam), muscle pain pain (IV.ii.1.E.1.b says call to get specific area, but even if can’t clarify can still get exam), neurological signs or symptoms, headache, neuropsychological signs or symptoms, gastrointestinal signs or symptoms, abnormal weight loss, fatigue, sleep disturbances, respiratory signs and symptoms (upper and lower), cardiovascular signs or symptoms, skin signs and symptoms, and menstrual disorders

IV.ii.2.D.1.p - Time Limits for Manifestation of Infectious Diseases:

Infectious Disease Time Limit for ManifestationBrucellosis one yearCampylobacter jejuni one yearCoxiella burnetii (Q fever) one year

W. Rees 185 updated 7/25/18

Malaria one year, or at a time when standard or accepted

treatises indicate that the incubation period began during a qualifying period of service

Mycobacterium tuberculosis no time limitNontyphoid Salmonella one yearShigella one yearVisceral leishmaniasis no time limitWest Nile virus one year

IV.ii.2.D.1.q – Long-Term Health Effects Potentially Associated with Infectious Diseases, including associated conditions

IV.ii.2.D.1.r – direct SC for brain cancer can be granted with diagnosis, SWA service 1/17/91-4/11/91 (GW I only) & medical nexus with “rational, scientific explanation” (see IV.ii.1.E.3 for development procedures)

IV.ii.2.D.2.h – if have an undiagnosed illness & GW service, no opinion needed to grant SC (if receive negative opinion with no rationale, still grant SC); deny if negative opinion with rationale

IV.ii.2.D.3.a - changed 7/14/16, for undiagnosed illness or MUCMI, use 88 codes & Environmental Hazard in Gulf War special issue in VBMS-R; for infectious disease, use Gulf War Presumptive special issue in VBMS-R & basis specific to the disease

IV.ii.2.D.3.b, c & d - tables for 88 DC codes

IV.ii.2.D.3.e – if have to terminate/sever or reduce because disability subsequently diagnosed

IV.ii.2.D.4.g – analogous codes for undiagnosed illnesses manifest by 13 signs/symptoms under 3.317

12/19/14 DBQ Call – Do not request exam simply because the veteran had service in SWA. Need to have something that would lead us to apply 3.317. See IV.ii.1.E.19.f [now IV.ii.1.E.2.f]

1/16/15 DBQ Call – for initial claims where GW Issues are claimed, inferred, or considered possible, the GW Gen Med examination should be ordered. There is no need to also order a Gen Med Comp exam. The GW exam is a Gen Med examination and will be able to address all issues possibly contained in the Gen Med Comp DBQ. When ordering pre-discharge program examinations where a Separation Health Assessment (SHA) exam is required, it is not necessary to also order the GW Gen Med examination. Simply cut and paste the “Notice to Examiners” found at: M21-1MR IV.ii.1.E.19.g into the exam request remarks section and identify those conditions claimed or inferred as being GW issues. [now IV.ii.1.E.2.j]

Notes from May 2015 Adjudicating Gulf War Claims Training (Carlos Rosario):

Training documents are under “Adjudicating Gulf War Claims” at http://hvnc.gdit.com/lc/ or at H:\VSC\Training\NTC Class Material\RVSR-Adjudicating Gulf War Claims

Gulf War Examinations (Flowchart) is saved at H:\VSC\Development & Rating Resources\Examination Information

Very helpful sheet - Gulf War Overview – Claims Based on Undiagnosed Illnesses of Gulf War Veterans - https://www.ttande.org/VBA_Learning_Catalog/Comp_svc/Add_Ref/3893762_Add_Ref.docx - anyone who got Kuwait Liberation Medal, but Southwest Asia Service Medal / SWA was given to those also serving in Israel, Egypt, Turkey, Syria, and Jordan, but they are excluded under 3.317; GWOT medal is excluded since awarded for many locations besides those considered SWA for the purposes of 3.317

VSR info - H:\VSC\Training\NTC Class Material\Undiagnosed Illness (Gulf War) Claims Development

o DO NOT DENY WITHOUT A Gulf War General Medical DBQ

W. Rees 186 updated 7/25/18

o The Global War on Terrorism Service/Expeditionary medal (GWOT) is NOT sufficient to verify service in Southwest Asia theater of operations / SWA, as detailed above.

o After an initial grant of service connection, schedule a routine future exam / RFE after 24 months/2 years. My Notes: I cannot find this in the M21-1.

o If a veteran has been diagnosed with chronic fatigue syndrome (8863-6354), fibromyalgia (8850-5025), or functional gastrointestinal disorders (8873-7319), (MUCMI) there is no requirement of a medical nexus (they are presumptive). See February 2014 Rating Quality Call. See IV.ii.2.D.3.b, c & d for 88 codes.

o A veteran who served in Afghanistan is NOT considered a Persian Gulf War veteran (for purposes of PGW under 3.317 eff 9/2/94, but they are a GW veteran for purposes of the period of war from 8/2/90 to present)

o VA has determined the Secretary does NOT have the authority to compensate for aggravation of disabilities resulting from pre-existing undiagnosed illness. If started before GW service, not GW-related.

o Infectious dieases (for PGW & Afghanistan veterans) under 3.317 added 9/10

o Might be able to use GW Registry exam to see if in SWA (see above for list of areas), if had treatment for 6+ months (can use lay stmt to show if greater than or less than 6 months, positive or negative evidence) & if at 10%

o “objective indicators” are (1) signs (something examiner can feel/see/note) and (2) symptoms (reported/subjective, including buddy stmts)

o partially understood is NOT medically unexplained

o functional – tests normal, but have it; structural – something physically wrong

o the opinion we ask on the DBQ is to find out if the symptom/illness/disability can be established based on DIRECT SC (can grant diarrhea for SWA veteran if in STRs & on DBQ, but will need medical nexus; can be 0% since direct)

o 4 patterns –

1. undiagnosed illness – GRANT [a diagnosis does not exclude SC for “undiagnosed illness”; if have conflicting opinions, cannot base weight of opinion on a diagnosis versus no diagnosis]

2. diagnosed but unexplained – GRANT

3. partially explained – DENY

4. clear & specific etiology - DENY

o Check all possible diagnostic codes if denying because not 10% (& explain WHY specific DC was chosen in Narrative)

o If a lay statement is not credible, explain WHY in Narrative.

o If there is evidence of another cause, it does not have to be conclusive (just affirmative).

o cardiovascular symptoms (8870-7005), muscle pain (8850-5021), seizures (8889-8910), joint pain (8850-5002), headaches (8881-8100). See IV.ii.2.D.3.b, c & d for 88 codes.

o ANY joint pain without diagnosis in a SWA veteran – need GW exam

o Apply reconsideration & N&M evidence, as needed

Q-Tip for GW claims 6/4/15 -The following Q-Tip is provided as a follow up to recent training to this regard. 

The threshold for ordering Veterans Affairs (VA) examinations for Gulf War Veterans claiming an undiagnosed illness or medically unexplained chronic multi-symptom illness is very low.  The Veteran must have served in the Southwest Asia theater of operations, covered in 38 CFR 3.317 (e) (2), and provide a statement of the disability and benefit sought.  Medical evidence could show that the Veteran has sought treatment for the disability claimed, or the Veteran’s lay testimony alone could be used to describe the disability pattern. 

The Veteran does not have to explicitly state that the claim is “due to Gulf War.”   

VSRs/RVSRs should verify Gulf War service when reviewing the claim.  If the Veteran does not indicate that a claim is due to Gulf War service, but the claim fits the description of conditions listed under 38 CFR 3.317(a) (2)

W. Rees 187 updated 7/25/18

(B) or 3.317(b), and the Veteran’s service in the Southwest Asia theater of operations is confirmed, then consider the claim for service-connection on the basis of Gulf War service. 

VSRs/RVSRs are not expected to determine what is, or is not, an undiagnosed illness or medically unexplained chronic multi-symptom illness. They are expected to determine whether a Veteran had Gulf War service and whether sufficient medical or lay evidence has been submitted showing a chronic disability pattern, lasting at least six months, that fits the symptoms described in 38 CFR 3.317.  Please see Training Letter 10-01, Adjudicating Claims Based on Service in the Gulf War and Southwest Asia, for additional guidance.

Refer the claim to an RVSR who will make the determination as to whether or not the condition is chronic (see definition/explanation above).  If an examination is warranted, the VSR should request a GW exam with the specific opinion (is it due to a known clinical diagnosis, etc.....)

IN EVERY CASE where the Veteran alleges a condition is due to GW exposure a GW/GENMED will be requested.    

The following can also be used as additional guidance: Gulf War Examination Flowchart

Quick Start Claims – Do not request a GW/GENMED examination.  A Separation Health Assessment (SHA)/GENMED will be requested.  Cut and paste the “Notice to Examiners” found in: M21-1 IV.ii.1.E.19.g [now IV.ii.1.E.2.j] into the SHA examination request remarks section and identify those conditions claimed or inferred as being GW issues.   Note:  Quick Start is not exempt from rating Gulf War claims if the condition claimed had its onset in service and we are able to grant the condition locally (upon receipt of the SHA/GEN MED exam.   If, however, a condition must be deferred due to additional prolonged development (i.e. verification of Gulf War service or a Gulf War exam with medical opinions is needed), the claim must be excluded from the QS program and transferred to the Regional Office of jurisdiction (ROJ) with explicit instructions for deferred development on the deferred rating.     

References:M21-1: IV.ii.1.E:   Claims Based on Service in Southwest AsiaM21-1-MR:  IV.ii.1.E.19.f:  Requesting Medical Examinations and Opinions in Claims Under 38 CFR3.31738 CFR 3.317:  Compensation for certain disabilities occurring in Persian Gulf Veterans38 CFR 3.317(e)(2):  Qualifying Service in Southwest Asia Theater of Operations 38 CFR 3.317(a)(2)(B):  A medically unexplained chronic multi-symptom illness that is defined by a cluster of symptoms38 CRF 3.317(b):  Signs or symptoms of undiagnosed illness and medically unexplained chronic multi-symptom illnessesTL 10-01:  Adjudicating Claims Based on Service in the Gulf War and Southwest AsiaCompensation Bulletin January 2015: Ordering Gulf War examinations

My Notes: Quick Start discontinued 10/1/17

Q-Tip for GW claims 6/5/15 -To further clarify the below guidance, a GW exam does not need to be scheduled on every claim for conditions listed in 38 CFR 3.317(a) (2) (B) or 3.317(b).  It is still up to the VSR / RVSR to determine whether there is a fact pattern, i.e. medical evidence that the Veteran has sought treatment for the disability claimed and/or the Veteran’s lay testimony that describes the disability pattern.  This is no different than any other claim for SC, with the exception that the VSR / RVSR must know what conditions are covered in 38 CFR 3.317(a) (2) (B) or 3.317(b) as having potential for service connection when there is verified Gulf War service, and then proceed accordingly with necessary development.  Please refer to TL 10-01 for guidance. 

Please note that if the Veteran specifically claims “GW exposure” or a condition related to service in the GW, and their GW service is verified, then a GW exam is required (regardless of whether the claimed condition is shown).  It will then be up to the examiner to determine if the condition is “diagnosed” or “undiagnosed.”  

Reminder:  All Rating decisions for undiagnosed illness must be second signed by either a Coach or a designee within the Team, per guidance provided in our local 2nd sign policy, M21-1, and prior emails to this regard.   

From: Walsh, Erin, VBASDGO Sent: Thursday, August 06, 2015 4:08 PMSubject: VSCCR1,2,7 - GW Refresher Training - FOLLOW UPImportance: High

Good afternoon all, W. Rees 188 updated 7/25/18

Thank you to all who attended the Gulf War claims refresher class this afternoon. As promised, below are the main points we discussed and their corresponding references. PLEASE NOTE: All written below can be found in M21-1 IV.ii.2.D.1. I highly encourage you to read that in its entirety as it was just changed as of 6/3/2015.

For service connection to be granted as related to Gulf War service, there are requirements.

First, we must be able to verify that the Vet has qualifying Gulf War service. A qualifying Veteran, under 38 CFR 3.317, is a Veteran who served on active military, naval, or air service in the

Southwest Asia theater of operations during the GW period. Per 38 U.S.C. 101(33), the GW period extends from August 2, 1990, through a date yet to be determined by law or Presidential proclamation. Reference: For a definition of the Southwest Asia theater of operations, see M21-1, Part IV, Subpart ii, 2.D.1.f, and 38 CFR 3.317(e)(2).

This is crucial! If the Vet does not have qualifying service, the provisions under 3.317 do not apply.

Next, figure out what the Vet is claiming. Is the Vet claiming a disability under 3.317(c)(2) or 38 CFR 3.317(a)(2)(i)(B)? If so, ask yourself the following questions:

1. Do we have a clinical diagnosis of record of the claimed disease?2. Did it manifest to a compensable degree within the specified time limit? See the chart attached.

In order to warrant an examination, we must have clinical evidence of a diagnosis of the disease and evidence that it manifested to a compensable degree within the presumptive period. NOTE: There are different presumptive periods, they are not all the same. See the chart attached to the email, which is listed in M21-1 IV.11.2.D.1.p.

Pursuant to 38 CFR 3.317, these diseases will be considered to have been incurred in or aggravated by service under the circumstances even though there is no evidence of such disease during the period of service. There is no medical opinion needed for these diseases as they are presumed to be related to Gulf War service.

OK, now let’s move on to the disabilities for which we will require a medical opinion so long as we have qualifying service.

Under 3.317(b), an undiagnosed illness is a type of chronic qualifying disability where qualifying signs and/or symptoms cannot be attributed to any known clinical diagnosis by history, physical examination and laboratory tests. The claimed disability must be chronic, that is, it must have persisted for a period of six months. Measure the six-month period of chronicity from the earliest date on which all pertinent evidence establishes that the signs or symptoms of the disability first manifested.

Note: If a disability is subject to intermittent episodes of improvement and worsening within a six-month period, consider the disability to be chronic.

Qualifying chronic disability means a chronic disability resulting from either an undiagnosed illness, or a medically unexplained chronic multi-symptom illness (MUCMI).

An undiagnosed illness is a type of chronic qualifying disability where qualifying signs and/or symptoms cannot be attributed to any known clinical diagnosis by history, physical examination and laboratory tests.

o Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to:

(1) Fatigue. (2) Signs or symptoms involving skin. (3) Headache. (4) Muscle pain. (5) Joint pain. (6) Neurologic signs and symptoms. (7) Neuropsychological signs or symptoms. (8) Signs or symptoms involving the respiratory system (upper or lower). (9) Sleep disturbances. (10) Gastrointestinal signs or symptoms. (11) Cardiovascular signs or symptoms. (12) Abnormal weight loss. (13) Menstrual disorders.

W. Rees 189 updated 7/25/18

A MUCMI is a type of chronic qualifying disability in which there is a diagnosed illness but that illness has no conclusive pathophysiology or etiology, overlapping symptoms and signs, and

o features such as fatigue and pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.

When considering disabilities under the provisions of 38 CFR 3.317, a Veteran’s lay statement describing his or her own symptoms of a qualifying disability takes on a greater importance than when considering other claims under direct SC principles. Confirmed by June 2013 VSCM Bulletin, referenced in class

First, as indicated in M21-1, Part IV, Subpart ii, 1.E.1.h, the threshold for ordering an examination based on claims under 38 CFR 3.317 is low, as the claimant’s statement alone, describing symptoms, may be sufficient to trigger an examination. Second, lay evidence describing symptoms unsupported by clinical findings is sufficient to establish SC under 38 CFR 3.317 as long as there is medical evidence showing that “no medical diagnosis” is present.

If the claimed contention was been diagnosed, it cannot be generalized as an undiagnosed illness. (RVSRs: There is a pick in VBMS-R for this basis for denial.)

Remember: Service connection will not be for a chronic disability:

1. If there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or

2. If there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or

3. If there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs.

TAKE AWAY NOTES: If you have a Vet with qualifying GW service with a diagnosed disability in 3.317(a)(2)(i)(B) or (c) and medical

evidence showing that it was manifest to a compensable degree within the presumptive period, order an examination (the specific DBQ, not a GW gen med) with no opinion.

If you have a Vet with qualifying GW service, claiming something that fits the criteria discussed in class and listed in 3.317(b), with medical or lay evidence that it has persisted for at least 6 months, order a Gulf War gen med exam and include the necessary verbiage to the examiner. Additionally, if you see that the condition is claimed on a different basis and evidence of record supports the claim, include the appropriate medical opinion request based on the applicable basis for entitlement.

o Example: Verified GW Vet claims respiratory condition as directly related to service. STRs show complaints of chest pain and difficulty breathing on active duty. Vet reports continued symptoms since service. The best practice is to order a GW exam, include the GW verbiage to the examiner, AND include a request for medical opinion on a direct basis (Is the Veteran’s respiratory condition at least as likely as not related to or the progression of the respiratory condition treated in service?)

Please let me know if you still have questions or concerns.

Thanks!-EErin B. WalshRating Quality Review SpecialistDepartment of Veterans Affairserin.walsh@va.gov

Notes from October 2015 Adjudicating Gulf War Claims Training (GiBao) :o IV.ii.1.E – development

o IV.ii.2.D – rating

o exceptions – IV.ii.1.E.2.d-h, no GW exam if:

W. Rees 190 updated 7/25/18

1. claim can be substantiated/granted without exam (directly, presumptively or secondarily; just get specific DBQ to evaluate, if needed)

2. there is a diagnosis of a MUCMI (CFS, fibromyalgia, FGID/IBS; just get specific DBQ to evaluate, if needed), grant presumptively if at 10% at any point before 12/31/16

3. there is a single joint injury in STRs or post service & x-ray shows arthritis or meniscal tear

o for the 9 infectious diseases – DBQ Persian Gulf & Afghanistan Infectious Diseases

o burn pits, etc – separate too

o SWA service verified if have dates in SWA, Iraq Campaign Medal, Kuwait Liberation Medal; NOT verified with just SWA medal (cannot be used if Israel, Egypt, Turkey, Syria, and Jordan), NOT verified with just GWOT medal (need to know location served)

o To get GW exam, need symptoms for 6 months or more (chronic, including waxing & waning, can use lay statements in TRs or directly from veteran); CFS has to meet our regulation requirements for diagnosis; FGIDs (IBS, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, functional dysphagia) cannot be structural (IV.ii.2.D.1.j shows structural is inflammatory bowel disease (ulcerative colitis or Crohn’s disease) & gastroesophageal reflux disease (GERD)); evidence of a diagnosis does NOT exclude an exam

o If getting exam with direct opinion, may sometimes also get GW Gen Med

o get GW Gen Med (plus eyes, ears, dental, mental, if applicable), use Notice to Examiner from IV.ii.1.E.2.j & fill in specific symptoms

o call veteran to clarify these issues in order for examiners to do correct exam:

1. area of muscle/joint

2. are “sleep” symptoms respiratory or mental

3. are “respiratory” symptoms lung or nose

o 4 patterns –

1. undiagnosed illness – GRANT under 3.317 [even if with negative opinion without rationale, don’t send back for clarification, just grant; deny if negative opinion with rationale based on rebuttal of presumption]

2. diagnosed but unexplained – GRANT under 3.317

3. partially explained/understood (including DM & MS) – DENY under 3.317 [partially understood etiology cannot be considered medically unexplained; can get GW exam if diagnosis is “rule out MS” or “possible diabetes”]; but need further opinion on if related to specific exposure event, if yes, grant under 3.304;

4. clear & specific etiology – DENY under 3.317; but need further opinion on if related to specific exposure event, if yes, grant under 3.304

*4/17 Rating Consistency Study says to add this statement for 3&4 above:

Service connection may be established for disability resulting from undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of symptoms, or a diagnosed illness that is determined by VA regulation to warrant a presumption of service connection which manifested itself either during active service in the Southwest Asia theater of operations during the Gulf War period, or to a degree of ten percent or more after the date on which the Veteran last performed service in the Southwest Asia theater of operations during the Gulf War period.

o use 88 codes if grant/deny due to Gulf War

o sleep apnea is not listed in the manual anymore & they are still looking at it, but for now continue to get GW exam

IV.ii.1.E.2.b – as of 11/5/15, no GW exams if have sleep study showing sleep apnea; sleep apnea is not a recognized qualifying, chronic disability under the provisions of 38 CFR 3.317; also see VA Pulse, https://www.vapulse.net/thread/10077; IV.ii.1.E.2.b - changed 6/24/16, do not get a subsequent Gen Med if have one on pending claim or on decision that is not yet final; sleep apnea example moved to IV.ii.1.E.2.f on 6/24/16

IV.ii.2.D.1.n – added example about sleep apnea on 11/30/15, sleep apnea cannot be presumptively SC under 3.317 since it is a diagnosable condition (must be considered on an non-presumptive SC basis)

W. Rees 191 updated 7/25/18

Notes from June 2016 Rating Gulf War Claims (Konane Stradling - video) :

o use 88 codes even if deny – See IV.ii.2.D.3.b, c & d for 88 codes.

o schedule routine future exam / RFE 24 months from date of last exam, per Live Manual – My Notes: I cannot find this in the M21-1.

My Notes:

3.317(a) – MUCMIS

chronic fatigue syndrome 8863-6354also see fatigue below

3/1/02

fibromyalgia 8850-5025 3/1/02functional gastrointestinal disorders (excluding structural gastrointestinal diseases)

ulcer 8873-7305 hiatal hernia 8873-7346IBS 8873-7319also see GI below

3/1/02

3.317(b) Signs or symptoms of undiagnosed illness and medically unexplained chronic multisymptom illnesses

fatigue CFS 8863-6354anemia 8877-7700

11/2/94

signs or symptoms involving skin 8878-7806 11/2/94headache 8881-8100 11/2/94

muscle pain 8850-5021 11/2/94

joint pain 8850-5002 11/2/94

neurological signs or symptoms seizure 8889-8910 or 8885-85__

11/2/94

neuropsychological signs or symptoms 8893-9300 11/2/94

signs or symptoms involving the respiratory system (upper or lower) 8865-65__or 8866-66__ or 8868-68__

11/2/94

sleep disturbances 8894-9400 11/2/94

gastrointestinal signs or symptoms ulcer 8873-7305 hiatal hernia 8873-7346IBS 8873-7319also see GI above

11/2/94

cardiovascular signs or symptoms 8870-7013or 8870-7005

11/2/94

abnormal weight loss 8873-7328 11/2/94

menstrual disorders 8876-7622 11/2/94

W. Rees 192 updated 7/25/18

W. Rees 193 updated 7/25/18

*the two scenarios above are the same, first answer is 8873-7319, second one is 7346

W. Rees 194 updated 7/25/18

August 2016 Quality Call Notes – many ‘Gulf War General Medical Examinations’ are being requested for Veterans whose only service is in Afghanistan. Afghanistan is not included in the Southwest Asia Theater of Operations – M21-1, IV.ii.2.D.1.f and TMS # 4178422 (Claims Based on Environmental Hazards).

Amyotrophic Lateral Sclerosis (ALS) – III.iv.4.N.6

ALS – 8017, eff 9/23/08 anytime after service if had at least 90 days of service (unless evidence not incurred/aggravated or due to willful misconduct) [Bowers v. Shinseki says has to be active service or National Guard service that meets active service, cannot be active duty for training, see III.iv.4.N.6.b], 3.114 applies

3.318 - Presumptive Service Connection for Amyotrophic Lateral Sclerosis – SC if manifested at any time after discharge or release and have active, continuous service of 90 days or more [cannot be due to willful misconduct or another cause]

ALS should be 100%, change dated 12/20/11, but effective 1/19/12, subject to 3.114If a complication is 100%, do hyphenated as 8017-#### & that satisfies the minimum 100% for ALS (& cannot assign a separate 100% under 8017), then evaluate all other complications separately. If no single complication at 100%, evaluate ALL complications at 100% under 8017 & include in the name of the disability (amyotrophic lateral sclerosis with loss of use of the left foot and partial ninth cranial nerve paralysis) & consider SMC.

May 2012 Compensation Service Bulletin (CSB) – Prior to the new regulation: We assign a 30 percent minimum evaluation for ALS.  However, once complications progressed, the higher evaluation for complications, such as a 100 percent rating for loss of use (LOU) of the lower extremities, would exceed and replace the minimum 30 percent evaluation.    Under the new regulation: We assign a 100 percent minimum evaluation.  The Veteran subsequently develops LOU of the lower extremities.  We assign a 100 percent evaluation for the LOU of the lower extremities. This evaluation replaces the minimum 100 percent evaluation previously assigned when service connection for the disease was first established. In this situation, do not grant the Veteran both a 100 percent evaluation on the basis of loss of use of the lower extremities and a separate 100 percent evaluation solely on the basis of a diagnosis of ALS.  If the Veteran has, in addition to loss of use of the lower extremities, loss of use of the upper extremities or bilateral blindness due to ALS, then assign separate 100% evaluations with special monthly compensation granted at the appropriate level.

ALS-Neuromusclar DBQ Rating Help (from VA Pulse) is saved at H:\VSC\Rating Reference

https://www.vapulse.net/docs/DOC-78794

Per Beth, 10/25/16, all should go to a prior SpecOps RVSR (Autumn, Geoff or Audrey) to rate (email Beth & Sally if get one)

W. Rees 195 updated 7/25/18

From: VAVBASDC/RO/VSC Sent: Friday, February 02, 2018 5:01 PMRVSRs, As reminder, claims for ALS need to be rated by RVSRs with specialized training. If you have not been trained to rate ALS and have one assigned to you, please notify your Coach so the claim can be reassigned to an RVSR with ALS training.  

CANCER CLASS by Celeste Otanez

3.309 - cancer falls under one year presumptive, specifically listed as:tumors, malignant (includes sarcoma, lymphoma, skin tumors-Basal Cell Carcinoma, Squamous Cell Carcinoma)Hodgkin’s Leukemia

METASTATIC – primary tumor site IS – dIStant tumor site ES – plural

IZE – new formations

You can get cancer anywhere and there is any diagnostic code for every body system. It is to be used for all cancer related service-connected conditions. It stands alone for a 100% evaluation i.e. prostate cancer 7528 or is hyphenated if rated on the residuals i.e. 7528-7527 prostate cancer status post prostatectomy.

3.309 and 3.311 special presumptive conditions

Agent Orange Exposure – 3.309

Radiation Exposure – 3.309 specific cancers related to radiation risk activityAtmospheric detonation of a nuclear deviceOccupation of Hiroshima or NagasaskiWWII Japanese POW250 days or more at K25 Oak Ridge Tennessee before February 1, 1992

Radiation Exposure – 3.311 occupational exposure, etc.Doesn’t apply to chronic lymphatic leukemia or Hodgkin’s disease(xxiv) any other cancer – i.e. in theory the veteran could claim metastatic cancer of an unknown primary site as a result of radiation exposure

CANCER/NAVY - think asbestos exposureAsbestos-Related Diseases originally issued as a circular on May 11, 1988 and can still be found in M21-1MR (manual re-write), Subpart ii, Chapter 2, Section C, Topic 9, page 2-C-5 The extent and duration of exposure is not a factor. Exposure may be as little as a month or two, direct or indirect. The latent period varies from 10 to 45 or more years between first exposure and the development of disease.Not a presumptive condition.The most common type of exposure: shipyards, military ships, demolition of old buildings, carpentry and construction, clutch facings and brake linings, etc. You must determine:

1. Whether the military records show evidence of asbestos exposure in service (STRs, DD214)2. Is there pre-service and/or post-service asbestos exposure. 3. The relationship between asbestos exposure and the claimed diseases, keeping in mind the

delayed onset of disease. 4. Reasonable doubt applies. THE REASONABLE DOUBT DOCTRINE IS FOR CONSIDERATION IN

SUCH CLAIMS.

W. Rees 196 updated 7/25/18

Asbestos fibers float in the air and may be swallowed or inhaled.Most common disease is:

interstitial pulmonary fibrosis/asbestosismesothelioma is synonymous with asbestos exposurepleural plaquespleural effusions and fibrosis

Asbestos fibers may also produce:1. lung cancer, not limited to the pleura/mesothelioma, not limited by cell type2. gastrointestinal tract cancer3. cancer of the larynx and pharynx4. urogenital cancer, but not prostate cancer

TREATMENT AND THE REGS Cancer is evaluated at 100% until the cessation/discontinuance of therapeutic procedures. After the specified time stated in the diagnostic code has passed, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 3.305(e). If there has been no local recurrence or metastasis, rate on residuals. EXCEPTIONS WHEN A “MANDATORY” VA EXAMINATION IS NOT NEEDED.If the medical records show the veteran has terminal cancer that would be considered chronic, incurable, and does not need a routine future exam / RFE as it is considered permanent. Be careful what you say in your rating. The vet might not know that he has cancer, let alone that the cancer is worse. It is up to the doctor to notify the vet of his medical condition or any change. The doctor may not want the vet to know, i.e. suicidal. If there are medical records showing local recurrence or metastasis, the 100% evaluation is permanent. Why? Because the prognosis is now worse, the treatment has failed. No routine future exam / RFE is necessary. According to 3.305(e) reductions or discontinuance will be prepared setting forth all material facts and reasons. 3.326(b) Provided that it is otherwise adequate for rating purposes, any hospital report, or any other examination report, from any government or private institution may be accepted for rating a claim without further examination.3.326(c) Provided that it is otherwise adequate for rating purposes, a statement from a private physician may be accepted for rating a claim without further examination.Conclusion: if the material facts and reasons show that we would not otherwise reduce the evaluation, no VA exam is necessary.

SPECIAL CONSIDERATIONSService connection may be granted to the areas affected by distant metastasis. Lung cancer with bone mets, 100% for lung cancer, 100% for bone mets, SMC S.Lung cancer with mets throughout the lung, single 100% as is did not effect a different body system.Consider A&A, hospice and home health routinely provide caregivers to assist with personal care.

When rating prostate cancer and the vet had brachytherapy/seed implants, per TL 00-02 (now per III.iv.4.I.3.h) brachytherapy - internal radiation therapy via seeds of radioactive isotopes placed in or near a tumor site:

1. Low dose rate (LDR) should be gone by one year. Evaluate at 100% for one year followed by a VA exam.

2. High dose rate (HDR) is present only for hours or days. Evaluate at 100% for 6 months followed by a VA exam.

3. Low dose rate (LDR) Iodine-125, 100% should continue for 26 months (radioactivity lasts about 20 months) and 1 year for Palladium-103 (radioactivity lasts about 6 months)

Watchful WaitingTreatment for individuals who are not good surgical candidates because they are older or have other serious health problems. May be considered for early stage of prostate cancer that is slow growing.Watch waiting is untreated cancer, it is not in remission or cured. It would be evaluated at 100% as it is W. Rees 197 updated 7/25/18

considered chronic and active.Lupron – hormone therapy injections given as often as daily or as seldom as twice yearly. Lupron implants are under the skin and usually given yearly. The length of time for treatment is determined by the physician. Order a routine future exam / RFE in 6 months after treatment stopped, if no change in treatment then P&T.BREAST CANCER – TamoxifenUsed as adjuvant therapy for early stage breast cancer, generally prescribed for 5 years.Drug reduces the risk of recurrence or developing a new primary cancer of the breast.People with advanced breast cancer may take Tamoxifen for varying lengths of time, depending on their response to treatment. Order routine future exam / RFE in 6 months, if continues treatment with Tamoxifen order a second routine future exam / RFE in 5 years.

MALIGNANT BRAIN TUMORSCertain factors affect prognosis (chance of recovery) and treatment options.The prognosis (chance of recovery) and treatment options depend on:

The location of the tumor. Can they operate? The type of tumor cell diagnosed. Glioblastoma multiforme –grows rapidly, may be enormous before

diagnosed. The amount of tumor remaining after surgery. Increased intracranial pressure.

Whether the cancer has spread to other parts of the central nervous system (brain and spinal cord), or to other parts of the body, such as the bones.

Per March 2012 Compensation Service Bulletin (CSB) & QRT Bulletin March 2012 - The treatment of an active cancer with watchful waiting will require continuation of a 100 percent evaluation because the cancer is active. However, if the physician indicates that watchful waiting is being used to monitor a cancer in remission, the cancer will be rated on the basis of any residuals, since the cancer is no longer active.

III.iv.5.B.3.b – Addressing the P&T Status of Malignancies (if not doing RFE & conceding P&T status, replace the VBMS-R System-Generated Text with this:

The medical evidence shows that permanence of this disability has been established. Consequently, no future VA examination will be requested.

III.iv.5.B.3.c – Evaluating Malignant Neoplasms and Associated Impairments (can give separate eval for related diagnosed disability, but not for symptomatic complaint from neoplasm or treatment; cannot give separate eval for metastases to same body system, but can for metastases to different body system (& can give SMC S, if applicable, as considered separate & distinct)), III.iv.5.B.3.d – examples; per QRT, 2/18 – cannot give separate evals for anemia or thrombocytopenia due to multiple myeloma

IV.ii.2.B.2.c – Considerting Presumptive SC for Metastatic Cancer

SECONDARY SERVICE CONNECTION –

Issue: Service connection for {}.

Decision: Service connection for {} (claimed as secondary to {}) is denied.

3.310 Proximate results, secondary conditions –when service connection for a secondary condition is established as proximately due to or the result of a service-connected disease or injury, “the secondary condition shall be considered a part of the original condition”

III.iv.5.C.3 – effective dates

IV.ii.2.B.5 IV.ii.2.K Tobin v. Derwinski (12/18/91) - only SC the increase caused by the SC condition; only examine & get W. Rees 198 updated 7/25/18

Allen v. Brown (3/17/95) – if SC cond. worsens NSC, take baseline level of NSC prior & subtract it from current NSC (incremental SC) [subtract even if at 100%]

Lalonde v. West (5/11/99) - TRs not informal claim for secondary condition, but if an informal claim is filed, we will treat it like a claim for increase (and the date of treatment can be used for the effective date)

Ellington v. Nicholson (7/25/07) – The effective date for a secondarily s/c condition is not identical to that of the original condition; the effective date could arise no earlier than the date on which the appellant applied for benefits for the condition at issue. (III.ii.2.C.1.a says the Court of Appeals for Veteran Claims (CAVC) (in Ellington v. Nicholson ) ruled that complaints noted by a Veteran during a VA examination (and included in the corresponding examination report) do not constitute an informal claim unless "the veteran sufficiently manifested an intent to apply for benefits for a particular disease or injury."

Douglas v. Shinseki (2009)? – need baseline level of severity on NSC disability before get agg opinion

Delisio v. Shinseki (8/24/11) – “a disability that is secondarily service-connected could have an effective date earlier than the date a claim was filed explicitly for theprimary service-connected disability, but only under certain, limited circumstances.” "The Court rejected the Secretary’s argument that a claimant must explicitly file a claim for the causal disease or disability to establish entitlement to secondary service connection for the claimed condition as overly technical and incompatible with the veteran-friendly, nonadversarial, claims system. The Court stated that the Secretary’s position contravened applicable case law that (1) a claimant need not file a claim for benefits for the precise medical causes of his condition; (2) the Secretary must sympathetically read claimant’s filing and investigate potentially applicable theories of service connection; and (3) a claim for benefits for one disability reasonably may encompass other disabilities."

Frost v. Shulkin (2017) - establishment of causation prior to a finding of SC or formal diagnosis for the primary disability, IV.ii.2.B.5.b & III.iv.5.C.3.f (effective dates)

AG1

W. Rees 199 updated 7/25/18

EVALUATIONS –

3.951 Preservation of disability ratings, 38 USC 110 – III.iv.8.B, III.iv.8.C (a) cannot reduce unless “actually improved,” (b) do not reduce an evaluation (unless fraudulent) if in effect for 20 years or more (this includes the combined evaluation), same w/P&T, compute from effective date of evaluation to effective date of reduction

FY 2013 Quality Call Training – Inter-Rater Reliability (IRR)/IRR Consistency Questionnaire – no reductions after 20 years (except in cases of fraud); no routine future exam / RFE

January 2014 Compensation Service Bulletin (CSB) – also applies to SMC

3.952 Protected ratings, 38 USC 1155 – III.iv.8.C; 1925 schedule ratings, “which were the basis of compensation on 4/1/46” can only be reduced based on 1925 criteria, or increased based on 1945 criteria

3.957 Service connection, 38 USC 1159 – III.iv.8.C.2; cannot sever (unless fraudulent, or did not have required service or character of discharge) if SC for 10 years or more, compute from effective date of SC to effective date of severance; can grant increase & SC for secondary disabilities

VAOPGCPREC 6-02 (7/11/02) - 3.957 protects even service connection erroneously and recently granted, but with an effective date more than ten years before the date of the decision establishing service connection. VA may not sever such a grant of service connection (in the absence of fraud or lack of requisite service or character of discharge). In the absence of the veteran's own willful misconduct or abuse of alcohol or drugs, VA must pay compensation otherwise in order for a disability that was erroneously service connected, where service connection is protected from severance.

Hornick v. Shinseki (2010) – protection of SC is applicable to disabilities compensated under 1151

III.iv.8.C.2 IV.ii.3.A.2.k eff date of severance is first day of month following 60 days from date of notice of final rating

action

4.1 Essentials of evaluative rating – 4.2, 4.10, 4.40, 4.45; percentages represent “average impairment in earning capacity,” exams should emphasize “limitation of activity imposed by the disabling condition”

4.7 Higher of two evaluations – “higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating”; even if doesn’t meet all criteria; III.iv.5.B.2.a – conjunctive, disjunctive, cumulative, successive, variable; III.iv.5.B.2.e

4.10 Functional impairment – 4.1, 4.2, 4.40, 4.45; “evaluations are based on lack of usefulness,” “especially in self-support,” need examiner to give a “full description of the effects of disability upon the person’s ordinary activity”

4.14 Avoidance of pyramiding – do not evaluate the same disability under various diagnoses

III.iv.5.B.2.b Brady v. Brown (2/17/93) – can’t rate psych disability & it’s physical manifestations separately

Fanning v. Brown (2/19/93) – cannot give separate, compensable evaluation for a hernia & for the scar

Esteban v. Brown (2/25/94) – Pyramiding; can grant for related, but different conditions if not duplicative or overlapping with the symptomatology (i.e. scar disfigurement, scar pain & muscle damage); includes cold injury residuals & peripheral neuropathy

VAOPGPREC 23-97 (7/1/97)

VAOPGPREC 9 - 98 (8/14/98)

VAOPGPREC 9-2004 (9/17/04)

May 2015 Quality Call Notes - VBMS-R pyramiding functionality is driven by DCs (do not override pyramiding errors if you have (1) 5055 with 5257, 5260 or 5261 on same knee; (2) 5258 with 5260 or 5261 on same knee (changed 4/13/18, III.iv.4.A.6.f, per Lyles v. Shulkin (2017); (3) 6847 with 6602 & other respiratory DCs; (4) 7806 with 7813 (should be 7813-7806); (5) 6100 with 6201; there is a potential pyramiding conflict between 7903 and 9400 series DCs. The criteria under DC 7903 specifically references mental disturbance, dementia, and depression. If the decision-maker used any of these symptoms to determine an evaluation under DC 7903 while also granting a separate evaluation under a mental code in the DC 9400 series, there would be a pyramiding conflict. This is the reason why the system generates an error message. So, it is not a needless

W. Rees 200 updated 7/25/18

pyramiding conflict.

July 2015 Quality Call Notes – Here are some additional reminders on avoiding improper pyramiding overrides.

DCs 5258 and 5259 cannot be rated separately from DCs 5257, 5260, or 5261 as both 5258 and 5259 contemplate limitation of motion and instability. Separate evaluations between these codes would constitute pyramiding. (changed 4/13/18, III.iv.4.A.6.f, per Lyles v. Shulkin (2017)

DC 5055 cannot be rated separately from DCs 5257, 5260, or 5261 as once the joint replacement occurs, the residuals are rated under the joint replacement code. This also applies to other joint replacements, too.

Any visual field defect DC with any visual acuity DC cannot be rated separately. Visual DCs must be combined into one evaluation.

Any co-existing mental disorders as mental disorders are rated under the same General Rating Formula as each other.

October 2015 Quality Call Notes – Still seeing overrides on digestive & respiratory, plus 5258 & 5259 with 5257, 5260, 5261 (changed 4/13/18, III.iv.4.A.6.f, per Lyles v. Shulkin (2017)); now also seeing overrides on 6205 with 6100 & 6260; also cannot have 6201 or 6202 with 6100

4.15 Total disability ratings – a rating “is based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it,” “Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation; Provided, That permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person.” (always includes loss of the use of both hands, both feet, one hand and one foot, sight of both eyes, or becoming permanently helpless or permanently bedridden)

4.21 Application of rating schedule – do not need all the findings specified, but need enough to identify the disease and disability, and to coordinate the rating with the impairment of function

4.25 Combined ratings table – III.iv.6.E; start with most disabling, then deduct those less disabling in order of severity

4.26 Bilateral factor –

III.iv.6.E.4.b - both upper extremities, both lower extremities, or paired skeletal muscles (for the latter- “regardless of location or specified type of impairment”)

III.iv.6.E.4.b – for skin, only applies to 7801 & 7802 (My Notes: Check prior RDs, as they might have it incorrectly applied to 7804 evaluations, which needs to be corrected if now granting SC or increasing/decreasing an evaluation.)

February 2017 Compensation Service Bulletin (CSB) - bilateral disabilities rated under a single evaluation, such as pes planus under diagnostic code (DC) 5276, the bilateral factor may only be applied if another compensable disability involves the same extremity.  The example provided in M21-1 indicates that the bilateral factor may be applied for a Veteran rated 30 percent disabling for bilateral pes planus that is also service-connected for left leg muscle damage with a 20 percent evaluation under DC 5311. 

The bilateral factor may also be applied if there are compensable service-connected disabilities of the bilateral extremities not involved with the bilateral extremity disability that has been assigned a single disability evaluation.  For example, the bilateral factor would be applied if a Veteran is rated 30 percent for bilateral pes planus under DC 5276 and also has bilateral shoulder arthritis that is evaluated with the assignment of separate 20 percent evaluations under DC 5201. 

The bilateral factor would not be applied for a Veteran rated 30 percent under DC 5276 for bilateral pes planus and 10 percent disabling under DC 5215 for a right wrist disability, as only one upper extremity is involved.  

4.31 A no-percent rating – III.iv.5.B.2.f – zero percent / noncompensable / 0% evalusions are always available even if not listed, use “when the requirements for a compensable evaluation are not met”; III.iv.4.A.2.b discusses 0%s for 5207, 5213, 5251, 5252, 5253

III.iv.6.A.1.b & III.iv.6.A.1.e – can do partial rating decision (for a time was called intermediate rating) if grant/award any claim at issue (including SC at a noncompensable level) &/or (added 6/15/18) proposing/finalizing a previous proposal to reduce/sever/find incompetent

My Notes: If doing a partial grant, create & finalize deferral in VBMS (claim will change to OPEN status),

W. Rees 201 updated 7/25/18

THEN finalize rating (ensure claim is in RDC status). Do not use the old 21-6789 unless it’s a 930 & the deferral chevron is not available.

WEEKLY QRT TIP FOR WEEK OF 12/03/2012 - Make an intermediate rating decision if the record contains sufficient evidence to grant any claim at issue, including service connection at a noncompensable level. Reference: M21-1MR III.iv.6.A.1.a

Do not use an intermediate rating decision to deny one claim when resolution of another issue is pending examination or receipt of other evidence, or deny service connection for cause of death if development is being undertaken for another condition that is possibly involved.  In this situation, the case is no longer ready to rate and should be returned to the proper location until development is completed. Reference: M21-1MR III.iv.6.A.1.b

FY 2012 & 2013 Quality Call Training – Inter-Rater Reliability (IRR)/IRR Consistency Questionnaire – can make an interim rating decision if the record contains sufficient evidence to grant any claim at issue, including granting SC at a noncompensable level & granting SC plus deferring for an exam to evaluate properly

From: VAVBASDC/RO/VSC Sent: Monday, September 19, 2016 1:16 PMSubject: FW: Quality Tip: ATTN: RVSRs/DROs; Deferred Rating Responsibility

Quality Tip:  RVSR Deferred Rating Responsibility (Post Interim Decision)

Issue:  RVSR’s have requested guidance/clarification of what their responsibilities are when completing a secondary rating decision when the prior interim rating decision contained one or more deferred issues.

Reference:

III.iv.6.B.1.a.  Recognizing Issues and Claims When Preparing a Rating Decision:o When preparing a rating decision, the decision maker must recognize, develop, clarify, and/or

decide all issues and claims, whether they are: expressly claimed reasonably raised, or unclaimed subordinate issues and ancillary benefits.

The RVSR is responsibilities for ensuring that all issues from the pending EP have been properly addressed:

o Examples: If the Veteran files claims for 5 issues and the prior rating decision issued decisions for 3

of the issues, and deferred 2 issues, the RVSR is now responsible for addressing the 2 deferred issues.

If the Veteran files claims for 5 issues and the prior rating decision issued decisions for 2 of the issues, and deferred 2 issues, the RVSR is now responsible for addressing the 2 deferred issues, and the missed issue from the prior decision. The RVSR must ensure that all issues are properly addressed.

If the Veteran files a Quick Start claim with 32 contentions, rates 30 contentions in the interim rating decision, and defers 2 contentions, for additional development, the next RVSR is responsible for rating the two deferred issues and confirming that all of the 32 contentions have been addressed.

Note:  The RVSR is not responsible for conducting a quality review of the interim rating decision(s).  Errors, noted on decided issues, discovered in the interim decision(s), would be cited as comments (not critical errors), requiring correction.

From: VAVBASDC/RO/VSC Sent: Wednesday, August 30, 2017 4:06 PMSubject: FW: Q-Tip: When to Make a Partial Rating Decision (RVSRs and DROs)VSC – For your information:

W. Rees 202 updated 7/25/18

Q-Tip:  When to Make a Partial Rating DecisionTarget Audience:  RVSRs and DROsWhen to Make a Partial Rating Decision

Make a partial rating decision when the record contains sufficient evidence to grant any claim at issue, including service connection (SC) at a non-compensable level, but other issues require additional development before they can be decided. 

When deferring an issue in a partial rating decision, the decision

must award at least one issue, and

may deny one or more issues for which adequate evidence exists to decide the claim.

Note:  Awarding at least one issue includes SC at a non-compensable level, even when the same issue requires its evaluation to be deferred.

Improper Use of a Partial Rating Decision

Do not use a partial rating decision to deny all other issues of a claim when resolution of another issue, including SC, is pending examination or receipt of other evidence.

A confirmed and continued evaluation is considered a denial.  M21-1 III.v.2.A.3.a.

Rating decisions completed in which all issues are denied while others are deferred violates the policy set forth in M21-1 III.iv.6.A.1.  QRT has been directed to cite such violation as a critical error under Task 6 (Was the denial of all issues correct) on the new RVSR Quality Checklist.

4.28 Prestabilization rating from date of discharge from service – IV.ii.2.J; do not use if total rating is immediately assignable (including IU), or 50% if it is assignable, only for immediate postdischarge period, continues for 12 months minimum (unless can give real 100% or increase from 50%), exam in 6 months minimum, 12 months maximum; auto accidents, burns, etc.; consider Ch. 35 & A&A/HB with all 100% grants, including 4.28, 4.29 & 4.30 (but do not infer to deny); 1/30/03 Legal Update Broadcast

4.29 Ratings for service-connected disabilities requiring hospital treatment or observation – IV.ii.2.J hospital treatment or observation (for the latter- at DVA expense) for more than 21 days (cannot be 21 days

exactly, has to be more than 21 days), effective 1st day of continuous hospitalization, terminated last day of month of discharge (Per Ed Ortiz on 9/24/09 “the veteran has to be paid in full month and any changes or reduction in pay has to be made on the first day of each month” & the effective date charts tend to support this: We have assigned an evaluation of 20 percent from February 1, 2009, the first day of the month after discharge.), can be extended for 1-3 months, sign by VSCM if more than 3 months extension, check with Director of C&P Service if fewer than 21 days but need care on convalescence following discharge, check reg for restrictions on temporary releases, can still give real 100% if warranted; psych conds usually; consider Ch. 35 & A&A/HB with all 100% grants, including 4.28, 4.29 & 4.30 (but do not infer to deny)

38 CFR 4.29 states that para 29 benefits "will be terminated effective the last day of the month of hospital discharge.” So we use the 1st of the following month as the effective date.

IV.ii.2.J.2.a – changed 2/12/16, must address competency for 100% for mental under 4.29

4.30 Convalescent ratings – surgery needing 1 month convalescence, surgery with severe postoperative residuals (IV.ii.2.J.4.b says severe postoperative residuals include incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited)), or casting of a major joint (elbow, knee, ankle; necessary use of wheelchair or crutches (no weight-bearing)), effective date of admission/treatment, for 1-3 months from 1st day of month following discharge/release, can be extended for 1-3 months, sign by VSCM if more than 3 months extension (can be extended 1-6 months further)

Termination of convalescence for a veteran with a temporary total rating is the last day of the month in which convalescence ends, so we use the 1st of the following month as the effective date. (My Notes: The end date for 4.30 is not indicated anywhere in the regs or manual, but is confirmed by the July 2018 Temp 100% & Under-Evaluations Consistency Study.)

W. Rees 203 updated 7/25/18

IV.ii.2.J – an RVSR can grant up to six months without a 2nd/3rd signature, but a VSCM signature is needed for an additional six months, for a total of 12 months (Coach needs to sign before VSCM); [BVA decision, Citation Nr: 1015395, Decision Date: 04/28/10 says “However, the Board notes that extensions of periods of convalescence may not be authorized for longer than one year.  Therefore, the Veteran has been granted the maximum benefit permitted under 38 C.F.R. § 4.30.”]; examine prior to end of 100% period if cannot evaluate; see what MD says, usually until can put weight on a weight-bearing joint; consider Ch. 35 & A&A/HB with all 100% grants, including 4.28, 4.29 & 4.30 (but do not infer to deny)

Rossiello v. Principi (11/4/92) - evaluations are based upon the level of disability after the temporary period of total evaluation [3.105/due process not involved in 4.29 & 4.30]

February 2009 Compensation Service Bulletin (CSB)

From Policy: Joint Replacements, Diagnostic Codes (DCs) 5051 to 5056:

For purposes of entitlement to a schedular total evaluation for 12 months following one month of convalescence under § 4.30, a total joint replacement is necessary, except for the provision under DC 5054 for replacement of the hip joint, which specifically includes replacement of either the head of the femur or the acetabulum. Partial joint replacement should be evaluated based on the facts found and any period of convalescence under § 4.30 based on the recommended convalescent period required for that veteran.

The simple wording of the diagnostic code language is clear that the surgery required is prosthetic “replacement of the ______ joint” inserting which joint applies, and requires replacement of the total joint, not some part of it. If that were not the case, there would have been no reason to make special provisions for one or the other parts of the hip joint.

Orthopedics has progressed exponentially since the advent of prosthetic joint replacements. Surgical procedures called “joint replacements” can be as simple as the insertion of a prosthetic spacer in place of a meniscus. Surgical procedures that involve only partial joint replacement generally do not warrant the 13 month temporary total evaluation. Hence, the requirement to evaluate the residual disability following the convalescent period recommended by the medical provider.

[Per Rene Wilterding, PA-C at Loma Linda VAMC, March 2015, a bicondylar knee arthroplasty involves about 3/4ths of the knee joint. A unicondylar knee arthroplasty would only involve about half of the knee joint, but can also vary. The closest choice on the DBQ to the bicondylar knee arthroplasty is a total knee arthroplasty.] – see above for partial joint replacement

January 2014 Compensation Service Bulletin (CSB) – when evaluating joint replacements and the Veteran is hospitalized toward the end of the month and released at the beginning of the next month; the evaluation builder is generating the temporary 100% for a total of 14 months. The evaluation builder is correct; therefore, QA will not cite benefit entitlement errors in this instance. Decision makers should not override the evaluation builder in these instances to pay only the temporary 100% for 13 months, doing that would result in QA citing a benefit entitlement payment error.

March 2014 Compensation Service Bulletin (CSB) – Convalescent ratings may be granted or extended based solely on consideration of a work excuse from a medical provider, provided there’s a clear connection between the claimant’s inability to return to previous employment and the surgery or cast immobilization, and there is no contrary evidence of record. However, in determining whether or not to grant or extend Paragraph 30 benefits, the work excuse will be weighed as one piece of evidence for consideration if there is any contrary medical evidence in the record.

…

Reorganization of M21-1 III.iv.4, Rating Specific Disabilities, starting 12/17

A The Musculoskeletal System Part I

B The Musculoskeletal System Part II

C The Organs of Special Sense (including eyes)

D Impairment of Auditory Acuity

E Infectious Diseases, Immune Disorders, Nutritional Deficiencies

W. Rees 204 updated 7/25/18

F The Respiratory System

G The Cardiovascular System

H The Digestive System

I The Genitourinary System

J Gynecological Conditions and Disorders of the Breast

K The Hemic and Lymphatic Systems

L The Skin

M The Endocrine System

N Neurological Conditions and Convulsive Disorders

O Mental Disorders

Historical MR References for Body Systems Old Section

Date Moved New Section

Musculoskeletal III.iv.4.A   III.iv.4.A      III.iv.4.BOrgans of Special Sense Eyes III.iv.4.B 2/2/18 III.iv.4.C Organs of Special Sense Audio III.iv.4.B 2/2/18 III.iv.4.DInfectious Diseases, Immune Disorders, and Nutritional Deficiencies III.iv.4.C 1/25/18 III.iv.4.E

Respiratory III.iv.4.D 1/31/18 III.iv.4.FCardiovascular III.iv.4.E 1/25/18 III.iv.4.GDigestive III.iv.4.I 1/11/18 III.iv.4.H

Other (Digestive/Hepatitis/GU/GYN/Hemic III.iv.4.I   III.iv.4.H; I; J; K

Genitourinary III.iv.4.I 1/11/18 III.iv.4.IGynecological III.iv.4.I 1/11/18 III.iv.4.JHemic and Lymphatic III.iv.4.I 1/11/18 III.iv.4.KSkin III.iv.4.J 12/21/17 III.iv.4.LEndocrine III.iv.4.F 12/11/17 III.iv.4.MNeuro III.iv.4.G 1/24/18 III.iv.4.NMental Disorders III.iv.4.H 1/4/18 III.iv.4.O

W. Rees 205 updated 7/25/18

4.40 - 4.73. The Musculoskeletal SystemIII.iv.4.AIII.iv.4.B

4.40 Functional loss – 4.1, 4.2, 4.10, 4.45, 4.59; “Disability of the musculoskeletal system is primarily the inability…to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance.” This can be due to missing joint structures, deformity, pain "supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion,” weakness, limitation of motion, pain with use, & atrophy. Exams need to “adequately portray the anatomical damage, and the functional loss, with respect to all these elements.” “a part which becomes painful on use must be regarded as seriously disabled,” weakness is the same as pain is the same as limitation of use

III.iv.3.D, III.iv.3.D.3 – insufficient, clarification, inconsistent, inadequate exams, III.iv.3.D.4.g – send back musculoskeletal DBQs w/contradictory findings

Deluca v. Brown (12/22/95) – III.iv.4.A.1.b says “exams must assess the impact of pain on functional impairment including additional loss of motion due to pain”; III.iv.4.A.1.c says “the disability is evaluated based on most severe loss of motion due to pain or following repetitive motion testing. DL1

Training documents are under “Applying Deluca” at http://hvnc.gdit.com/lc/

Floyd v. Brown (4/17/96) – adequacy of examinations

Mitchell v. Shinseki (8/23/11) – reiterates DeLuca’s requirement that when pain is associated with movement, the medical examiner must be asked to express an opinion on whether pain could significantly limit functional ability during flare-ups or when the (joint) is used repeatedly over a period of time. It states that when there is pain noted on range of motion, or a history of pain associated with flare-ups, the pain itself could limit function of that joint. Therefore, looking only at the loss of function associated with three repetitions of ROM in a person with pain on range of motion testing may not always be an accurate indication of loss of function due to pain associated with repetitive use. Need an opinion on functional loss (in degrees of loss) during real-life repetitive use (walking, stairs, etc.) and during flare-ups. III.iv.4.A.1.d says “When painful motion on repeated use over time or during a flare-up results in additional loss of ROM, then the condition should be evaluated based on the additional loss of ROM. ROM must be actually limited. Do not assign an evaluation for loss of ROM based on the point at which pain accompanies motion unless the pain actually causes reduced ROM on objective assessment.”

Per STAR Quality Conference Call February 23, 2012 and March 22, 2012 & QRT Bulletin March 2012 – Do not check the PAIN box if the record only shows tenderness or pain upon palpation of the joint. [Confirmed by September 2013 Compensation Service Bulletin (CSB)]

April 2014 Rating Quality Call Notes –

Q: During a VA examination, the examiner notes a Veteran’s right knee joint has no pain on motion, no limited range of motion (LROM), and no pain or LROM on repetitive movement. However, the examiner opines the Veteran has painful right knee motion during flare-ups, but there is no LROM during flare-ups. An evaluation of 10 percent is assigned for the right knee based on pain during flare-ups using Mitchell and 38 CFR 4.59. Is this rating action correct?

A: Policy Staff (211) advises the rating action in the scenario above is not correct. A review of the Mitchell decision shows that pain on motion during the examination is the gateway to the DeLuca and Mitchell tests. If no pain on motion is shown, to include the repetitive motion test, there is no need for the examiner to provide a Mitchell assessment. Furthermore, Mitchell findings must be expressed in terms of additional loss of motion.

In the March 2013 CS Bulletin, Policy Staff (211) advised that flare-ups and repeated use over long periods should only be addressed when a 38 CFR 4.40 or 38 CFR 4.45 factor is shown on examination.

In the Mitchell decision, the Court indicated that in the context of examinations evaluating functional loss under diagnostic codes (DCs) based upon limitation of motion and when pain is associated with movement, DeLuca v. Brown, 8 Vet.App. 202 (1995), requires examinations to comply with the requirements of § 4.40. In such examinations, the examiner must express an opinion on whether pain could significantly limit functional ability during flare-ups or upon repeated use over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional ROM loss due to pain on use or during flare-ups.

W. Rees 206 updated 7/25/18

**MITCHELL IS ONLY RELEVANT IF THERE IS PAIN ON INITIAL ROM OR ON REPETITION** (but pain during repeated use over time/flare-ups can be used to grant a compensable

evaluation if it causes actual LOM to a compensable level)

III.iv.4.A.1.g – “When pain results in additional functional loss during flare-ups or upon repeated use over a period of time, evaluate the joint based on the resulting LOM.” - removed as of 5/25/17

From Carlos Rosario 5/5/15 –

Subject: Mitchell and flare ups

If during examination the veteran:

1.      does not have pain on motion, or limited range of motion; and

2.      during repetitive motion the veteran does not have pain on motion or limitation of motion; and

3.      the examiner opines the veteran has painful motion during flare-but no additional limitation of motion during flare ups; limitation of motion cannot be estimated

Then,

        A compensable evaluation is not warranted. Mitchell findings must be expressed in terms of additional degree loss of motion.

Carlos also said, with Mitchell: we cannot compensate using 4.59 it would have to be a schedular evaluation. For example if during flare ups there is a 5 degree loss during flexion and extension due to pain it is a 0% evaluation using the Mitchel criteria. But if there was an additional loss of 10 degrees during flexion and extension because of pain, the extension would be compensable because it is a schedular 10%.

Rating Note: Although the VA examiner indicated that pain causes functional loss with {flare ups/repeated use over time} for the {enter joint}, there is no limitation of motion to a compensable level and Mitchell cannot be used to apply 4.59, so a compensable evaluation is not warranted. Ref: April and November 2014 Rating Quality Call Notes. – CHECK SUBJECTIVE COMPLAINTS OF PAINFUL MOTION, will need to address that too, if can’t grant compensable evaluation

Per Melvin Moore, 7/11/16, “for muscular skeleton joint conditions, if the initial ROM and observed repeated ROM are normal with no pain, a compensable evaluation can only be awarded due to functional loss that is shown with the Mitchell consideration and flare-ups if there is pain that causes functional loss and the functional loss results in and is reported via degrees in ROM.”

DBQ results –> entries in EB For Initial range of motion (ROM) – enter degree in “Actual,” then for Select where objective

evidence of painful motion begins – if any degree selected, click the appropriate square under Painful Motion

Observed repetitive use / ROM measurements after repetitive use testing / Additional limitation in ROM following repetitive-use testing – enter degree in “Deluca” if different than “Actual”

Repeated use over time / Mitchell (i.e. repeated use over time) / some older DBQs covered this in Remarks [not needed or applicable if no pain on initial range of motion or during observed repetitive use/repetitive use testing (Deluca) unless there is LOM to a compensable level due to pain] – enter degree in “Mitchell” if YES & if ROM is provided & if different than “Actual” or “Deluca”

Flare-ups (also Mitchell) / some older DBQs covered this in Remarks [not needed or applicable if no pain on motion, to include during repetitive motion test (Deluca) unless there is LOM to a compensable level due to pain] – enter degree in “Flare-Up” ” if YES & if ROM is provided & if different than “Actual” or “Deluca” or “Mitchell” – if “No response” under 3d, see if checked No under 2b or 2c.

…4.41 History of injury – trace medical-industrial history; trauma v. congenital/developmental4.42 Complete medical examination of injury cases – complete exam covering all systems of the body on 1st

exam4.43 Osteomyelitis – III.iv.4.A; is a continuously disabling process, give permanent rating, don’t exceed

amputation rating

W. Rees 207 updated 7/25/18

4.44 The bones – need complete study with regard to deformity and affect on neighboring (especially weight-bearing) joints

4.45 The joints – look for less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, deformity, atrophy, instability, disturbance of locomotion, and interference with sitting, standing and weight-bearing, “pain on movement” cited as a factor of disability regarding the joints

III.iv.4.A.2.j - Major joints: Shoulder Elbow Wrist Hip Knee Ankle

III.iv.4.A.2.k - Minor joint groups: Multiple involvements of the distal interphalangeal (DIP), proximal interphalangeal (PIP),

metacarpophalangeal (MCP) and/or carpometacarpal (CMC) joints of the same upper extremity Multiple involvements of the interphalangeal (IP), metatarsophalangeal (MTP) and/or transverse tarsal

joints of the same lower extremity Multiple involvements of the cervical vertebrae Multiple involvements of the dorsal (thoracic) vertebrae Multiple involvements of the lumbar vertebrae, or lumbosacral articulation together with both sacroiliac

joints

For 10% under 5010, you need x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups.

So, you would need more than one joint involved on each (1) hand, (2) foot or (3) section of the spine to equal a minor joint group. For a 10 percent, you would need at least two finger joints on one hand (1st group), and at least two finger joints on the other hand (2nd group).

QRT Bulletin August 2012 & Q&A Session – do not deny joints just based on no objective findings; if diagnosis is ambiguous/equivocal or don’t know if it’s current, get clarification; can deny if acute or resolved, with no objective findings or a statement of no residuals [Local Narrative Feb 2013 says okay to deny a diagnosis of lumbar strain with no residuals]; should still grant if diagnosis, but no objective findings and the examiner says in remission or quiescent, or STR/TRs show active treatment. - *THIS IS FOR JOINTS, see IV.ii.2.B.1.b for more info on “current disability” with “near-contemporaneous” diagnosis

Rating Note: QRT Bulletin August 2012 & Q&A Session indicated that we should deny if acute or resolved, with no objective findings or a statement of no residuals; but we should still grant if there is a diagnosis, but no objective findings and the examiner says in remission or quiescent, or STR/TRs show active treatment.

*THIS IS FOR JOINTS, see IV.ii.2.B.1.b for more info on “current disability” with “near-contemporaneous” diagnosis

January 2013 Compensation Service Bulletin (CSB) – A minor joint in the upper extremity would be a distal interphalangeal joint, proximal interphalangeal joint, metacarpophalangeal joint, or carpometacarpal joint. In the lower extremity, it would be an interphalangeal joint, metatarsophalangeal joint, or transverse tarsal joint. A combination of two or more minor joints in the upper extremities constitutes a group of minor joints. A combination of two or more minor joints in the lower extremities also constitutes as a group of minor joints. The two groups of minor joints must both be in either the upper extremities OR the lower extremities, not a combination of one group in the upper, and one group in the lower. Under DeLuca requirements, compensable evaluations are allowed for pain on motion of joints. Also, under DC 5003, a compensable evaluation may be assigned for painful motion of certain minor joints. Entitlement to a 10 percent evaluation requires pain on motion in at least two of the following digits of the same extremity: thumb, index finger, and middle finger. Pain in the ring finger or little finger will not be considered. Pain on motion in the toes does not warrant a compensable evaluation, however the facts of the case could be considered in determining if a compensable evaluation is warranted under DC 5284.

4.46 Accurate measurement – needed for length of stumps, range of motion, dimensions of scars, muscle atrophy, helps if use a goniometer

W. Rees 208 updated 7/25/18

From: Rosario, Carlos H., VBASDGO Sent: Tuesday, April 18, 2017 1:09 PMSubject: FW: RQRS Notification - Use of the Goniometer

The QRT just received the following message. I am happy to share with you guys… Carlos

Good afternoon,

VHA has notified us that musculoskeletal examinations are being returned as insufficient because the examiner did not clearly indicate that a goniometer was used.

VBA’s Procedural Manual was updated on February 9, 2017 and originated with this Pulse post, wherein a user pointed out that the manual was, at that point, silent as to the necessity for the goniometer’s use. The Manual added III.iv.4.A.1.r as a passing procedural nod to 38 CFR 4.46, acknowledging the goniometer requirement, but the intent of this update was not to subject musculoskeletal exams to a higher level of discernment or scrutiny.

For C&P examinations, the goniometer’s use has been the standard. The examiner does not have to specifically state that a goniometer was used as we will assume under the presumption of administrative regularity that the goniometer was used, unless there is specific evidence to the contrary.

References:

III.iv.4.A.1.r. Importance of Accurate Measurements in Joint Cases

§4.46 Accurate measurement.

Thank you for your cooperation,

DEMO and 214C

4.55 Principles of combined ratings for muscle injuries – no separate evaluations if involve nerves OR ankylosed joint (with exceptions, read regulation)Please note that our regulations state that a "muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions." Since the same function is involved, we cannot grant a separate evaluation for {} nerve damage.

III.iv.4.B.7 4.56 4.73 GC Opinion 23-97

Notes from April 2013 AMPUTATION RULE, PYRAMIDING, AND GUNSHOT WOUNDS Training :

Training documents are under “Application of the Amputation Rule, Pyramiding, and Gunshot Wounds” at http://hvnc.gdit.com/lc/

4.55 - does not apply if the MG does not act on a joint AND there is no peripheral nerve damage to the same body part affected by the muscle injury (if one or both is true, 4.55 applies)Don't combine a muscle injury rating with a rating for peripheral nerve paralysis of the same body part unless the injuries affect entirely different functions.

Don't assign a rating for muscle groups that act on an ankylosed joint except:- if the knee is ankylosed and there is a disability of MG XIII (you'll rate MG XIII but at the next lower level than would otherwise be assigned)- if the shoulder is ankylosed and MGs I & II are severely disabled (you'll evaluate the shoulder joint under 5200 as unfavorable ankylosis, if not already assigned, but do not assign an evaluation for MG I or II)

When there is an injury of more than one muscle group acting on a single, unankylosed joint, assign a

W. Rees 209 updated 7/25/18

combined evaluation for the muscle group that is lower than the evaluation for unfavorable ankylosis of that joint (except for MGs I and II acting on the shoulder).

When there are multiple muscle groups injuries that:- are in the same anatomical region, AND- are NOT acting on the same joint, AND- are compensable;You'll rate the most severely injured MG one level higher than would otherwise be assigned, and use this as the combined evaluation for all affected muscle groups in this region.

The "Application of the Amputation Rule HO" has nice pictures of all the muscle groups.

(0) Absent: No contraction felt.(1) Trace: Muscle can be felt to tighten, but no movement is produced.(2) Poor: Muscle movement is produced only with gravity eliminated.(3) Fair: Muscle movement is produced against gravity, but cannot overcome resistance.(4) Good: Muscle movement is produced against resistance, however, less than “normal” resistance.(5) Normal: Muscle movement can overcome “normal” resistance.

Remember, when rating wounds of the chest or abdomen, you must rate the muscle groups penetrated, as well as any affected internal organs.

4.56(a) - An open (or compound, bone sticking through the skin) comminuted (bone is broken, splintered or crushed into a number of pieces) fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal.

4.56(b) - A through-and-through wound injury (has an entrance and exit wound, destroys muscle tissue by crushing it, exit wounds are generally larger) with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged.

As there are currently many wounds incurred from improvised explosive devices (IEDs), RVSRs should be aware that fragments often result from such devices. Fragments from Explosive Devices - Most result in decreased tissue penetration, compared to denser rifle bullets. When struck by multiple fragments in a localized area, the crush mechanism results in massive tissue disruption.

4.56(d)(1) - do NOT assign a slight evaluation if there are cardinal signs or symptoms of muscle disability; fascial defect, atrophy or impaired tonus; impairment of function; or metallic fragments retained in muscle tissue

4.14 - Don't combine overlapping symptoms from injuries to the muscles, nerves and joints. Separate ratings under 7800, 7801, 7802, 7803 & 7804 is not pyramiding, but a separate rating under 7805 is pyramiding if it's for the same body part that is receiving a rating for muscle injury because 7805 evaluates limitation of function.

THINGS TO REMEMBER WHEN EVALUATING GUNSHOT WOUND CLAIMS

Rate all disabilities - All manifestations of a GSW or SFW injury affecting different bodily functions are separately ratable.

Amputation Rule - The combined rating for residuals of a GSW/SFW to an upper or lower extremity, with certain exceptions related to osteomyelitis, cannot exceed the rating for amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68

Pleural Cavity Injury and MG XXI - Separate ratings for a pleural cavity injury (diagnostic code 6800) and injury to Muscle Group XXI are prohibited. 38 C.F.R. § 4.97, Diagnostic Codes 6840 to 6845, note 3.

Pleural Cavity Injury and MG I & IV - Disabling injuries of shoulder girdle muscles (Groups I and IV) shall be separately rated and combined with respiratory involvement. 38 C.F.R. § 4.97, Diagnostic Codes 6840 to 6845, note 3.

Open comminuted fracture - severe muscle rating - Open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a).

GSW/SFW fractures all open - All GSW/SFW fractures should be considered open because all of them involve an opening to the outside. Most GSW/FSW fractures are also comminuted due to the

W. Rees 210 updated 7/25/18

shattering nature of the injury.

Through-and-through muscle injury minimum moderate – Through-and-through injury with muscle damage shall be evaluated no less than a moderate injury for each muscle group affected. 38 C.F.R. § 4.56(b).

Special Monthly Compensation for Loss of Use - Consider special monthly compensation for loss of use of any extremity or loss of use of both buttocks.

4.56 Evaluation of muscle disabilities –open comminuted fracture with muscle/tendon damage = severe, thru & thru with muscle damage = at least moderate, don’t forget amputation rule (read regulation), retained fragments = at least moderate, but Tropf (8/24/06) & Robertson (1993) (court cases) say that 4.56d “is essentially a totality-of-the-circumstances test and no single factor is per se controlling,” so can say no CUE because, “These findings warrant a 0 percent evaluation under VA rules, practices and procedures, including Court cases that have stated that under VA regulations the actual disability should be determined by the totality-of-the-circumstances and that no single factor is per se controlling.”Or special notation: Per Tropf v. Robertson, 4.56d "is essentially a totality-of-the-circumstances test and no single factor is per se controlling."

4.57 Static foot deformities – distinguish between congenital and acquired flat feet“Grant service-connection for acquired flat feet, or pes planus, DC 5276, but not for the congenital variant. The rating specialist should carefully review 38 CFR 4.57 to distinguish between the two. Simple flattening of the arches without evidence of abnormal callosities, areas of pressure, strain or demonstrable tenderness, is a congenital abnormality. In the acquired condition, there is depression of the longitudinal arch, but this is not the essential feature. There would also be associated anatomical changes, such as the inward rotation of the superior portion of the os calcis, medial deviation of the insertion of the Achilles tendon, or a medial tilting of the upper border of the astragalus. The plantar surface of the foot would be painful and show demonstrable tenderness, and manipulation of the foot would produce spasm of the Achilles tendon, peroneal spasm due to adhesion about the peroneal sheaths, and other evidence of pain and limitation of motion.”- Musculoskeletal Training Student Guideservice connect pes cavus (5278) only if trauma or definite aggravation

4.58 Arthritis due to strain – arthritis in only those joints directly affected by strain from lower extremity amputation or shortening will be considered for service connection, includes same extremity, both lower extremities, lumbosacral joints and lumbar spine, upper extremities are not considered causative

4.59 Painful motion – to justify “the minimum compensable rating” for an arthritic joint, painful motion can be shown by “facial expression, wincing, etc. on pressure or manipulation,” also mentions muscle spasm, and crepitation with flexion; tenderness, swelling, redness and crepitation are indicative of pain

Schafrath v. Derwinski (11/26/91) – functional loss due to pain or weakness is to be rated at the same level as the functional loss where motion is impeded. Veteran’s elbow cond was reduced even though it affected his employment.

Hicks v. Brown (1995) – painful motion is considered limited motion even though ROM is possible beyond the point when pain sets in

Burton v. Shinseki (8/4/11) – 4.59 is not limited to arthritis claims

Petitti v. McDonald (10/25/15) - 4.59 does not require objective evidence of painful motion for a compensable evaluation; III.iv.4.A.1.f

Sowers v. McDonald (2/12/16) – 4.59 is limited by the DC applicable to the disability & not applicable to a DC that does not provide a compensable evaluation

Correia v. McDonald (7/5/16) – exams must assess ROM testing to evaluate joint disabilities for painful motion in weight-bearing, nonweight-bearing, with active and passive motion, and in comparison to the opposite joint; painful passive motion is sufficient to satisfy criteria for minimum compensable evaluation under 4.59

Southall-Norman v. McDonald (12/15/16) – 4.59 is not limited to DCs involving limited ROM

August 2016 Compensation Service Bulletin (CSB) – Need contralateral joint examined, per Correia v. McDonald. Per QRT, send DBQ back if not done.

May 2017 Quality Call Notes –

Question: Is Correia required for the spine?

W. Rees 211 updated 7/25/18

Answer: Yes. DEMO advises that C&P examiners have been instructed to include Correia information in all applicable examinations. DEMO will be updating all appropriate DBQs with Correia language.

III.iv.4.A.1.h (updated 10/24/17) says Correia section for ROM of the opposite, undamaged joint NOT required for spinal disabilities, since there is no opposite joint (but still need both active & passive ROM in weight-bearing and nonweight-bearing, as can apply 4.59 for pain with passive ROM);also says Correia holding is effective July 5, 2016

Question: Does 38 CFR 4.59 apply to pain on passive range of motion (i.e. Correia responses) in regards to assigning a compensable evaluation for objective evidence of painful motion. We are seeing many DBQs where the examiner marks “No” to whether there was pain during initial/repetitive ROM testing; however, the examiner advises that there is pain on passive motion of the joint in the Correia questions. Should clarification be sought? Basically, what does the decision maker do with the Correia question responses as far as assigning an evaluation based on those responses?Answer: Historically, VA has only applied 38 CFR 4.59 to pain on active motion. However, with Correia, we cannot avoid applying 4.59 with a minimal compensable evaluation if pain is shown on passive motion.

Question: Is the prior guidance to not return completed examinations for Correia information applicable, or applicable in limited circumstances (especially with older exams and exam requests that did not ask for Correia information)?Answer: Compensation Service released guidance in the September 2016 VSCM CSB to not return the examination for Correia compliance, unless a Substantive Appeal has been submitted. Since then, DEMO has provided guidance concerning the language that needs to be inserted into the DBQs.

Per QRT/GiaBao Nguyen –

for 5280/hallux valgus, do manual entry to give 10% under 4.59 as there is no option for this in VEB/LEB

for 5276/pes planus, can still give 10% under 4.59 if there is complete relief with orthotics, confirmed by III.iv.4.A.1.r on 4/13/18 change & by April 2018 Quality Call Notes

pinkie/ring finger is 0% max under 5230, thumb/index/long – need two fingers to give 10% under 4.59 per III.iv.4.A.2.n; can give compensable evaluations for the thumb, index finger and long finger (separate evals for each) under 5228 and 5229, per 10/24/17 change to III.iv.4.A.1.j (which was moved to III.iv.4.A.1.p&q & further clarified on 4/13/18) & 10/24/17 change to III.iv.4.A.3.n (which was then moved to III.iv.4.A.4.h on 4/13/18); My Notes: Maybe not super clear that can get 5229 10% for index & 5229 10% for long until 4/13/18 clarification at III.iv.4.A.1.p…

can use 5010 & 5003 to give 10% under 4.59

they have requested clarification on if we can give 10% under 4.59 for 5213/forearm supination/pronation (twisting) & another 10% under 4.59 for 5206/5207 elbow flexion/extension if the veteran just says “arm pain” * see below notes on pdf

5260/5261/5257/knee – can only give ONE 10% under 4.59

5251/5252/5253/hip – can only give ONE 10% under 4.59

pain at rest is not painful motion under 4.59, “bothered” is not sufficient; need statement of “pain with activity”

you cannot rate on just a lay statement without treatment records or a DBQ

they recommend that you add a line about where you found lay painful motion allowing 10% under 4.59

July 2017 Quality Call Notes – can use 3.157 & 3.400(o)(2) for subjective complaints of painful motion under 4.59; can give 10% for 5280 & another for 5276; My Notes: seems to imply that you can grant 10% with just “I have pain” or “It hurts” but without any mention of a “motion” (maybe because can give if have pain with “use” or “activity,” including standing/weightbearing).

https://www.vapulse.net/message/148943 - good questions on 4.59 (no answers as of 6/13/17)

July 2017 Quality Call Notes – look for symptom of painful motion in exam, TRs or lay testimony; does not absolve VSRs from ordering exams in CFIs if veteran indicates painful motion in lay testimony; 38 CFR 4.59 considerations are now based on diagnostic codes rather than on range of motion disabilities only.

W. Rees 212 updated 7/25/18

Minimum compensable evaluations can be established for any diagnostic code that both provides a minimum compensable evaluation (10 percent or more) and demonstrates pain on movement, whether in objective medical evidence or subjective credible testimony. PowerPoint shows: pain/tenderness on palplation & crepitus are not sufficient, alone, to establish painful motion; only one 10% for knee for 4.59

III.iv.4.A.1 (lots of new info 10/24/17)

From: VAVBASDC/RO/VSCSent: Friday, November 03, 2017 8:11 AMSubject: Updated Q-Tip: Evaluating Painful Motion under 38 CFR 4.59 Q-Tip:  Evaluating Painful Motion under 38 CFR 4.59 (with attachment)  Target Audience:  RVSRs and DROsBackground  

The musculoskeletal section of the manual at M21-1 III.iv.4.A.1 was updated on May 25, 2017 to provide instruction on when a minimum compensable evaluation is warranted under 38 CFR 4.59.  Significant changes included that 38 CFR 4.59 does not require objective evidence of painful motion in order to assign the minimal compensable evaluation for the joint.  A claimant’s credible lay statement describing his/her pain is acceptable proof that the he/ she has “painful motion.”  Due to gaps in the manual instructions relating to certain issues, QRT provided interim guidance in VSC email “ QRT Q&A – Minimum compensable evaluation under 38 CFR 4.59” dated June 22, 2017 until the manual can be further clarified.  The “Q&As” were rescinded due to additional clarification published to the manual on October 24, 2017.

Updated Guidance

The latest guidance provided at M21-1 III.iv.4.A.1 must be followed when evaluating for painful motion under 38 CFR 4.59.  The attached document provides on overview of what is considered satisfactory evidence of painful motion to warrant a minimum compensable evaluation under 38 CFR 4.59 along with some examples that are provided in the manual.  Guidance from the manual relating to specific disabilities are also included based on previous inquiries received.  Changes deemed to be significant from prior guidance are highlighted in yellow.

Evaluating Painful Motion 10-24-17.pdf is saved at H:\VSC\Rating Reference

My Notes from the above pdf file:

Veteran’s/buddy statement of painful motion = 10% for painful motion, if credible per III.iv.5.A.2.b (usually credible unless have conflicting info in TRs)

Pain with weight-bearing, nonweight-bearing or passive ROM (including positive Hawkin’s sign); pain reported during repeated use or flare-ups = 10% for painful motion

Examiner’s opinion that painful motion would be present with repeated use over time or during flare-ups = 10% for painful motion

Cannot give 10% for crepitus/crepitation or pain on palpation

Can give 10% for 5276, 5284(including painful motion of multiple toes, February 2018 Quality Call Notes confirmed only one 5284 for each foot even if have multiple painful toes, per III.iv.4.A.1.p), 5280(for hallux valgus, don’t use for painful motion of the first toe, per III.iv.4.A.1.p & III.iv.4.A.1.q) & 5229(February 2018 Quality Call Notes confirmed can give multiple 10%s for fingers per III.iv.4.A.1.p & III.iv.4.A.1.q, they mean 5228 & 5229), but not for 5230(per III.iv.4.A.1.g & III.iv.4.A.1.q)

Clarify with examiner if have painful motion of elbow/forearm, but you cannot tell if apply it to 5206/5207 or to 5213 (examiner should check which box, but if examiner cannot delineate, resolve reasonable doubt in the veteran’s favor)

Note for Narrative: The {} DBQ shows your lay statement of painful motion based on your reports of {pain with standing / pain with walking / pain with running / }.

My Notes: I’d add a note to the codesheet if complaints are not pain on motion / use / activity / weight-bearing / nonweight-bearing / passive motion(Hawkin’s sign) / repeated use(can be just reported pain) / flare-ups(can be just reported pain):

W. Rees 213 updated 7/25/18

Rating Note: The {} DBQ shows “He reports the {} pain was worse during physical therapy activity and sometimes when picking up his son.” This is not evidence of current painful motion, because it only talks about the veteran’s history.

Rating Note: The {} DBQ only shows reports of “pain” (alone, with nothing else) / “pain at rest” / “pain in certain positions”(unless it can be considered nonweight-bearing) / “discomfort” / “being bothered” / “difficulty”(My Notes: This is up for debate), which is not painful motion (or pain with use/activity) under 4.59.

Rating Note: The {} DBQ only shows “pain on palpation,” which is not painful motion under 4.59.

Rating Note: The {} DBQ does not show painful motion under 4.59.

III.iv.4.A.1.s (as of 4/13/18) - for 5228 & 5229, go directly to the Disability Decision Information (DDI) screen to grant 10%, then add this:

We have assigned a 10 percent evaluation based on: • Painful motion due to [input name of affected digit].

38 CFR §4.59 allows consideration of functional loss due to painful motion to be rated to the minimum compensable rating for the affected disability. Since you demonstrate painful motion, a minimum compensable evaluation of 10 percent is assigned.

Then modify the text below to include only the criteria that is relevant to the fact pattern being addressed and incorporate into the rating narrative as the next higher evaluation criteria.

A higher evaluation of 20 percent is not warranted unless there is: Limited motion of the thumb: with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; or, Favorable ankylosis involving the index finger and any other finger; or, Favorable ankylosis involving the long, ring and little fingers; or, Unfavorable ankylosis involving the thumb; or, Unfavorable ankylosis involving the long and ring fingers; or, Unfavorable ankylosis involving the long and little fingers; or, Unfavorable ankylosis involving the ring and little fingers; or, Amputation of the thumb at distal joint or through distal phalanx; or, Amputation of the index finger without metacarpal resection, at proximal interphalangeal joint or proximal thereto; or, Amputation of the long, ring or middle finger with metacarpal resection (more than one-half the bone lost).

In some situations, evaluation of disabilities of the hand requires multiple digits to be combined into a single diagnostic code. Therefore, some higher evaluation criteria listed above include all possible higher digit-combination criteria.

III.iv.4.A.1.t (as of 4/13/18) - for 5276-5284, go directly to the Disability Decision Information (DDI) screen to grant 10%, then add this:

We have assigned a 10 percent evaluation based on: • Painful motion due to [input name of disability].

38 CFR §4.59 allows consideration of functional loss due to painful motion to be rated to the minimum compensable rating for the affected disability. Since you demonstrate painful motion, a minimum compensable evaluation of 10 percent is assigned.

Then get the higher eval info from LEB.

Next higher for 5284: A higher evaluation of 20 percent is not warranted for foot injuries unless the evidence shows moderately severe symptoms.

Saunders v. Wilkie (4/3/18) – per July 2018 Quality Call Notes, IV.ii.2.A.2.c (updated 7/18/18) & IV.ii.2.A.2.d (added 7/18/18), if lay/medical evidence shows “functional impairment of earning capacity” (i.e. limited ability to perform occupational tasks to the extent that work performance is impaired, examples: inability to perform certain movements or tasks d/t pain, time lost from work d/t/ pain, pain resulting from

W. Rees 214 updated 7/25/18

increased fatigability or incoordination affecting job performance), we can grant for PAIN ALONE without an actual diagnosis of a disease/injury, but it cannot just be subjective pain

see “Functional Impact” section of the DBQ, examples: “subjective bilateral knee pain” diagnosed with functional limitations on walking, can only stand for a few minutes, sometimes requires cane/brace; “subjective cephalgia” diagnosed with FI since needs to leave work & lie down to get relief; does NOT apply if examiner says the pain would not impact the veteran’s ability to perform any type of occupational task; clarify exam if there I sno analysis as to whether the pain impacts the ability to perform occupational tasks unless that info is shown in other credible evidence)

this is about establishing a “disability,” not about the evaluation of the disability (Petitti covers the evaluation under 4.59 & DCs 5002 & 5003)

can be noncompensable

applies to all body systems, not just musculoskeletal

this is not liberalizing

applies to claims pending or received on or after 4/3/18

…

4.61 Examination – for any non-traumatic arthritis, the exam needs to cover all major joints

4.62 Circulatory disturbances – might require a rating under phlebitis

4.63 Loss of use of hand or foot – loss of use is when no effective function remains except for what would exist if had prosthesis, loss of use exists with extremely unfavorable complete ankylosis of the knee, or complete ankylosis of 2 major joints of an extremity, shortening of the lower extremity of 3-1/2 inches (8.9 cm) or more, or complete paralysis of the external popliteal nerve (common peroneal) with footdrop and characteristic organic changes

3.350 IV.ii.2.H

4.64 Loss of use of both buttocks – 3.350; loss of use is when there is severe damage to MG XVII, bilateral (DC 5317), and the person cannot rise from a seated/stooped position, as well as maintain postural stability without assistance from another person, or the person’s own hands/arms, or a special device

4.66 Sacroiliac joint – usually arthritis here, lumbosacral and sacroiliac are considered one anatomical segment, trauma causing arthritis is rare so need objective evidence of damage to joint and history of severe trauma

4.67 Pelvic bones – rate specific residuals, faulty posture, limitation of motion, muscle injury, painful motion of the lumbar spine, manifest by muscle spasm, mild to moderate sciatic neuritis, peripheral nerve injury, or limitation of hip motion

4.68 Amputation rule – combined cannot exceed amputation rating at that level; applies to musculoskeletal conds only (does not apply to neurological, skin or vascular, unless part of musculoskeletal injury, III.iv.4.A.8.e confirms neuro, but not skin or vascular)

5/20/03 Traumatic Injuries Broadcast - “The total evaluation of the amputation, and residuals such as nerve and skin damage, do fall under the auspices of the musculoskeletal section because the disability you are evaluating is an amputation.”

Notes from May 2011 Amputation Rule Training –

The amputation rule does not apply to non-musculoskeletal disabilities in general, but if the nerve residuals are part of an amputation disability, the amputation rule applies. In situations where the disability at issue is entirely separate from the amputation, the amputation rule would not come into play.

Musculoskeletal disabilities (with the exception of osteomyelitis, as it’s based on constitutional symptoms), nerve and skin damage associated with an actual amputation, neurologic injuries and skin damage associated with musculoskeletal injuries

Notes from A pril 2013 AMPUTATION RULE, PYRAMIDING, AND GUNSHOT WOUNDS Training –

Amputation rule applies to musculoskeletal conditions (other unrelated disabilities affecting the extremity can combine at a rate higher than the elective amputation site)

W. Rees 215 updated 7/25/18

Disarticulation of the thigh & below = max 90%Middle third of the thigh & below = max 60% (knee involvement is considered "above the knee" amputation)Below the knee = max 40%

August 2014 Compensation Service Bulletin (CSB) Addendum – Amputation rule does not apply to peripheral nerve evaluations.

New Amputation Rule functionality – see VBMS Major Release 8.0 Functionality Preview [no longer online] (no more Amputation Rule check-box, it’s automated started 12/15/14 & Amputation rule item will be added after you “Document,” select link to verify amputation rule, check Master Record for new condition under 5164)

III.iv.6.D.9.a – example of codesheet w/amputation rule

November 2015 Quality Call Notes – amputation rule discussion & clarification

III.iv.4.A.8.e – The amputation rule does not apply to bilateral evaluations under 5276, 5277, 5278, 5279. Link to 8/13/13 VBMS-R Job Aid.

III.iv.4.N.4.i (added 11/16/17) – peripheral nerve disabilities – if associated with a musculoskeletal injury or amputation, follow III.iv.4.A.8.e regarding the amputation rule; amputation rule does not aply to diabetic neuropathy or peripheral nerve disbliies not associated with a musculoskeletal injury

My Notes: The “Amputation Rule” warning in VBMS-R is not useful. You get it when you have a Temporary 100% grant. You also get it anytime you use 5276, but III.iv.4.A.8.e says “The amputation rule does not apply to bilateral evaluations under DC 5276 to 5279.”

4.69 Dominant hand – only 1 hand can be dominant, if ambidextrous then the injured hand or the most severely injured hand will be considered dominant

4.70 Inadequate examinations –

4.2 III.iv.3 – need review of file (if required, see III.iv.3.A.15.b), rationale for medical opinion, etc.

III.iv.54.71 Measurement of ankylosis and joint motion – anatomical position is 0 except for shoulder rotation and

supination and pronation of the forearm

4.71a Schedule of Ratings—Musculoskeletal System

changed 5/7/96 (DC 5025)changed 8/26/02 (DCs 5216-5230), prior to 8/26/02 & see “Historic Part 4 Sections” in Rating References Archivechanged 9/23/02 (DC 5293), prior to 9/23/02 & see “Historic Part 4 Sections” in Rating References Archivechanged 9/26/03 (DCs 5285 to 5293 changed and now called 5235 to 5243), see “Historic Part 4 Sections” in Rating References Archive*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.71; or in CPKM

1945 schedule added bilateral factor (if rated after that & not separated, it’s a CUE; 3.952 says that 1925 schedule ratings “were the basis of compensation on 4/1/46”); 1945 SCHEDULE EFFECTIVE 4/2/46

degenerative changes are: productive changes, compartment narrowing, spurring, osteophytes, calcification, per QTC calcaneal bone spurs are considered degenerative changes

ACUTE, SUBACUTE, AND CHRONIC DISEASES – 4.435000 Osteomyelitis, acute, subacute, or chronic – III.iv.4.B.5; bone & bone marrow dying, “sequestrum” is dead tissue

separated from the surrounding tissue; leave at 10% because can recur, no 0%6/30/03 Medicine for Adjudicators Broadcast- Musculoskeletal Systemosteomyelitis classified by location (acute, subacute), sequestra- large dead bone fragmentsconstitutional sx- fatigue, fevers, weight loss, amyloid liver changes & anemia come from chronic osteomyelitis, but are RARE, inactive is 5 years w/o infection, need 2 episodes after initial for 10%

W. Rees 216 updated 7/25/18

5001 Bones and joints, tuberculosis of, active or inactive

5002 Arthritis, rheumatoid (atrophic) – III.iv.4.B.1; need blood work/lab findings, in spine called rheumatoid spondylitis, ankylosing spondylitis or Marie-Strumpell disease

5003 Arthritis, degenerative (hypertrophic or osteoarthritis) –

9/23/04 Evaluating Degenerative & Traumatic Arthritis Claims Broadcast

III.iv.4.B Note 1 means the 10% & 20% ratings for arthritis under 5003 based on x-ray findings are not allowed if there are

other joints with arthritis that have compensable evaluations based on limitation of motion (this was detailed in FAQ 9/29/03 – Arthritis & DC 5003, which is no longer available, but is discussed on VA Pulse, https://www.vapulse.net/message/46345 in reference to a needed update of III.iv.4.A.8.a, AND in June 2012 Compensation Service Bulletin (CSB)), example under III.iv.4.B.4.d as of 1/11/16

Rating Note: Per Note 1 under 5003, “Important” under III.iv.4.B.3.b & example under III.iv.4.B.4.d, since a 10% evaluation is already assigned under 5003 for osteoarthritis, multiple joints, to include the bilateral knees, a compensable evaluation is not being assigned for left shoulder impingement syndrome, rotator cuff tendonitis and acromioclavicular osteoarthritis (previously rated as left rotator cuff tendonitis with healed clavicle fracture per x-ray, DC 5201-5024) under DC 5201-5003.

Add to Reasons for Decision:Although the DBQ shows your disability warrants a 10 percent evaluation based on x-ray evidence of degenerative arthritis with limitation of motion of the joint, VA regulations say that we cannot grant a 10 percent evaluation based on limitation of motion of a joint if a compensable evaluation is assigned based on X-ray findings, and you already have a 10 percent evaluation for osteoarthritis, multiple joints, to include the bilateral knees based on X-ray findings.

A higher evaluation of 20 percent is not warranted for degenerative arthritis unless the evidence shows: • X-ray evidence of involvement of two or more major joints* or two or more minor joint groups, with occasional incapacitating exacerbations.*including your bilateral knees and left shoulder

*10% under 5003 says:Please note: in the absence of arthritis, the above joints would warrant a noncompensable evaluation by themselves. Should there be any limitation of motion of any of these joints, or should the joint itself warrant a compensable evaluation by another means, these joints would be rated separately as appropriate.

5004 Arthritis, gonorrheal5005 Arthritis, pneumococcic5006 Arthritis, typhoid5007 Arthritis, syphilitic5008 Arthritis, streptococcic5009 Arthritis, other types5010 Arthritis, due to trauma – also POW presumptive under 3.309(c)5011 Bones, caisson disease of

IV.ii.2.K.5 – Diving-Related Disabilities (use 5011 hyphenated with appropriate DC)

5012 Bones, new growths of, malignant, RFE is 1 year (not 6 months)5014 Osteomalacia5016 Osteitis deformans – Paget’s disease5017 Gout

Weekly Q-Tip (2/13/14) - This week’s QRT quality tip provides information for requesting an examination for a Gout disability.

The proper DBQ is DBQ MUSC non-degenerative arthritis worksheet when requesting an exam for GOUT.  In Capri, this is under RHEUM arthritis – non degenerative (inflam, imm, cryst, infect).

We must inform the examiner which joints to examine. If you cannot determine which joint is affected by the GOUT in the previous rating decision(s), ask an RVSR or clarify with Veteran.  The examiner is required to complete the DBQ non degenerative arthritis and is also required to complete the applicable knee, ankle, foot, etc. DBQ.

W. Rees 217 updated 7/25/18

Example:  Veteran claims increase/service connection for:

1.      Gout (ankles/big toes) 

The examiner is required to identify the joints affected and address any limitation of joint motion attributable to gout. Therefore, in this example the examiner will be required to complete DBQ MUSC non-degenerative arthritis and the Ankle and Foot DBQs.

Note to Raters: This condition may be rated as an active process with constitutional manifestations or; limitation of motion under the joints involved, but not both.

References:38 CFR 4.71(a) M21-1MR III.iv.4.A.6.e

5025 Fibromyalgia – changed 5/7/96, see “Historic Part 4 Sections ” in Rating References Archive; GW presumptive under 3.317 October 2014 Compensation Service Bulletin (CSB) – Mental symptoms cannot be included with fibromyalgia

AND a diagnosed mental disability (anxiety symptoms, for example), only in one of the evaluations.

5055 Knee replacement (prosthesis) – III.iv.4.A.6.a – Hudgens v. McDonald (Fed Cir 2016) – partial knee replacements (*no eval under 5055 if filed and decided on or after 7/16/15 [because 4.71a was clarified to only apply to total knee replacements on 7/16/15]; *assign eval under 5055 (if higher eval allowed under 5055) if filed before 7/16/15 & still pending on 7/16/15; *no CUE (whether assigned 5055 or not) if filed before 7/16/15 & finally adjudicated before 7/16/15

PROSTHETIC IMPLANTS – 1 month at 100% based on 4.30, then 12 months at 100%, reduce to minimum, then examine

Combinations of disabilities – 4.63 & 4.64

AMPUTATIONS: UPPER EXTREMITY – 4.69Amputation Rule:60% minor, 70% major for hand OR below insertion of pronator teres70% minor, 80% major for above insertion of pronator teres OR below insertion of deltoid80% minor, 90% major for above insertion of deltoid90% for disarticulation

AMPUTATIONS: LOWER EXTREMITY – 4.68; check for cardiovascular conditions per III.iv.4.G.1.fAmputation Rule:40% for below the knee60% for above the knee (including knee joint involvement)90% with hip involvement

THE SHOULDER AND ARM shoulder = glenohumeral / scapulohumeral joint; between scapula & humerus

5202 – impairment of humerus, including loss of head, nonunion, fibrous union, recurrent dislocation of the humerus at the scapulohumeral head, malunion

5203 – impairment of the clavicle or scapula, including dislocation, nonunion, malunion

2/15/13 DBQ Call – Diagnostic code 5203 pertains to dislocation of the AC (acromioclavicular) or the sternoclavicular joint. Diagnostic code 5202 involves only dislocation of the glenohumeral or scapulohumeral joint. Dislocation of the AC or sternoclavicular joint does not warrant application of Diagnostic code 5202. Additionally, the evidence must show a current dislocation in order for a 20 percent evaluation to be assigned under Diagnostic code 5203. Diagnostic code 5203 contemplates a chronic position of dislocation which would not be a common finding.

III.iv.4.A.3.a - Separate evaluations may be given for disabilities of the shoulder and arm under DCs 5201, 5202, or 5203 if the manifestations represent separate and distinct symptomatology that are neither duplicative nor

W. Rees 218 updated 7/25/18

overlapping.

III.iv.4.A.3.b shows when you should check this box:

humeral fracture resulting in restriction of arm motion at shoulder level (20% under 5202-5201 because humerus affects ROM) & clavicular fracture resulting in malunion of the clavicle (10% under 5203, only warranted because does not affect ROM). *If don’t enter anything under Humerus (DC 5202), will need to add 5202 to the 5201 if the humerus is involved:

If check “Clavicle/Scapula affect Range of Motion,” will only get 20% under 5201:

W. Rees 219 updated 7/25/18

If you have normal ROM, but recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint under 5202 with infrequent episodes & guarding at the shoulder level. *whether or not you check “Humerus affects Range of Motion,” you get 5202 20%:

My Notes:

If you can get separate evaluations under 5202 or 5203 unless ROM is affected (by the humerus or by the clavicle, respectively). If ROM is limited, you check the box & you can only get one evaluation under 5201.

The examiners need to tell us if the clavicle or scapula condition affects the ROM of the shoulder / glenohumeral joint (8C) [5203] or if the humerus condition affects the ROM of the shoulder / glenohumeral joint (9C) [5202].

However, there are dislocation answers under “7. Shoulder instability, dislocation or labral pathology" which need to be entered under 5202 even if there is no true humerus condition. So, you can have “No” for 9a & 9b under “9. Conditions or impairments of the humerus,” plus no answer under 9c). In that situation, we would need to check the box. It’s odd to check the box “Humerus affects

W. Rees 220 updated 7/25/18

Range of Motion” when we have no actual humerus condition, but the way the Rating Schedule is written, 5202 is the only place for dislocation symptoms.

If there is just one disability, you would also need to check the box even if the examiner did not give an answer, as there is no other disbility to account for the limited range of motion, and only one evaluation is warranted.

Rating Note: The examiner indicated there is no condition or impairment of the humerus under 9a & 9b, so we are not asking for the answer to 9c. The dislocation answers under #7 are entered, in the VEB, under 5202 & I checked “Humerus affects Range of Motion” even though there is no true humerus condition, as separate evaluations under 5201 & 5202 are not warranted.

Rating Note: There is only one shoulder disability, so I checked “Humerus affects Range of Motion,” as separate evaluations under 5201 & 5202 are not warranted.

THE ELBOW AND FOREARM –

III.iv.4.A.1 – can give separate evals for 5206, 5207 & 5213

5206 – right/left elbow {} with limitation of extension5207 – right/left elbow {} with limitation of flexion5213 – right/left elbow {} with forearm supination and pronation impairment

Per QRT/GiaBao Nguyen, 6/17, elbow & forearm are separate “joints.”

III.iv.4.A.3.d – If elbow flexion is limited to 100 degrees & elbow extension is limited to 45 degrees, assign a single 20% eval under 5208

THE WRIST

EVALUATION OF ANKYLOSIS OR LIMITATION OF MOTION OF SINGLE OR MULTIPLE DIGITS OF THE HAND – changed 8/26/02 (DCs 5216 to 5230), see “Historic Part 4 Sections” in Rating References Archive; III.iv.4.A.2 for Dupuytren’s contracture (5299-5224/5/6/7)

Multiple Digits: Unfavorable AnkylosisMultiple Digits: Favorable AnkylosisAnkylosis of Individual DigitsLimitation of Motion of Individual Digits

VBMS Tips & Tricks 9.0 (June 2015) -In certain scenarios, the VEB incorrectly generates more than one evaluation for the hand condition when there are multiple fingers with arthritis and limited motion. This occurs when there is arthritis and limited motion in any combination of two or more of the following groups:

Thumb Index and Long fingers Ring and Little fingers

Therefore, if there is arthritis and limited motion in the thumb and index fingers, the system will generate two evaluations when there should be one.

End-Users should process the evaluation with the highest award or highest potential future award (hyphenated code) and ignore other generated evaluations for the hand. OR Utilize the LEB for these cases.

III.iv.4.A.1.g says “Painful motion of a right ring finger fracture that is rated under 38 CFR 4.71a, DC 5230 would not receive a compensable evaluation under 38 CFR 4.59 because this DC does not contain a compensable evaluation.”

III.iv.4.A.4.a - nomenclature of digits of the hand / fingers - thumb, index, long, ring, littleMy Notes: ORDER OF FINGER JOINTS/BONES (starting from wrist): metacarpophalangeal (MCP) joint, proximal phalanx, proximal interphalangeal (PIP) joint, middle phalanx, distal interphalangeal (DIP) joint, then

W. Rees 221 updated 7/25/18

distal phalanx

THE SPINE

changed 9/23/02 (DC 5293), see “Historic Part 4 Sections” in Rating References Archivechanged 9/26/03 (DCs 5285 to 5293 changed and now called 5235 to 5243), see “Historic Part 4 Sections” in Rating References Archive

The rating criteria for intervertebral disc disease was revised effective September 23, 2002.The rating criteria for the spine was revised effective September 26, 2003.

III.iv.4.A.5 – radiculopathy, incapacitating episodes (prescribed bedrest by a physician)

(the DBQ shows your reports of bed rest, but there is no medical evidence of prescribed bed rest)

Rating Note: There is no medical evidence of prescribed bed rest to support the incapacitating episodes indicated by the DBQ.

7/11/14 DBQ Call – Policy staff says can grant mechanical low back pain if there is some objective symptomatology or other clinical findings that demonstrate an actual disability. BVA says it does not represent an underlying diagnosis so cannot grant without a diagnosis or identifiable underlying malady. STAR said can grant for mechanical low back pain syndrome but not mechanical low back pain (unless mlbp is an undiagnosed illness due to GW hazard) [similar to retro-patellar pain and retropatellar pain syndrome]. So, Keith said it’s only on the DBQ (like chronic diarrhea and chronic constipation) so that the examiner can enter a diagnosis and complete the DBQ, otherwise if there is no diagnosis most of the DBQ is disabled and can’t be answered.

vertebrae: 7 cervical, 12 thoracic/dorsal, 5 lumbar, 5 sacral (fused as one), 4-5 coccyx (fused as one)(see note 5 for definition of favorable and unfavorable ankylosis)

5235 to 5243:5235 Vertebral fracture or dislocation 5236 Sacroiliac injury and weakness 5237 Lumbosacral or cervical strain 5238 Spinal stenosis 5239 Spondylolisthesis or segmental instability 5240 Ankylosing spondylitis 5241 Spinal fusion 5242 Degenerative arthritis of the spine (see also diagnostic code 5003) 5243 Intervertebral disc syndrome [March 2013 QRT comment says DDD is IVDS (not arthritis) & is not subject to presumptive SC; however I see examiners diagnose DDD based on arthritis on x-ray AND diagnose DDD then select the box indicating no IVDS; also see VA examiners say no arthritis when there is disc space narrowing; also see examiners diagnose DDD & say no IVDS & no arthritis on x-ray; also see examiners diagnose strain & say no arthritis when the x-rays show DDD; III.iv.4.A.5.a says IVDS is also called slipped disc, herniated disc, ruptured disc, prolapsed disc, bulging disc, protruded disc, degenerative disc disc (DDD), sciatic, discogenic pain syndrome, herniated nucleus pulposus (HNP), pinched nerve;

Rating Note: III.iv.4.A.5.a indicates that degenerative disc disease is IVDS & not degenerative arthritis, so it does not fall under 3.309(a).

January 2017 Quality Call Notes – You cannot assign separate evaluations for a neurological condition with an evaluation based on IVDS rating criteria because it would constitute pyramiding.

Question: The IVDS scenario presented during the Call involved a Veteran with IVDS and mild neuralgia of the left sciatic nerve. The answer provided a hyphenated diagnostic code of 8720-5243. When using VBMS-R, how do you generate this hyphenated code?Answer: In the example presented, a hyphenated code was used because a separate evaluation cannot be granted for the neurological condition with the IVDS. A hyphenated code is used to reflect that the neurological symptoms were considered. The decision maker would grant the 5243 as it was of the greater benefit and manually enter in the hyphenated code on the DDI screen.

W. Rees 222 updated 7/25/18

III.iv.4.A.5.a – “spinal disease can cause objective neurological abnormalities, onset of a neurological complication represents medical progression or worsening of the spinal disease.  For that reason and because neurological complications of spinal disease are contemplated in the evaluation criteria for spinal conditions under 38 CFR 4.71a, a claim asserting new complications of spinal disease is a claim for increase rather than a claim for secondary SC

THE HIP AND THIGH

III.iv.4.A.1 – can give separate evals for 5251, 5252 & 5253

5251 – right/left hip {} with limitation of extension5252 – right/left hip {} with limitation of flexion5253 – right/left hip {} with thigh impairment

Rating Note: The veteran cannot cross his legs, but we are not asking for clarification on abduction being {40/45/full abduction} degrees yet he cannot cross his legs, as 10% is warranted based on painful motion. [choose “Yes” for crossing legs]

August 2015 Quality Call Notes – AP 38 – Agency Interpretation of Prosthetic Replacement of a Joint Final Rule, for 5051 through 5056, 100% is only for TOTAL replacement (for 5054, total means a total replacement of the head of the femur or of the acetabulum)

Q: I have a question regarding the ramifications of rating DC 5051-5056.The post evaluation of a partial replacement is a mystery in light of the new regulations on partial replacements, but also applies to total replacements, too. Only DC 5054 for total hip replacement contains the same prescriptions as the other codes 5051, 5052, 5053, 5055, and 5056. It appears that DC 5054 does not explicitly prohibit multiple evaluations for loss of flexion/extension as do the other replacement codes. However, the Evaluation Builder does not appear to take this into consideration.

Am I reading the rating schedule correctly? Two of our RQRSs have concurred with my reading of the rating schedule (RS). But the evaluation builder language concerns me in that I could be pyramiding, even though the RS does not explicitly prohibit multiple evaluations for the hip post-replacement.

A: It’s important to reiterate that the new policy discussed on August’s call did not change the way VA evaluates musculoskeletal conditions. It merely added an explanatory note to diagnostic codes 5051-5056 to clarify that the temporary total disability evaluation warranted under those codes applies only when there has been a total replacement of the named joint.

With regard to multiple evaluations for loss of flexion/extension under diagnostic code 5054, please refer to 38 CFR 4.20. There is no authority under § 4.20 to rate analogously to another joint code because the condition is not unlisted (e.g. prosthetic replacement of the hip joint) and DC 5054 criteria does not direct the adjudicator to rate analogously to another diagnostic code. Therefore, multiple evaluations that might apply to analogous evaluations under other prosthetic joint codes do not apply to prosthetic replacement of the hip.

Q: The example cited femur replacement in the hip and I was curious if this applied to the knee?

A: Femur replacement refers to diagnostic code 5054, which requires by its terms total “[p]rosthetic replacement of the head of the femur or of the acetabulum.”  In other words, there must be a total replacement of the head of the femur or total replacement of the acetabulum for the 1 year, 100 percent evaluation to apply. This does not apply to the criteria under diagnostic code 5055.  

October 2015 Quality Call Notes – VEB now has joint replacement functionality, includes Job Aid, check for video?

…

THE KNEE AND LEG – III.iv.4.A.1 – can give separate evals for 5260 & 5261

5260 – right/left knee {} with limitation of flexion5261 – right/left knee {} with limitation of extension

May 2012 Compensation Service Bulletin (CSB) & QRT Bulletin June 2012 – 5257 includes lateral instability, as well as anterior and posterior instability; subluxation means “partial or incomplete dislocation” of the joint, so evaluate as slight, moderate or severe

W. Rees 223 updated 7/25/18

If already SC for the knee under one DC, add the other(s) DC(s) as secondary & change the language to:

Issue: Entitlement to a separate evaluation for {}.

Decision: A separate evaluation for {} is granted with an evaluation of {} percent effective {}.

Reasons for Decision: A separate evaluation for {} has been granted with an evaluation of {} percent from {}, the day VA received your claim.

5/11/12 DBQ Call – The DBQ asks (about patellar subluxation); however it cannot be applied to the Rating Schedule. Under 5257, we can only evaluate lateral instability or subluxation (incomplete dislocation of the joint). In today’s medicine the more recently trained clinicians immediately go to patellar subluxation. Actual subluxation of the knee joint is extremely rare and can only be caused by severe trauma. Current medicine doesn’t really consider it that much anymore. This is additional information for the rater; the new revised musculoskeletal system schedule will include patellar subluxation information.

FY 2013 Quality Call Training – Inter-Rater Reliability (IRR)/IRR Consistency Questionnaire – instability is not to be rated separately from 5055 under 5257; instability, painful motion and LOM are included in the evaluation under 5055

April 2013 IRR & Consistency Training (training conducted in May) - If have a separate diagnosis of ankle or knee disability, do not rate under shin splints (5262), but under joints.

III.iv.4.A.6.e – can give eval for knee instability under 5257 in addition to evals based on LOM; includes subluxation, lateral instability, posterior instability and anterior instability. Cannot give 5257 with 5055. Cannot give 5258 or 5259 with 5260 or 5261 (changed 4/13/18, III.iv.4.A.6.f, per Lyles v. Shulkin (2017)).

April 2014 Compensation Service Bulletin (CSB) - Cannot give 5257 with 5055. Even if 5257 is in effect for 20 years, it can be reclassified under 5055 (the eval is still protected).

5258 & 5259 – semilunar cartilage = meniscus; In April 2016, QRT/Carlos Rosario said dislocation / dislocated = tear, can apply 4.7 & give 20% if think warranted under 5258 (maybe has 2 of 3 criteria)

DBQ shows dislocation & tear separately:

But VEB shows only dislocated:

Weekly Q-Tip: DC 5258 (9/3/14) –

Discussion: The Evaluation Builder does not apply the provisions under 38 CFR 4.7, higher of two evaluations to musculoskeletal conditions. Guidance from Comp Service indicates that we can apply 4.7 to DC 5258.

W. Rees 224 updated 7/25/18

When rating under DC 5258, remember:

There must be meniscus (semilunar cartilage of the knee) impairment to evaluate under DC 5258. Although DBQ may show effusion, locking, or dislocation, in the absence of meniscus involvement, evaluating under DC 5258 is improper. Ensure that question 11A indicates a meniscus condition.

My Notes: Effusion is water on the knee causing swelling.

From: VAVBASDC/RO/VSC Sent: Wednesday, September 21, 2016 1:52 PMSubject: ATTN: RVSRs/DROs: DC 5257 and findings of +1, +2 or +3 for QR purposes

Recently, a question was brought forward in regard to instability of the knee, and findings listed in an examination of “+1 (0-5 millimeters), +2 (5-10 millimeters) and +3(10-15 millimeters)” in regard to instability with no indication from the examiner of how such a finding related to the rating schedule for recurrent subluxation or lateral instability of a knee (i.e. DC 5257 “slight, moderate or severe”).  Please be advised that since these specific findings are not listed in the rating schedule, and as there is currently no official Agency policy on the interpretation of such findings or how to equate them to the levels of “slight, moderate, severe” as listed in the rating schedule, QRTs should refrain from citing C2 errors based upon such findings (i.e. deciding that a finding of “+1” equates to slight instability, and citing an error on the RVSR if they assign an evaluation other than 10% under DC 5257).  If your RO QRT currently has a policy of equating the +1, +2 or +3 findings to a specific level of instability, and the QRT is currently citing errors if RVSRs do not follow that policy, we ask that you refrain from citing such errors from this point forward.  The matter is currently under consideration with various Compensation Service staffs to include Policy and Procedures.  National quality reviews (i.e. STAR reviews) are currently following this guide line of refraining from citing C2 errors for this specific fact pattern.

As additional developments occur, we will keep you apprised.

VSC Front Office

My Notes: Knee DBQ shows “recurrent subluxation” under Joint Stability Tests & “recurrent patellar dislocation” under Additional Comments.

Rating Note: The Knee DBQ shows slight recurrent patellar dislocation, but there are no other symptoms to warrant a 20% under 5258 (plus III.iv.4.A.4.i indicates 5258 & 5259 are for meniscus disabilities). A 10% is warranted under 5257, as III.iv.4.A.4.i says dislocation under 5258 is consistent with instability.

III.iv.4.A.6.c – tibiofemoral versus patellar dislocation / subluxation, 5257

III.iv.4.A.6.d (eff 4/13/18) -

DBQ Finding Correlated Level of Impairment1+ (0-5 millimeters) slight2+ (5-10 millimeters) moderate3+ (10-15 millimeters) severe

III.iv.4.A.6.f (eff 4/13/18) - per Lyles v. Shulkin (2017) – can give 5258 or 5259 even if already have 5257, 5260 and/or 5261; BUT be very careful to avoid pyramiding/4.14; VEB workaround III.iv.4.A.6.h

if give 5258/5259 with 5257, the 5258/5259 cannot be for recurrent subluxation or lateral instability

if give 5258/5259 with 5260/5261, the 5258/5259 symptoms cannot have been used to give an evaluation under 5260/5621 based on Deluca (i.e. if the 5258/5259 disability causes function loss due to pain, per DeLuca, 4.40 & 4.45, with additional loss of range of motion with repetitive movements as it relates to pain, weakness, excessive fatigability or incoordination, AND we used that to give an eval under 5260 or 5261, we cannot give a separate eval under 5258/5259)

…

THE ANKLE

April 2013 IRR & Consistency Training (training conducted in May) - If have a separate diagnosis of ankle or knee disability, do not rate under shin splints, but under joints.

February 2014 Compensation Service Bulletin (CSB) - separate evaluations may not be assigned for ankle instability under DC 5262 and ankle limitation of motion under DC 5271. Also, 5262 should only be used when there is impairment of the tibia and fibula.

W. Rees 225 updated 7/25/18

III.iv.4.A.6.m - moderate limitation of ankle motion is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion; marked limitation of motion is less than five degrees dorsiflexion or less than 10 degrees plantar flexion.

5275 SHORTENING OF THE LOWER EXTREMITY – usually of long bones, 4.58 for info on arthritis of joints, back, etc. due to strain

THE FOOT – 4.57 for congenital v. acquired pes planus/flatfoot/flat feet (5276); pes cavus (5278) only if trauma or aggravated

loss of use is 40%

Rating Note: Although policy is to evaluate plantar fasciitis analogous to 5276, flatfoot, the veteran’s plantar fasciitis symptoms are due to pes cavus/claw foot, so DC 5278 better represents the disability picture. Also, there is definite evidence of aggravation of pes cavus since the veteran developed pain in the arches and plantar fasciitis during service, which he did not have at entrance / enlistment.

III.iv.4.A.7.a – foot disabilities, don’t use 5284 if covered under 5276, 5277, 5278, 5279, 5280, 5281, 5283

III.iv.4.A.7.b - nomenclature of digits of the foot / toes - first/great, second, third, fourth, fifth

III.iv.4.A.7.e – evaluating plantar fasciitis

III.iv.4.A.7.g – 5279 – metatarsalgia, Morton’s Disease / Morton’s Neuroma

III.iv.4.A.7.h – do not assign separate evaluations for metatarsalgia under 5279 & plantar fasciitis / pes planus under 5276

QRT Bulletin September/October 2012 - Per DC 5282 and the DBQ titled “Foot Miscellaneous (Other than Flatfoot/Pes Planus), a Veteran must have all 5 toes affected by the hammer toe condition (unilateral) in order to receive a 10 percent evaluation, as all 5 toes can be properly diagnosed with this condition

WEEKLY QRT Q-TIP FOR WEEK OF 06/10/2013 – This week’s QRT quality tip provides information to consider S/C for hallux valgus following a bunionectomy.

Per the Rating Schedule, a 10% evaluation is warranted for hallux valgus following a bunionectomy.  A bunionectomy is a surgical procedure to excise (or remove) a bunion, which is a resection of the metatarsal head.

It is important to consider entitlement to Paragraph 30 if the requirements under 38 CFR 4.30 are met.  Not all bunionectomy cases will warrant entitlement Paragraph 30 based on the evidence, and a Rating Decision note in the Special Notation box to indicate that you considered Paragraph 30 is advised.

Reference: 38 CFR 4.30; DC 5280; DBQ Foot Miscellaneous; Bunionectomy Definition

June 2015 Quality Call Notes – Pes Planus and the Evaluation Builder, extreme tenderness is a pronounced foot diability & warrants 30% for one foot or 50% for both feet under 5276; VA Pulse has discussions of extreme tenderness - https://www.vapulse.net/message/14798 & https://www.vapulse.net/message/22478

June 2016 Quality Call Notes – The DBQ has two options- “side relieved” and “side not relieved.”  “Side relieved” is interpreted as total or complete relief and “side not relieved” is only partial relief.

As of 12/16, VEB generates 30% for bilateral pes planus with “Extreme tenderness of plantar surfaces of the feet” unless you select:

o “Symptoms NOT improved by orthopedic shoe or appliance” - then gives 50%; OR

o “Symptoms relieved by built-up shoe (renders diagnosis asymptomatic)”/ “Symptoms relieved by arch support (renders diagnosis asymptomatic)” - then gives 0%

This is correct, per VA Pulse, https://www.vapulse.net/message/22478. “A 50% evaluation will only be generated if you select pronounced symptoms AND the radio button for ‘Symptoms NOT improved by orthopedic shoe or appliance. This was a determination change made by Compensation Service and Policy Staff and implemented in this last release. “ and “A bilateral disability at the severe level is a 30% per the Rating Schedule. And since the symptom for ‘not improved by orthopedic shoe or appliance’ was not selected, a severe disabilty is warranted rather than a pronounced level. Therefore a 30% is correct. If it was unilateral, it would be a 20%.”

January 2017 Quality Call Notes – To be eligible for a pronounced disability under 5276, the Veteran must demonstrate (i.e., appropriate boxes marked on DBQ) that his/her symptoms are not improved by orthopedic devices

W. Rees 226 updated 7/25/18

or appliances to warrant the highest evaluation level. If the Veteran does not demonstrate that his/her symptoms are not improved by orthopedic devices or appliances, and you do not select that corresponding radio button, the Evaluation Builder will generate an evaluate equivalent to the severe level. These changes were made at the direction and approval of Compensation Service (CS) Policy Staff.

Rating Note: “Extreme tenderness of plantar surfaces of the feet” was selected & “Symptoms NOT improved by orthopedic shoe or appliance” was NOT selected, as 3F shows the tenderness is improved by orthopedic shoes or appliances, which is considered partial relief. *This will give 30% for partial relief, per VA Pulse & January 2017 Quality Call Notes above.

Rating Note: The DBQ shows the right foot “extreme tenderness of plantar surfaces of the feet” is not improved by orthopedic shoes or appliances under 3F. So, although 3E shows the symptoms in both feet are relieved by built-up shoes, that radio button was not selected for the right foot based on the answer under 3F.

Rating Note: “Extreme tenderness of plantar surfaces of the feet” was selected & “Symptoms NOT improved by orthopedic shoe or appliance” was NOT selected, as the Remarks show the veteran has not used any arch supports, built up shoes, or orthotics.

Rating Note: VEB does not have a choice for "orthotics,” so "arch support" was selected.

THE SKULL – 22 bones

THE RIBS – 25 bones in ribs & sternumRibs – LEB – Musculoskeletal System – Other – Ribs, removal of, 5297

THE COCCYX – 4 or 5 bones (fused as one)

4.73 Schedule of Ratings—Muscle injuries

changed 7/2/97 (DCs 5301 to 5329)*you can find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.73; or in CPKM

4.55 4.56 4.73 GC Opinion 23-97

3/20/03 Gunshot, Shell Fragment & Shrapnel Wound Training Broadcasto scars always rated separately, even if 0%o if have multiple painful scars- can do 10% each if WIDELY separatedo deep means damage to soft tissueso damage to different muscles in same group- only 1 for group

5/20/03 Traumatic Injuries Broadcast

500 muscles

note under hand does not apply to fingersnote under foot does not apply to toesfor 5321 see note 3 under 6845 about gunshot wounds of the pleural cavity

Shoulder Girdle and Arm 5301    Group I Function: Upward rotation of scapula.5302    Group II Function: Depression of arm. 5303    Group III Function: Elevation and abduction of arm. 5304    Group IV Function: Stabilization of shoulder. 5305    Group V Function: Elbow supination. 5306    Group VI Function: Extension of elbow. W. Rees 227 updated 7/25/18

    Forearm and Hand 5307    Group VII Function: Flexion of wrist and fingers. 5308    Group VIII Function: Extension of wrist, fingers, thumb. 5309    Group IX Function: Forearm muscles.     Foot and Leg 5310    Group X Function: Movement of forefoot and toes. 5311    Group XI Function: Propulsion of foot. 5312    Group XII Function: Dorsiflexion.     Pelvic Girdle and Thigh 5313    Group XIII Function: Extension of hip and flexion of knee. 5314    Group XIV Function: Extension of knee. 5315    Group XV Function: Adduction of hip. 5316    Group XVI Function: Flexion of hip. 5317    Group XVII Function: Extension of hip. 5318    Group XVIII Function: Outward rotation of thigh.     Torso and Neck 5319    Group XIX Function: Abdominal wall and lower thorax. 5320    Group XX Function: Postural support of body. 5321    Group XXI Function: Respiration. 5322    Group XXII Function: Rotary and forward movements, head. 5323    Group XXIII Function: Movements of head.     Miscellaneous 5324    Diaphragm, rupture. 5325    Muscle injury, facial muscles. 5326    Muscle hernia. 5327    Muscle, neoplasm of, malignant. 5328    Muscle, neoplasm of, benign. 5329    Sarcoma, soft-tissue.

5327 Muscle, neoplasm of, malignant (excluding soft-tissue sarcoma)5329 Sarcoma, soft-tissue (of muscle, fat, or fibrous connective tissue) soft-tissue sarcoma (other than osteosarcoma,

chondrosarcoma, Kaposi’s sarcoma, or mesothelioma) are Agent Orange presumptive under 3.309(e) (see reg for inclusions)

From 8/31/10 Rating Team POD:Bone Infection in Muscle Group Injuries

When evaluating a muscle group injury, the presence of osteomyelitis warrants a separate evaluation, per BVA. Osteomyelitis is inflammation of the bone due to infection. Osteomyelitis is sometimes a complication of surgery or injury. Both the bone and the bone marrow may be infected. Symptoms include deep pain and muscle spasms in the area of inflammation, and fever. Treatment is by bed rest, antibiotics (usually injected locally), and sometimes surgery to remove dead bone tissue. The outlook is worse for those with chronic osteomyelitis, even with surgery, amputation may be necessary.

For VA purposes: §4.43 Osteomyelitis - Chronic, or recurring, suppurative osteomyelitis, once clinically identified, including chronic inflammation of bone marrow, cortex, or periosteum, should be considered as a continuously disabling process, whether or not an actively discharging sinus or other obvious evidence of infection is manifest from time to time, and unless the focus is entirely removed by amputation will entitle to a permanent rating to be combined with other ratings for residual conditions, however, not exceeding amputation ratings at the site of election.

W. Rees 228 updated 7/25/18

4.75 - 4.84a. The Organs of Special SenseIII.iv.4.C

My Notes: If between, round up (so 20/60 is interpreted as 20/70, 20/80 is interpreted as 20/100)

4.75 General considerations for evaluating visual impairment 3.383(a)(3)- eff. 8/9/04, if SC 10% for HL in 1 ear, pay the other NSC ear as SC if meets provisions of 3.385

4.76 Visual acuity4.76a Computation of average concentric contraction of visual fields – tells you how to compute4.77 Visual fields – III.iv.4.C.1.e says determine visual acuity & visual field loss, then combine4.78 Muscle function – tells you how to evaluate diplopia, III.iv.4.C.1.c, III.iv.4.C.1.d

Diplopia job aid is saved at H:\VSC\Rating Reference

Removed 12/10/08:4.80 Rating of one eye – cannot combine to more than total loss of vision unless there is enucleation (removal) or serious cosmetic

defect4.83 Ratings at scheduled steps and distances – use step where can read4.83a Impairment of central visual acuity – tells you how to compute4.84 Differences between distant and near visual acuity – refer to Director of C&P Service if substantial difference

4.79 Schedule of Ratings—Eye

changed 12/10/08 to 4.79; Revised: 6000, 6001, 6002, 6006, 6007, 6008, 6009, 6010, 6012, 6013, 6014, 6015, 6017, 6018, 6019, 6022, 6025, 6026, 6027, 6029, 6030, 6032, 6034, 6035, 6062, 6063, 6064, 6065, 6066, 6080, 6081, 6090, and 6091; Removed: 6003, 6004, 6005, 6028, 6031, 6033, 6067, 6068, 6069, 6070, 6071, 6072, 6073, 6074, 6075, 6076, 6077, 6078, 6079, and 6092; Added: 6036 and 6037. changed 5/13/18 (https://www.gpo.gov/fdsys/pkg/FR-2018-04-10/pdf/2018-06928.pdf, changes 4.77 to include Goldmann, Humphrey or Octopus, but don’t need chart, just numerical values; changes 4.78 to include Goldmann or Tangent; moves General Rating Formula to top; changes incapacitating episodes to use the number of clinic visits required to treat active eye disease; slight changes to names for 6000, 6006, 6009, 6014& 6015(now include eye, orbit & adnexa); changes to eval criteria for 6011, 6012, 6013, 6017, 6018, 6026, 6027, 6034, 6035, 6036, 6091; adds 6040-diabetic retinopathy, 6042-retinal dystrophy, 6046-post-chiasmal disorders) – NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 5/13/18 (if filed before 5/13/18 or within a year of 5/13/18), AND can’t go one year prior to DOC (if filed more than a year after 5/13/18, but had evidence of increase on 5/13/18, still have to use DOC). However, can use medical evidence of increase to take back to 5/13/18, if filed w/i 1 year & medical evidence shows increase warranted on 5/13/18.see “Historic Part 4 Sections” in Rating References Archive*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.118; or in CPKM

III.iv.4.C.1.b – Goldmann Bowl & other options, also see III.iv.3.D.4.b III.iv.4.C.1.c – Tangent screen for diplopia

III.iv.4.C.2.3 - long-established policy permits establishment of service connection for such unusual developments as choroidal degeneration, retinal hemorrhage or detachment, or rapid increase of myopia producing uncorrectable impairment of vision. Consider refractive error service-connected (SC) only under these unusual circumstances and when combined with uncorrectable residual visual impairment.  Note:  Irregular astigmatism may be due to corneal inflammation due to injury or operation.

June 2016 Eye Refresher Training (Tom Hendrickson) –

30% is maximum for 1 eye unless anatomical (which is 40%, 50% if can’t wear prosthesis), NSC eye is 20/40

3.383(a)(1) – paired organ, 20/200B or less (one eye) or visual field 20 degrees or less, then treat both as SC (other eye cannot be WMC)

Make sure near & distant are not 2 lines apart/separate

W. Rees 229 updated 7/25/18

Check with RQRS if get diplopia (6090) case, as can be confusing (unless occasional or correctable with spectacles)

Apply to one eye only

See Diploia job aid

If 2 separate quadrants in same eye, bump (down/worse) VA under 6090 to next poorer level (max 5/200)

From: VAVBASDC/RO/VSC Sent: Monday, May 14, 2018 1:06 PMSubject: FW: Q-Tip: Revised Rating Schedule Criteria for the Eye

Q-Tip:  Revised Rating Schedule Criteria for the EyeTarget Audience:  RVSRs and DROsThe Rating Schedule criteria for the Organs of Special Sense – Eye (specifically 38 CFR 4.77, 4.78 and 4.79) was revised effective May 13, 2018.

The revised evaluation criteria can be viewed here (pdf version) and soon at e-CFR (if not so already).

Overview of Changes

Visual Fields – Goldmann chart no longer needed Instead of needing the actual chart, only the numerical values of the test results will be needed

Incapacitating Episodes - Definition updated Prescribed bedrest is replaced with required clinic visits to a provider specifically for treatment purposes

General Rating Formula (GRF) revised Raters must evaluate all eye conditions under the GRF, unless otherwise directed by a specific DC

Added three new diagnostic codes 6040 - Diabetic retinopathy

Currently, this condition is evaluated under DC 6006. Diabetes is the most significant cause of visual impairment and blindness in the US.  This DC is added in order to track and evaluate the Veteran population with this condition.  It will be evaluated under the GRF.

6042 - Retinal dystrophy (including retinitis pigmentosa) Previously this condition is evaluated analogous to DC 6006.  It will be evaluated under the GRF.

6046 - Post-chiasmal disorders This category was not currently accounted for in the rating schedule and was analogous to

several DCs.  It is caused by TBI or other cerebral injuries.   It will be evaluated under the GRF.

For a more detailed list of the changes, see the student handout from the associated TMS training course on this topic. 

M21-1 Updates

The manual was updated at M21-III.iv.4.C on May 14, 2018 to consider these changes, to include:

Updating the criteria for documentation of visual field testing as modified in updates to 38 CFR 4.77. Updating the criteria for documentation of muscle function testing for diplopia as modified in updates to 38 CFR

4.78. Adding the definition of incapacitating episodes of eye disease as included in updates to 38 CFR 4.79. Updating the guidance on evaluating glaucoma for consistency with revision of the rating schedule criteria. Updating the guidance on evaluating cataracts for consistency with revision of the rating schedule criteria.

The updates to 38 CFR 4.77, 4.78 and 4.79 are not liberalizing (M21-1 III.iv.4.C.1.f).

If a Veteran’s claim was pending or there was an Intent to File (ITF) notice received by VA at the time of regulation’s effective date (May 13, 2018), then the claim must be considered under both previous and new rating criteria.  For handling claims when there are regulatory changes, see M21-1 III.iv.5.C.7.m.

DBQs

An updated DBQ for “Eye Conditions” was released to VHA Facilities and VBA Contract Vendors on May 13, 2018 to comply with the Rating Schedule updates.  The new DBQs for Contract and Internal Use can be viewed on the DBQ Switchboard.  In the additional exam remarks field in the Examination Request Builder (ERB), continue to enter the intent to file (ITF) date as this will alert the examiner whether historical DBQ information must be provided. 

VBMS-R

Updates have not been made to VBMS-R and rating calculator functionality to allow for rating consideration for eye conditions across multiple schedules.  Please follow Policy Letter 21-18-01 (link to letter on CPKM), which

W. Rees 230 updated 7/25/18

provides temporary procedures for tracking and deferring affected eye claims until VBMS-R functionality is available.  The procedures outlined in Policy Letter 21-18-01 are effective beginning May 13, 2018.  Once the appropriate VBMS functionality is in place, Compensation Service will rescind this temporary guidance and replace it with procedures outlining how to process any deferred cases.

Training

TMS training on “Introduction to Eye Rating Schedule Changes” (TMS #4449901) has been added as a required item for RVSRs and DROs with a due date of June 4, 2018.  It is highly recommended that the training be completed as soon as possible for familiarization with the Rating Schedule changes and immediate application. 

NOTE: RQRSs will also discuss this topic in upcoming team huddles. Questions on VBMS-R should be referred to your Coach or team Super-User. Questions on the Rating Schedule changes may be referred to your Coach or team SME.

From TMS training:

VBMS-R was updated with the new eye rating criteria on 6/25/18 & Policy Letter 21-18-01 was revised

*(Update) VSR Claims Processing:  Currently, all affected eye claims are being deferred and held by National Work Queue (NWQ). These claims will be released to the field this week (06/25/18).

Please refer to the guidance, found in revised Policy Letter 21-18-01, for instructions on how to process these claims.  The link to the policy letter is shown below:https://vaww.vrm.km.va.gov/system/templates/selfservice/va_kanew/help/agent/locale/en-US/portal/554400000001034/content/554400000085439/Policy%20Letter%2018-01  

From: VAVBAWAS/CO/21WEB Sent: Monday, July 02, 2018 5:52 AMSubject: VASRD Eye Display Error Within VBMS-R - Compensation Service Calendar Update

The Compensation Service Calendar has been updated. The following update is now online. To view the calendar on the Intranet, please click here.

Monday, July 2, 2018

VASRD Eye Display Error Within VBMS-R:  The meridian degree values, which would be associated with a Goldmann Perimeter Chart, are mislabeled for the OS - Left Eye.  The correct axes values and order are provided below:Visual Field (OS-Left Eye)Temporally - 180 degreesDown Temporally -  225 degreesDown - 270 degrees

W. Rees 231 updated 7/25/18

Down Nasally - 315 degreesNasally - 0 degreesUp Nasally - 45 degreesUp - 90 degreesUp temporally - 135 degreesThe display is expected to be corrected with the next VBMS release scheduled for August 2018.

OD = right eyeOS = left eyeOU = bilateral

DISEASES OF THE EYE6001 Keratopathy – Mustard Gas presumptive under 3.316, also corneal opacities6018 Chronic Conjunctivitis (nontrachomatous) – Mustard Gas presumptive under 3.3166012 Angle-closure glaucoma6013 Open-angle glaucoma6027 Cataract of any type 6034 - a pterygium is a non-cancerous growth of the clear, thin tissue that lays over the white part of the eye (conjunctiva)6037 - a pinguecula is a common, non-cancerous growth of the mucus membrane lining the eyeball and underside of the eyelids (conjunctiva). 6090 Diplopia (double vision) – Rating Vision & Eye Conditions training (video) says must be constant, but Note

says can give 0% if occasional or correctable with spectacles.

IV.ii.2.H.4.j - LPO = light perception only = no more than light perception = cannot recognize test letters at one foot or recognize objects/hand movements, count fingers at three feet = blindness for VA purposes

This is a brief list of some of the abbreviations used on clinic notes. Many of these abbreviations change from year to year, and there are dozens more, which are used less often.

30-2 Commonly used automated Humphrey visual fieldsA/C or AC Anterior chamber ACG Angle closure glaucoma

ALPC Argon laser photocoagulation (often for diabetic macular edema for pupil dilation)

ALT Argon laser trabeculoplasty (for glaucoma)

AMD Age-related macular degeneration APD Afferent pupillary defect BCC Basal cell cancer

BDR Background diabetic retinopathy (outside the disc)BRVO Branch retinal vein occlusion c or cc With refractive correction

C/D Cup-to-disc ratio of the optic nerve CF Count fingers visual acuity CL, HC Contact lenses, hard SCL, EWSCL Soft and extended wear CME Cystoid macular edema CRAO Central retinal artery occlusion CRVO Central retinal vein occlusion

CSR or CSCR Central serous chorioretinopathy CVF Confrontation visual field

cyl Cylinder (in refraction) D Diopter DCR Dacryocystorhinostomy

DVD Dissociated vertical deviation (a form of strabismus)DVS Ductions, versions, saccades DWSCL Daily wear contact lenses

ECCE c IOL Extracapsular cataract extraction with intraocular lens implantationEOG Electrooculogram ERG Electroretinogram EOM Extraocular muscle ERM Epi-retinal membrane

ET, E(T), E, E’ Esotropia, intermittent esotropia, esophoria, and esophoria at nearEUA Exam under anesthesia HM Hand motion vision ICCE Intracapsular cataract extraction IF 1% Inflamase Forte 1% IK Interstitial keratitis IO Inferior oblique IOL Intraocular lens IOP Intraocular pressure IR Inferior rectus

K Keratometer reading (measures the

curvature of the cornea), or abbreviation for cornea KCS Keratoconjunctivitis sicca KP Keratitic precipitate

L HoT, R HoT Left Hypotropia, right hypotropia

LHT, RHT Left hypertropia and right hypertropia

LOC Laxative of choice Ä Prism diopterLPI Laser peripeheral iridectomy

LP, LPO Light perception, light perception onlyLR Lateral rectus

M Manifest (non-cyclopleged) refraction

M&N Mydriacyl & Neosynephrine mixture usedNLP No light perceptionNS or NSC Nuclear sclerotic cataractNVD Neovascularization of the disc

NVE Neovascularization of the retina elsewhereNVI Neovascularization of iris

OD, OS, OU Right eye, left eye, both eyesOHT Ocular hypertension

P1, P2, P4 Pilocarpine (with concentration)

W. Rees 232 updated 7/25/18

PC Posterior chamber or posterior capsulePD Prism dioptersPE, PHACO PhacoemulsificationPEE Punctate epithelial erosionsPEG Punctate epithelial granularity

PEK Punctate epithelial keratitis or keratopathyPERL Pupils equal and reactive to light

PF, PA 1% Pred Forte eye drops, prednisolone acetatePH Pinhole

PKP or PK Penetrating keratoplasty (cornea transplant)PI 1/8 Phospholine Iodine 1/8%POAG Primary open angle glaucoma

POHS Presumed ocular histoplasmosis syndrome

PPDR Pre-proliferative diabetic retinopathyPRP Pan-retinal photocoagulationPSC Posterior subcapsular cataractPVD Posterior vitreous detachmentRD Retinal detachmentROP Retinopathy of prematurityRPE Retinal pigment epitheliumRP Retinitis pigmentosas or sc Without refractive correctionSLE or SLX Slit lamp exam

SPK Superficial punctate keratitis (Thygeson or keratopathy)SR Superior rectus

SRN, SRNVM Subretinal neovascular membraneTa Applanation tonometry

T ½, T ¼ Timoptic (with concentrations)Va Visual acuityVF Visual fieldvit VitreousVTX VitrectomyW4D Worth 4-dot test (in strabismus)

XT, X(T) Exotropia, intermittent exotropiaX, X’ exophoria, exophoria at near

YAG Neodymium-yttrium aluminum garnet laser

CSME – clinically significant macular edema

GOLDMANN BOWL NOTES:

Left eye- OS (put on left) Right eye- OD (put on right)Temporally (normal 85) 180 0Down Temporally (85) 225 315Down (65) 270 270Down Nasally (50) 315 225Nasally (60) 0 180Up Nasally (55) 45 135Up (45) 90 90Up Temporally (55) 135 45Normal total 500

The DBQ shows a left eye average contraction of {} degrees, which is equivalent to a visual acuity of {}, and a right eye average contraction of {} degrees, which is equivalent to a visual acuity of {}.

Rating Note: Medical Liaison has previously advised me that if a Goldmann Chart does not show a contraction of visual field or loss of visual field, no Goldmann chart will be provided, per question 10b.

February 2017 Compensation Service Bulletin (CSB) - If the examiner indicates that there is a visual field defect (in block 10), the appropriate visual field testing must be undertaken.  No visual field testing is required if the examiner indicates that the veteran does not have a visual field defect, irrespective of the eye disability that is the subject of the examination. 

W. Rees 233 updated 7/25/18

Hearing Loss and TinnitusIII.iv.4.D

Hearing Loss and Tinnitus DBQ is for internal VA use only, see DBQ at http://vbacodmoint1.vba.va.gov/bl/21/dbq/default.asp

We need to request a Hearing Loss and Tinnitus DBQ with direct opinion. The Hearing Loss and Tinnitus DBQ says “Internal Veterans Affairs Use” and “This form is only for use by VHA staff or contract examiners.” Dr. Gubin is not VHA staff or a contract examiner. Additionally, III.iv.3.D.2.k says “Hearing loss examinations must be completed by a state-licensed audiologist.” There is no evidence that Dr. Gubin is a state-licensed audiologist. {Thirdly, Dr. Gubin only reviewed the DD214 when providing his opinion (although he marked Yes for 3A, he then marked only the 214 for 3B). – delete if not appropriate for specific case} Lastly, Dr. Gubin often indicates very high decibel losses/very low speech discrimination scores, but the VA DBQs do not confirm the decibel losses/speech discrimination scores.

Rating Note: The Hearing Loss and Tinnitus DBQ says “Internal Veterans Affairs Use” and “This form is only for use by VHA staff or contract examiners.” Dr. Gubin is not VHA staff or a contract examiner. Additionally, III.iv.3.D.2.k says “Hearing loss examinations must be completed by a state-licensed audiologist.” There is no evidence that Dr. Gubin is a state-licensed audiologist. Thirdly, Dr. Gubin only reviewed the DD214 when providing his opinion (although he marked Yes for 3A, he then marked only the 214 for 3B). Lastly, Dr. Gubin often indicates very high decibel losses/very low speech discrimination scores, but the VA DBQs do not confirm the decibel losses/speech discrimination scores.

3.385 Disability due to impaired hearing – hearing loss is 40 decibels or more in any frequency (500, 1000, 2000, 3000 & 4000) OR 26 decibels or more for 3 or more frequencies OR less than 94%

4.85 - 4.87a. Impairment of Auditory Acuity4.85 Evaluation of hearing impairment4.86 Exceptional patterns of hearing impairment – (a) 55 decibels or greater at all frequencies (1000, 2000, 3000 &

4000) OR (b) 30 decibels or less at 1000 with 70 decibels or greater at 2000 [elevate to next higher Roman numeral if falls under (b)]

4.87 Schedule of Ratings—Ear III.iv.4.D.1.b - http://vbaw.vba.va.gov/bl/21/rating/docs/dutymosnoise.xls - as of 9/29/17 – “Based on the Veteran’s

records, review each duty MOS, Air Force Specialty Code, rating, or duty assignment documented on the Duty MOS Noise Exposure Listing to determine the probability of exposure to hazardous noise.  When the duty position is shown to have a high, moderate, or low probability of hazardous noise exposure, concede exposure to hazardous noise for the purposes of establishing an event in service.”

III.iv.4.D.1.d says “In most instances when noise exposure is conceded as a result of MOS, combat, or event in service this will also satisfy the indication of association between service and current disability for the purposes of finding an examination necessary.” My Notes: So, the MOS covers Element 2 & Element 3.

Rating Note: In the HL Calculator, the MOS was entered under “Hazardous Noise” since III.iv.4.D.1.b says “When the duty position is shown to have a high, moderate, or low probability of hazardous noise exposure, concede exposure to hazardous noise for the purposes of establishing an event in service.” That HL Calculator entry generates the sentence “You have in-service acoustic trauma…,” which seems contradictory to the part of the examiner’s rationale that indicates the MOS has low probability for hazardous noise exposure. However, we are merely following the new MOS policy.

9/5/14 DBQ Call – Do not concede “acoustic trauma” on opinion request, only concede “noise exposure” if appropriate. Acoustic trauma is a medical decision.

12/19/14 DBQ Call – Again, do not concede “noise injury” or “acoustic trauma” Notes from December 2015 DBQ Medical Opinion Training (Konane Stradling) –

No longer (unsure when this changed, as this is the first I’ve heard of it) have to write up a separate opinion for HL & tinnitus, just have to “include statements of the Veteran's noise exposure in service and statement to the examiner to complete the etiology sections” (both go in the Remarks section).

III.iv.3.A.7.h says “In any case involving SC for hearing loss or tinnitus where an etiology opinion is required, follow the medical opinion procedures outlined in M21-1, Part III, Subpart iv, 3.A.7.b and c.”

III.iv.3.A directs you to use the CAATS templates or ERB tool. Also says “Do not submit a separate medical opinion DBQ unless a medical opinion is needed that is not included on the DBQ.” (so don’t need to select a Medical Opinion DBQ as well).

March 2017 Quality Call Notes - Do not request a Medical Opinion for hearing loss and tinnitus since it is already embedded into the Hearing Loss and Tinnitus DBQ. changed 1/3/18 to say: Do not request a separate Medical Opinion DBQ for hearing loss and tinnitus since it is already embedded into the Hearing Loss and Tinnitus DBQ unless a medical opinion that is not already included on the Hearing Loss and Tinnitus DBQ is needed. Please remember that the exam request still needs to identify the medically answerable question that needs to be addressed so that the examiner knows which avenue(s) of causation to specifically consider. Per M21-1 III.iv.3.A.7.h, the only item discouraged is the selection of a separate Medical Opinion DBQ (i.e., worksheet in CAPRI or CAATS) since none is needed.

Notes from March 2017 Disability Benefits Questionnaires (DBQs) and Medical Opinions Training:

Assessment Question: What information must be included in the Hearing Loss and Tinnitus DBQ comments when the Veteran is claiming hearing loss and tinnitus due to service on the deck fo an aircraft carrier?… Answer: Comments about the Veteran’s noise exposure while serving on the deck of an aircraft carrier and statement to the examiner to complete the etiology sections.

Hearing Loss and Tinnitus DBQConsider the following for the Hearing Loss and Tinnitus DBQ:

The Hearing Loss and Tinnitus DBQ includes the medical opinion. Do not request the Medical Opinion DBQ for Hearing Loss and Tinnitus. Continue to include statements concerning the Veteran’s exposure to Acoustic Trauma or Noise Exposure in service in

the remarks section of the exam request. Claims for increase will not need the etiology sections of the DBQ to be completed. When etiology is needed for service-connection include the following statement to the examiner in the remarks section:

Examiner: Please complete the etiology sections of the Hearing Loss and Tinnitus DBQ.

NEED HL & TINNITUS DBQ with the etiology sections completed:

for deferral: We need a Hearing Loss and Tinnitus DBQ with the etiology sections completed for bilateral hearing loss and tinnitus. *See Claim Note for details.

for Claim Note: Claim is not RFD. We need a Hearing Loss and Tinnitus DBQ with the etiology sections completed for the claimed bilateral hearing loss and tinnitus. {Veterans are competent to report hearing loss and tinnitus/ringing in ears (Element 1) OR The CAPRI records show hearing loss (Element 1)}. The DD214 shows the veteran's MOS was { }, {which has a {} probability of exposure to hazardous noise, plus the {enter sep exam date} audiogram shows a threshold shift when compared to the {enter enlist exam date} audiogram (Element 2). III.iv.4.D.1.d says Element 3 is also satisfied by the noise exposure conceded as a result of the MOS {or combat or event in service}. Deferral done.

For CAATS: DBQ based on MOS -

Examiner: The Veteran is claiming that his/her bilateral hearing loss and tinnitus are related to exposure to hazardous noise. His/Her MOS of {} has high/moderate probability for hazardous noise exposure (DD214 is Tab A). Please complete the etiology sections of the Hearing Loss and Tinnitus DBQ.

DBQ based on threshold shift or complaints of noise exposure –

Examiner: The Veteran is claiming that his/her bilateral hearing loss and tinnitus are related to exposure to hazardous noise. His/Her MOS of {} has a low probability of hazardous noise exposure, but the STRs show threshold shifts / but the veteran reported {} (DD214 is Tab A, STRs are Tab B). Please complete the etiology sections of the Hearing Loss and Tinnitus DBQ.

DBQ based on combat –

Examiner: The Veteran is claiming that his/her bilateral hearing loss and tinnitus are related to exposure to hazardous noise. He/She is a combat veteran, in receipt of a {} (DD214 is Tab A). Please complete the etiology sections of the Hearing Loss and Tinnitus DBQ.

For CAPRI: DBQ based on MOS (from ERB, when you click on “Basis for examination” you’ll get a pop-up that says “Are you requesting an opinion related to the Veteran’s MOS?,” select Yes, then it will have you enter the MOS info & it will complete the sections with “Direct (MO) – bilateral hearing loss – exposure to hazardous noise; add tinnitus, if applicable) -

The Veteran is claiming that his or her bilateral hearing loss and tinnitus are related to exposure to hazardous noise. Please fill out the Direct medical opinion template in the DBQ and review the following tabbed evidence.

Tab A (DD Form 214 in VBMS): Record showing MOS of {} which was highly probable for hazardous noise exposure / which had a moderate probability for hazardous noise exposure

DBQ based on threshold shift or complaints of noise exposure (I made this up) –

The Veteran is claiming that his or her bilateral hearing loss and tinnitus are related to exposure to hazardous noise. His/Her MOS of {} has a low probability of hazardous noise exposure, but the STRs show threshold shifts / but the veteran reported {}. Please fill out the Direct medical opinion template in the DBQ and review the following tabbed evidence.

Tab A (DD Form 214 in VBMS): Record showing MOS of {} which had a low probability for hazardous noise exposure

Tab B (STRs in VBMS): {date} enlistment exam p{}, {date} separation exam p{}

DBQ based on combat (from ERB, choose “Combat(MO)”) –

The Veteran is claiming that his or her hearing loss and tinnitus are related to {combat noise exposure with receipt of the Combat Infantryman Badge}. Please fill out the Combat medical opinion template in the DBQ.

From: VAVBASDC/RO/VSC Sent: Wednesday, March 22, 2017 1:06 PMSubject: FW: Q-Tip: Medical opinion requests & DBQ for Hearing loss and Tinnitus

VSC - The QR Team would like to put out the below quality tip; per a follow up to the Medical Opinion and DBQs training recently given.

Q-Tip:  Medical opinion requests & DBQ for Hearing loss and TinnitusTarget Audience:  VSRs, RVSRs, and DROsThis Q-Tip provides the following reminders on medical opinion requests relating to the DBQ for Hearing Loss and Tinnitus:

When a medical opinion is necessary for hearing loss and/or tinnitus claims, the exam request must ask for the requested opinion and identify the tabbed evidence for the examiner’s review.  However, since the DBQ for Hearing Loss and Tinnitus already contains specific sections for etiology opinions, do not select or request that a separate Medical Opinion DBQ be completed.

If using the Exam Request Builder (ERB), follow the prompts including the question on whether an opinion is requested based on the Veteran’s MOS.  Remember that the ERB-generated medical opinion language should be edited as need to ensure it is case-specific and will result in an adequate opinion.

Below is a sample exam request from the ERB when a medical opinion is needed for hearing loss:

Other sample exam request language that may be used (edit verbiage in {brackets} as needed):

DBQ based on threshold shift or complaints of noise exposure –

The Veteran is claiming that his/her bilateral hearing loss and/or tinnitus are related to exposure to hazardous noise.  His/Her MOS of {} has a {low/moderate/high} probability of hazardous noise exposure, {but {the STRs show threshold shifts} { but the veteran reported {}}.  Please fill out the Direct (etiology) medical opinion template in the DBQ and review the following tabbed evidence.

DBQ based on combat –

The Veteran is claiming that his/her bilateral hearing loss and/or tinnitus are related to exposure to hazardous noise.   He/She is a combat veteran, in receipt of a {}.  Please fill out the Direct (etiology) medical opinion template in the DBQ and review the following tabbed evidence.

For CAATS, follow input instructions for the system except do not select that an additional Medical Opinion Worksheet/DBQ be completed.

References:M21-1 III.iv.4.B.4.g, Requesting Audiometric Examinations and Medical Opinions M21-1 III.iv.3.A.7.h, Medical Opinions in the Hearing Loss and Tinnitus DBQ

Q&A from March 2018 Training Provided by Central Office by Andrew Grey (Site Visit Training):

Question from the VSRs about ordering a hearing loss/tinnitus exam without STRs is as follows:

M21-1, I.1.C.3.k states STRs must be of record prior to requesting audiological examination for hearing loss because the results of in-service audiological testing must be reviewed before an audiologist can give an opinion on the etiology of hearing loss.

San Diego RVSR Training (Version 2).pptx, recorded training & email message with answers to questions are saved at H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18\2018 Site Visit Training

…

VBMS-R Hearing Loss Calculator Generated Text:“Hearing loss on discharge” – Service connection is warranted because your service treatment records show that your hearing loss began in-service.

If check “Diagnosed with sensorineural hearing loss (3.309(a))” – Service connection is warranted because you were diagnosed with sensorineural hearing loss in-service.

If check “Chronic per 3.303(b)” – Service connection is warranted because your hearing loss became chronic in-service.

AD = right ear

AS = left earAU = bilateral

O = right earX = left earalways use Air conduction results, III.iv.4.D.2.i & III.iv.4.D.2.kif get PTRs & Maryland CNC shows results below 92%, need to ensure performance intensity function testing was conducted, III.iv.4.D.2.f

DISEASES OF THE EAR

changed 6/10/99 (DCs 6100 to 6260, used to have mastoiditis (6206) & otitis media, chronic, suppurative (6200) separate, but combined into 6200)*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.87; or in CPKM

6100 Hearing impairment

Ensure it says “Valid” under 1c. If not valid, choose “Test not reliable” under VAE Consideration in the Hearing Loss Calculator. *Please note that under 1a, the DBQ says “Clearly inaccurate, invalid or unreliable test results should not be reported.” BUT examiners still provide test results & sometimes positive opinions.

Hensley v. Brown (5/18/93) - says if decibels losses are at 25, 30, or 35 in any Hertz in service, or there is an increase 15 to 30 decibels per ear (consistently) in service [later interpreted by Dr. Miller (per Sue Haak) as a 10 decibel increase] and the veteran reports a report of significant noise exposure, we need to request a VA examination and opinion. [Dr. Sobieck also says 10 decibels or greater]

Escobar v. West (10/30/98) - increase for hearing loss, discussion of the regs

February 2014 Compensation Service Bulletin (CSB) - If audiometric testing contains a value above 105 decibels, it is to be entered as no higher than 105 decibels into the hearing loss calculator for the purpose of determining the pure tone threshold average. Also, in the event that the examiner certifies that speech discrimination scores are not appropriate or cannot be obtained, which is usually indicated with a cannot test (CNT) designation, use Table VIA, Numerical Designation of Hearing Impairment Based Only on Puretone Threshold Average, in accordance with 38 CFR 4.85(c). Do not use Table VI, utilizing a speech discrimination score of zero, in such situations for the purpose of obtaining a numerical designation of hearing impairment. My Notes: Choose No for “Speech Discrimination Scores Available” & keep entries for Right & Left under “Speech Discrimination” as 100.

CNT – “could not test” or “cannot test” – manual gives no direction on how to enter decibel losses if we have CNT at only some Hertz levels, only covers CNT for speech discrimination

III.iv.4.D.3.a - a claim for tinnitus is not a claim for hearing loss; if could grant, solicit claim

VSR, solicitation is needed, so please include this in the notification letter to the Veteran: “We have reviewed your records and they suggest you may be entitled to an additional benefit. If you want to file a claim for bilateral hearing loss, 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.” *We already have a DBQ on file for bilateral hearing loss with a positive opinion.

6204 Peripheral vestibular disorders, III.iv.4.D.4, rating criteria says “dizziness” but DBQ says “vertigo”

Rating Note: The evaluation criteria for 6204 says “dizziness” but the Ear Conditions DBQ does not mention “dizziness,” only vertigo. The evaluation is assigned based on occasional vertigo / vertigo and occasional staggering.

Note that III.iv.4.N.1.e says grant for disability that accounts for symptom of vertigo, if have such a diagnosis, only grant for vertigo if have no other diagnosis/etiology

6205 Meniere’s syndrome (endolymphatic hydrops) – one eval under 6205 OR separate evals for vertigo under 6204, hearing impairment under 6100 & tinnitus under 6260, III.iv.4.D.4.d, III.iv.4.D.4.e; III.iv.4.D.2.l says “in evaluating hearing impairment under 38 CFR 4.87, DC 6205 , the puretone thresholds or speech discrimination percentages are not required to meet the provisions of 38 CFR 3.385 as hearing impairment associated with Meniere’s disease is often transient.”

6208 Malignant neoplasm of the ear (other than skin only)

6260 Tinnitus – 1976-10% was added for acoustic trauma (“persistent tinnitus as a symptom of head injury, concussion, or acoustic trauma”); 6/10/99-allowed for disease process as well, per Sue Haak- all tinnitus should be separated from hearing loss and at 10%, 3.114- so from 6/10/99 to 6/10/00- effective date is 6/10/99, and after 6/10/00- effective date is one year prior)

VAOPGCPREC 2-2003 (5/22/03) - DC 6260 (currently codified at 38 CFR 4.87), as in effect prior to 6/10/99, and as amended as of that date, authorized a single 10% disability rating for tinnitus, regardless of whether tinnitus is perceived as unilateral, bilateral, or in the head. Separate ratings for tinnitus for each ear may not be assigned under DC 6260 or any other diagnostic code.

VAOPGCPREC 2-2004 (3/9/04) - VA is not required to provide notice of the information and evidence necessary to substantiate a claim for separate disability ratings for each ear for bilateral service-connected tinnitus because there is no information or evidence that could substantiate the claim, as entitlement to separate ratings is barred by current DC 6260 and by the previous versions of DC 6260 as interpreted by a precedent opinion of the General Counsel that is binding on all Department officials and employees.

I.1.C.3.j - no automatic exams of disabilities at schedular maximum evaluation

III.iv.4.D.2.a – sympathetic reading of hearing loss claims, “In cases where the claim is phrased as a claim for SC or increased evaluation for “hearing loss” (or similar wording) and other lay or medical evidence raises the issue of tinnitus and establishes entitlement to SC, consider the issue of tinnitus as within scope of the claim for hearing loss.”

III.iv.4.D.3.b says: A medical opinion is not required to establish direct service connection for claimed tinnitus if

·   service treatment records (STRs) document the original complaints and/or diagnosis of tinnitus

·   there is current medical evidence of a diagnosis of tinnitus or the Veteran competently and credibly reports current tinnitus, and

·   the Veteran claims continuity of tinnitus since service or there are records or other competent and credible evidence of continuity of tinnitus diagnosis or symptomatology

Rating Note: III.iv.4.D.3.c says “if the examiner states tinnitus is a symptom of hearing loss, then… establish service connection for tinnitus on a direct, not secondary, basis. Note: If the hearing loss is SC, and the tinnitus is a symptom of the hearing loss, we concede that the hearing loss and tinnitus result from the same etiology. Therefore, service connection is warranted for tinnitus on a direct basis in these cases.”

My Notes: Per QRT/Brian Puglise & III.iv.4.D.3.c (2nd box, “there is no hearing loss”), if the examiner links the tinnitus to NSC hearing loss (either it’s NSC because we have a negative opinion, or it’s NSC because there is no HL for VA purposes (even if the examiner gave a positive opinion on HL)), but gives no opinion on noise exposure, we should deny tinnitus UNLESS the veteran claimed it specifically as due to noise exposure. If no specific noise exposure claim, just that one opinion is sufficient & we would not send the case back for an addendum.

NIS STRs ACK_SX NONEX V_NONEX The DBQ indicates your tinnitus is a symptom associated with hearing loss {and that your hearing loss is not related to service OR , but your hearing loss is not related to service, OR, but your hearing loss is not service-connected since you do not have hearing loss for VA purposes}.

*If the Veteran claims tinnitus due to hearing loss, and the examiner says they are not related, no further action is needed.

…

max for 6211 (Tympanic membrane, perforation of) is 0%

suppuration is pus

4.87a Schedule of Ratings—Other Sense Organs

6275 sense of smell, complete loss (anosmia)6276 sense of taste, complete loss (decrease – hypogeusia, absence – ageusia)Note says requires anatomical or pathological basis for the condition

4.88 - 4.89. Infectious Diseases, Immune Disorders and Nutritional Deficiencies

III.iv.4.E

4.88a Chronic fatigue syndrome – requirements for CFS dx, III.iv.4.E.4

4.88b Schedule of Ratings—Infectious Diseases, Immune Disorders and Nutritional Deficiencies

changed 8/30/96 (DCs 6300-6354)*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.88; or in CPKM

6300 Cholera, asiatic6301 Visceral leishmaniasis6302 Leprosy (Hansen’s Disease) -3 year pres period6304 Malaria6305 Lymphatic filariasis6307 Plague6309 Rheumatic fever – III.iv.4.G.1.g6311 Tuberculosis, miliary6313 Avitaminosis – POW presumptive under 3.309(c) (malnutrition 6399-6313)6314 Beriberi – POW presumptive under 3.309(c)6315 Pellagra – POW presumptive under 3.309(c)6350 Lupus erythematosus, systemic

NOTE: Evaluate this condition either by combining the evaluations for residuals under the appropriate system, or by evaluating DC 6350, whichever method results in a higher evaluation.

6351 HIV-related Illness – III.ii.4.A.6 - nonretention of records; III.iv.4.E.3; normal CD4/T4 cell count is 800 to 1200 or 500 to 1500; 9301 for dementia, 6899-6845 for PCP6354 Chronic Fatigue Syndrome (CFS) – GW presumptive under 3.317; III.iv.4.E.4

4.88c Ratings for inactive nonpulmonary tuberculosis initially entitled after August 19, 1968 – rating criteria4.89 Ratings for inactive nonpulmonary tuberculosis in effect on August 19, 1968 – rating criteria

4.96 - 4.97. The Respiratory System

III.iv.4.F

4.96 Special provisions regarding evaluation of respiratory conditions – 4.96(a) - DCs 6600 through 6817 and 6822 through 6847 will not be combined with each other. Where there is lung or pleural involvement, DCs 6819 and 6820 will not be combined with each other or with DCs 6600 through 6817 or 6822 through 6847. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Basically, don’t rate any respiratory conditions separately (except neoplasms which have their own rule, above)!!! 4.96(d) - DCs 6600 , 6603, 6604, 6825, 6826, 6827, 6828, 6829, 6830, 6831, 6832, 6833, 6840, 6841, 6842, 6843, 6844 & 6845 require PFTs; III.iv.4.F.1.e says can also use PFTs for other DCs, like 6602

4.97 Schedule of Ratings—Respiratory System

changed 10/7/96 (DCs 6501-6524, 6600-6604, 6701-6732 & 6800-6847; used to have 6501 chronic atrophic rhinitis, replaced w/ 6522, 6523 & 6524)*you can find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.97; or in CPKM

Prior to the changes effective on October 7, 1996, the rating schedule was more subjective, basing evaluations on criteria such as: “pronounced,” “severe, ” “moderate, ” or “mild.” When pulmonary function testing was done, the test report was usually accompanied by a physician’s summary characterizing the results in terms corresponding to these evaluation criteria. Although the pulmonary function test reports may still include a physician’s summary, the rating criteria now in effect are much more objective based upon numerical results of the pulmonary function test report.

III.iv.4.F.6 – chronic upper respiratory tract infections (chronic rhinitis, chronic sinusitis, chronic tonsillitis & chronic laryngitis); give 100% for total spontaneous pneumothorax, 6843, as of the date of hospital admission, continuing for 3 months from the first day of the month after hospital discharge; III.iv.4.F.1.f – has table for use of PFTs (if not consistent with clinical findings; there is a disparity between FEV-1, FVC, FEV-1/FVC or DLCO=use test examiner says reflects disability; FEV-1 & FVC are greater than 100%=noncompensable; DLCO not done); III.iv.4.F.1.g - use POST unless:* PRE are normal (then POST won’t be done)* Examiner says POST should not be done & states why* Using the DLCO score

DO NOT RATE SEPARATELY - 6600 to 6817 and 6822 to 6847 – BEST TO DO THESE IN LEGACY EVALUATION BUILDER (LEB)Asbestosis (6833)Asthma (6602)Bronchitis (6600)Bronchiectasis (6601)COPD (6604)Chronic lung abscess (6824)Chronic pleural effusion or fibrosis (6845)Diaphragm, paralysis or paresis (6840)Emphysema (6603)Post-surgical (lobectomy, pneumonectomy, etc.) (6844)Pulmonary vascular disease (6817)Sleep apnea (6847)Spinal cord injury with respiratory insufficiency (6841)Traumatic chest wall defect, pneumothorax, hernia, etc. (6843)Tuberculosis; pleurisy (6701, 6702, 6703, 6704, 6721 , 6722, 6723, 6724, 6730, 6731, 6732) Less common conditions : Actinomycosis (6822); Aspergillosis (6838); Blastomycosis (6836); Coccidioidomycosis (6835); Cryptococcosis (6837); Diffuse interstitial fibrosis (interstitial pneumonitis, fibrosing alveolitis) (6825); Desquamative interstitial pneumonitis (6826); Drug-induced pulmonary pneumonitis and fibrosis (6829); Eosinophilic granuloma of lung (6828); Histoplasmosis of lung (6834); Hypersensitivity pneumonitis (extrinsic allergic alveolitis) (6831); Kyphoscoliosis, pectus excavatum,

pectus carinatum (6842); Mucormycosis (6839); Nocardiosis (6823); Pulmonary alveolar proteinosis (6827); Pneumoconiosis (silicosis, anthracosis, etc.) (6832); Radiation-induced pulmonary pneumonitis and fibrosis (6830); Sarcoidosis (6846)

CAN RATE SEPARATELYNeoplasms, malignant or benign (6819 & 6820), but they will not be combined with each other or with 6600-6817 and 6822-6847 if there is lung or pleural involvement

DISEASES OF THE NOSE AND THROAT6502 Septum, nasal, deviation of – III.iv.4.F.7.a says only if a result of trauma, 10% is highest6510, 6511, 6512, 6513, 6514 – III.iv.4.F.7.b – can give 50% based on 4.7 without radical/repeated surgery if other

criteria are met6515 Laryngitis, tuberculosis, active or inactive6516 Laryngitis, chronic – Mustard Gas presumptive under 3.3166522 Allergic or vasomotor rhinitis – was added 10/7/96

3.380

III.iv.4.F.7.c & III.iv.6.B.1.c – allergic rhinitis is “within the scope” (formerly “reasonably raised,” formerly “sympathetic”) of sinusitis claim

III.iv.4.F.7.d

loss of tongue goes under 7202, not 6519

DISEASES OF THE TRACHEA AND BRONCHI6600 Bronchitis, chronic – Mustard Gas presumptive under 3.316

6601 Bronchiectasis – 4.96(d) does not apply to 6601

6602 Asthma, bronchial – 4.96(d) does not apply to 6602, Mustard Gas presumptive under 3.316

3.380

COMMON ASTHMA MEDICATIONS:inhalational anti-inflammatory medications ( My Notes: usually called steroid/corticosteroid) that warrant a 30%:

Advair- inhalation corticosteroid (My Notes: Advair is the brand name for fluticasone combined with salmeterol)

Azmacort- inhalation corticosteroid Flovent- inhalation corticosteroid (My Notes: fluticasone) Flunisolide- inhalation corticosteroid (My Notes: brand name Aerospan)

My Notes: beclomethasone (inhaled corticosteroid, brand name QVAR) budesonide (inhaled corticosteroid, brand name Pulmicort; Symbicort is the brand name for budesonide

combined with with formoterol) ciclesonide (inhaled corticosteroid, brand name Alvesco) mometasone furoate (inhaled corticosteroid, brand names Asmanex & Twisthaler; Dulera is the brand name

for mometasone combined with fomoterol)

inhalational or oral bronchodilator therapy (intermittent use warrants a 10% and daily use warrants a 30%):

Albuterol- bronchodilator Formoterol Fumarate- bronchodilator Salmeterol- bronchodilator Serevent- bronchodilator Singulair- leukotriene inhibitor (My Notes: montelukast)

systemic (oral or parenteral) corticosteroids (intermittent (at least three per year) courses warrants a 60% and daily use of high dose corticosteroids or immunosuppressive medication warrants a 100%):

Prednisone Prednisolone Prelone Hydrocortisone Betamethasone Methylprednisolone Medrol Solu-medrol

September 2013 Compensation Service Bulletin (CSB) – “Be sure to review and consider medications prescribed to treat bronchial asthma…”

6604 Chronic obstructive pulmonary disease – Mustard Gas presumptive under 3.316

DISEASES OF THE LUNGS AND PLEURA—TUBERCULOSIS -3 year pres period3.370-3.3783.9596701 to 6724 6730 to 6732

NONTUBERCULOUS DISEASES6819 Neoplasms, malignant, any specified part of respiratory system exclusive of skin growths; cancer of the lung,

bronchus, larynx, or trachea is Agent Orange presumptive under 3.309(e) & cancer of the lung (except mesothelioma), nasopharynx & larynx is Mustard Gas presumptive under 3.316 & cancer of the lung, larynx & pharynx are associated with AsbestosBacterial Infections of the LungInterstitial Lung Disease – all are associated with Asbestos

6825 Diffuse interstitial fibrosis (interstitial pneumonitis, fibrosing alveolitis)6826 Desquamative interstitial pneumonitis6827 Pulmonary alveolar proteinosis6828 Eosinophilic granuloma of lung6829 Drug-induced pulmonary pneumonitis and fibrosis6830 Radiation-induced pulmonary pneumonitis and fibrosis6831 Hypersensitivity pneumonitis (extrinsic allergic alveolitis)6832 Pneumoconiosis (silicosis, anthracosis, etc.)6833 Asbestosis – also called interstitial pulmonary fibrosis; associated with Asbestos

Mycotic Lung Disease6835 Coccidioidomycosis

Restrictive Lung Disease6845 Chronic pleural effusion or fibrosis – associated with Asbestos6846 Sarcoidosis6847 Sleep apnea syndromes (obstructive, central, mixed) – not presumptive

III.iv.4.F.5 III.iv.3.D.4.m & III.iv.4.F.5.f – upper airway resistance syndrome (UARS), in and of itself, is not a

disability

III.iv.4.F.5.c – also includes APAP, BiPAP, nasopharyngeal appliances (nasal dilators, nasopharyngeal stents), oral appliances (mandibular advancement devices,tongue-retaining mouthpieces), implanted genioglossal nervestimulation devices; need medical determination that the device is necessary; can give 50% even if not using it because it is prescribed / medically required

There is discussion that Cheryl Spinweber, PhD is not an MD (she is a Clinical Psychologist) & cannot diagnose obstructive sleep apnea (OSA) or provide an opinion. However, III.iv.5.A.3.e says RVSRs may not rely on their own unsubstantiated medical conclusions to reject expert medical evidence & III.iv.5.A.2.e says we need to weigh the probative value of evidence (to include competency [if not competent, no probative value], credibility, thoroughness, precision, relevancy & the date of the evidence; also to include qualifications, knowledge of history, context of evidence, reasoning, specificity, certainty). Per Carlos Rosario, Dr. Spinweber is certified in sleep medicine & the DSMV added OSA as a sleep-wake disorder, so she is competent &

qualified to provide opinions in the field of sleep disorders. We need to weigh the probative value of EACH opinion. – 4/17 BVA Remand says “…C. Spinweber, Ph.D., while a specialist in sleep disorders, is not shown to be a medical doctor or to have any expertise as to the causes, development, diagnosis or treatment of metabolic disorders, including diabetes.” – so, can question her links to medical disabilities/symptoms, but maybe not to buddy statements of snoring/apneas in service

Sleep apnea/OSA 2nd PTSD on VA Pulse - https://www.vapulse.net/thread/16944, https://www.vapulse.net/docs/DOC-4456

NEED DBQ WITH DIRECT OPINION ON OSA:

for deferral: We need a DBQ with direct medical opinion for OSA. All 3 Elements are met. *See Claim Note for details.

for Claim Note: Claim is not RFD. The veteran is claiming sleep apnea. The PTRs show a diagnosis based on sleep study in 2009 which meets Element 1. His wife reported sleep problems started in service (80-91 period), which meets Element 2 The veteran reports continued symptoms, which meets Element 3.It's unclear if the veteran is still on a CPAP, since the PTRs are from 2009, so we need a DBQ & not just an opinion. Deferral done.

pleural plaques are associated with Asbestosmesotheliomas of pleura and peritoneum are associated with Asbestos

PFTs with DBQs : for most respiratory DCs, 6600, 6602, 6603, 6604, 6840, 6841/6842/6843/6844/6845, you will enter %

for FEV-1 predicted in “FEV-1 % Predicted” (box 3) & % for FEV-1/FVC in “FEV-1/FVC Ratio” (box 6) ***not required for 6833

DLCO required for 6600, 6603, 6604, 6833, 6841/6842/6843/6844/6845, you will enter DLCO predicted in “DLCO (SB) % predicted” (box 9) ***not required for 6602

***only 6833 uses “FVC % Predicted” 6600/bronchitis, 6603/emphysema, 6604/COPD, 6841/6842/6843/6844/6845 – FEV-1, FEV-1/FVC, DLCO6602/asthma – FEV-1, FEV-1/FVC6833/asbestosis – FVC, DLCO

6600/BRONCHITIS, 6603/EMPHYSEMA, 6604/COPD, 6841/6842/6843/6844/6845:% for FEV-1 predicted in “FEV-1 % Predicted” (3rd boxes on the left)% for FEV-1/FVC in “FEV-1/FVC Ratio” (6th boxes on the left)% for DLCO predicted in “DLCO (SB) % Predicted” (box 3 on the right)

*examples for 6600/bronchitis or 6603/emphysema or 6604/COPD (FEV-1, FEV-1/FVC, DLCO):

6602/ASTHMA (in same order as above, but only has top 6 entries, no DLCO):% for FEV-1 predicted in “FEV-1 % Predicted” (box 3)% for FEV-1/FVC in “FEV-1/FVC Ratio” (box 6)

*examples for 6602/asthma (FEV-1, FEV-1/FVC, NO DLCO):

(1) with post-bronchodilator:

(2) with only pre-bronchodilator:

6833/ASBESTOSIS (different from above):% for FVC predicted in “FVC % Predicted” (box 3)% for DLCO predicted in “DLCO (SB) % Predicted” (box 6)

*examples for 6833/asbestosis (FVC, DLCO, only one that uses FVC):

(1) with post-bronchodilator:

(2) with only pre-bronchodilator:

August 2016 Quality Call Notes –

Example 1: A DBQ provides a diagnosis of bronchitis with post-bronchodilator results showing an ‘FVC Percent Predicted’ of 55, an ‘FEV-1 Percent Predicted’ of 65, the ‘FEV-1/FVC ratio’ is 40%, ‘DLCO’ of 60, and ‘MOC’ of 65 milliliters per kilogram per minute. Please remember that the MOC is not always provided, and the diagnosis of bronchitis does not require a ‘FVC Percent Predicted’ value in order to be evaluated (which is why it does not appear in the EB for this disorder). In this example, the user should input values in the corresponding boxes in the EB which will generate an evaluation.

Example 2: The Veteran failed to report for a VAE; however, a recent respiratory treatment report for chronic obstructive pulmonary disease (COPD) was submitted with the claim. The report shows a ‘Predicted FEV-1’ of 3 with an ‘Actual FEV-1’ of 2.8, and a ‘Predicted FVC’ of 5 with an ‘Actual FVC’ of 4.7. Since VA will evaluate claimed disorders based on the evidence of record, the user would input the available values in the corresponding boxes in the EB.

This action will trigger a pop-up box. In this example, the user should click ‘Continue’ and generate an evaluation since a private treatment report is being used.

…

4.100 - 4.104. The Cardiovascular SystemIII.iv.4.G

4.100 III.iv.4.G.2.b - For codes 7000-7007, 7011 and 7015-7020- METs required unless medically contraindicated, the EF is 50% or less, there is chronic CHF or more than 1 episode of CHF in last year, or 100% can be granted on other criteria.- eff 10/6/06

4.104 Schedule of Ratings—Cardiovascular

changed 1/12/98 & 8/13/98 (DCs 7100-7122); separate each extremity eff 1/12/98, and more info can be found herechanged 10/6/06- includes addition of “Note (3): Evaluate hypertension separately from hypertensive heart disease and other types of heart disease.”

NORMAL: < 120 / < 80PRE-HTN: 120-139 / 80-89STAGE 1: 140-159 / 90-99STAGE 2: >= 160 / >= 1007101, Note 1: Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.

can check Vitals tab in CAPRI for BP readings

There is no evidence of a diagnosis of hypertension confirmed by readings taken two or more times on at least three different days (with diastolic blood pressure predominantly 90mm.or greater; or systolic blood pressure predominantly 160mm or greater with diastolic blood pressure of less than 90mm).

3 or fewer METS = 100%3.1-5 METS = 60%5.1-7 METS = 30%7.1-10 METS = 10%CV1

Otero-Castro v. Principi (10/4/02) - Diagnostic codes 7005 and 7007 do not require a separate showing of left-ventricular dysfunction in addition to an ejection fraction (LVEF) of 30 through 50% in order to qualify for a 60% rating.

July 2012 Compensation Service Bulletin (CSB) – if an examiner finds that the Veteran’s METS level due to cardiovascular limitations cannot be reasonably determined due to the effects of NSC conditions upon the METS level, and provides language to the effect that LVEF testing renders a more accurate finding regarding cardiovascular manifestations alone, then only consider the LVEF percentage shown on examination, rather than the METS level, in determining the correct disability evaluation for the SC cardiovascular disability.

III.iv.4.G.2.e – 7000, 7001, 7002, 7003, 7004, 7005, 7006, 7007, 7011, 7015, 7016, 7017, 7019, 7020 use LVEF. Use this table for records that show a range rather than an exact number:

If the ejection fraction range is...

Then use the following option in the Evaluation Builder …

25-30 percent (or lower) “<30”

The corresponding evaluation will be 100 percent.

Explanation: Under generally accepted medical conventions this range denotes an LVEF of less than 30 percent.

30-35 percent35-40 percent40-45 percent, or

“30-50”

The corresponding evaluation will be 60

45-50 percent percent.

Explanation: Under generally accepted medical conventions none of these ranges denotes an LVEF of less than 30 percent or greater than 50 percent.

50-55 percent (or higher) “>50”

The corresponding evaluation will depend on alternate criteria.

Explanation: Under generally accepted medical conventions this range denotes an LVEF of greater than 50 percent without associated left ventricular dysfunction.

Important: Do not assign a 60 percent evaluation solely on the basis of ejection fraction if this estimated range is provided in a report and the report is the only available evidence of ejection fraction.

DISEASES OF THE HEART III.iv.4.G.2.f – must have info on if there is hypertrophy or dilatation & if meds are needed

Per OGC guidance & confirmed by addition of III.iv.4.G.2.g on 10/5/16 – if Aspirin is prescribed by a physician as a continuous medication to treat a heart condition, a 10% evaluation is warranted (this does not include supplements such as fish oil)

7000 Valvular heart disease (including rheumatic heart disease)7001 Endocarditis7002 Pericarditis7005 Arteriosclerotic heart disease (also coronary artery disease (CAD) & ischemic heart disease (IHD)) – POW

presumptive under 3.309(c); assoc. w/peripheral vascular problems Otero-Castro v. Principi (10/4/02) - heart disabilities- 7005 and 7007 do not require a separate showing of

left-ventricular dysfunction in addition to an ejection fraction of 30 through 50% in order for a claimant to receive a 60% rating

III.iv.4.G.1.b – has to be documented by objective testing

7006 Myocardial infarction – POW presumptive under 3.309(c); old cardio used to call for min 30% after MI7007 Hypertensive heart disease – POW presumptive under 3.309(c)7011 Ventricular arrhythmias (sustained) – POW presumptive under 3.309(c); AICD in place = 100%7017 Coronary bypass surgery – POW presumptive under 3.309(c);7018 Implantable cardiac pacemakers – POW presumptive under 3.309(c)7019 Cardiac transplantation - POW presumptive under 3.309(c)7020 Cardiomyopathy – POW presumptive under 3.309(c)

DISEASES OF THE ARTERIES AND VEINS7101 Hypertensive vascular disease (hypertension and isolated systolic hypertension) – POW presumptive under

3.309(c);

III.iv.4.G.3 – 

“Do not establish service connection for hypertension if the evidence does not contain readings specified in 38 CFR 4.104, Diagnostic Code 7101, Note 1.” per III.iv.4.G.3.c. BUT III.iv.4.G.3.c says “Note 1 in 38 CFR 4.104, DC 7101 does not require that a diagnosis of either type of hypertensive vascular disease in

service treatment records (STRs) have been confirmed by readings taken two or more times on each of three different days.” (My Notes: Note 1 must only be for post-service diagnoses.)

Pre-hypertension is not a disability for VA purposes.  

If additional arteriosclerotic manifestations are subsequently diagnosed in a veteran with SC hypertension, grant service connection on a secondary basis to hypertension: cerebral arteriosclerosis (8046) or thrombosis (8008) with hemiplegia [includes TIA, stroke, CVA, per Carlos Rosario]; nephrosclerosis of the kidneys with impairment of renal function (7507); myocardial damage or coronary occlusion (7006) [does not include IHD/CAD, just MI, per Carlos Rosario]; November 2013 Compensation Service Bulletin (CSB) – has to be claimed, effective date is date of claim or date entitlement arose, cannot apply 3.157 or 3.400 (it’s not a worsening of hypertension)

IV.ii.2.A.2.a – pre-hypertension is a subthreshold diagnosis

Rating Note: November 2013 Compensation Service Bulletin (CSB) says the effective date for conditions listed at III.iv.4.G.3.g is date of claim or date entitlement arose, and you cannot apply 3.157 or 3.400 since it’s not a worsening of hypertension.

7114 Arteriosclerosis obliterans - May 2014 Rating Quality Call Notes - ischemic leg pain at rest with any abnormal ankle-brachial index (ABI) = 100% evaluation for that extremity

7115 Thrombo-angiitis obliterans (Buerger's disease)

7117 Raynaud's syndrome

7120 Varicose veins

7122 Cold injury residuals – POW presumptive under 3.309(c)

III.iv.4.G.4 – Battle of the Bulge, Chosin Reservoir

Esteban v. Brown (2/25/94) – Pyramiding; can grant for related, but different conditions if not duplicative or overlapping with the symptomatology (i.e. scar disfigurement, scar pain & muscle damage); included cold injury residuals & peripheral neuropathy

DBQ is for internal VA use only, see DBQ at http://vbacodmoint1.vba.va.gov/bl/21/dbq/default.asp

7123 Soft-tissue sarcoma (of vascular origin) – soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma) are Agent Orange presumptive under 3.309(e) (see reg for inclusions)

4.110 - 4.114. The Digestive SystemIII.iv.4.H

4.110 Ulcers – “peptic ulcer” is not sufficient; need “esophageal,” “gastric,” “duodenal” or “marginal”4.111 Postgastrectomy syndromes – gastrointestinal complaints and symptoms simulating hypoglycemia, “dumping

syndrome,” occur during or immediately after eating, while those occurring 1-3 hours after eating show hypoglycemia

4.112 Weight loss – “substantial weight loss” is greater than 20% of baseline weight for 3 months or longer, “minor weight loss” is 10-20% for 3 months or longer, “inability to gain weight” is substantial weight loss with no gain on therapy, “baseline weight” is the average weight for 2-years before the disease

4.113 Coexisting abdominal conditions – only one evaluation if have common symptoms

4.114 Schedule of Ratings—Digestive System

changed 7/2/01 (DCs 7311, 7312, 7337-new, 7343, 7344, 7345, 7351-new, 7354-new)*you can find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.114; or in CPKM

III.iv.4.H.1– table for evaluating (especially if there are non-overlapping symptoms & possible elevation to the next higher evaluation)

DO NOT RATE SEPARATELY - DC 7301 to 7329, 7331, 7342, and 7345 to 7348 – BEST TO DO THESE IN LEGACY EVALUATION BUILDER (LEB)Colitis, ulcerative (7323)Diverticulitis (7327)Gall bladder, injury or removal (7317 & 7318)Gastritis (7307)Hernia hiatal (7346) – Subordinate Issues handout says this is a chronic disabilityIntestine, resection of (7328 & 7329) [fistula rated separately under 7330]Irritable colon syndrome (7319)Liver, residuals of injury (7311) [may also be separately evaluated, read details under 7311]Liver: cirrhosis of; chronic disease without cirrhosis (includes hepatitis B) (7312 & 7345) [Hepatitis C rated separately under 7354] Pancreatitis (7347)Stomach, injury or stenosis of (7309 & 7310)Ulcers: gastric, duodenal, marginal (7304, 7305 & 7306)

Less common conditions:Amebiasis (7321); Cholecystitis (7314); Cholelithiasis (7315); Cholangitis (7316); Distomiasis, intestinal or hepatic (7324); Dysentery (7322); Enteritis (7325); Enterocolitis (7326); Peritoneum, adhesions of (7301); Postgastrectomy syndromes (7308); Peritonitis, tuberculous (7331);Vagotomy with pyloroplasty or gastroenterostomy (7348); Visceroptosis (7342)

CAN RATE SEPARATELYAno, fistula (7335)Hemorrhoids, external or internal (7336)Hepatitis C (7354)Hernias: inguinal, ventral, femoral (7338, 7339 & 7340)Intestine, fistula of (7330)Liver transplant (7351)Neoplasms, malignant or benign (7343 & 7344)Rectum and anus: impairment of sphincter control, stricture of, prolapse (7332, 7333 & 7334)Pruritus ani (7337)

7304 Ulcer, gastric – also POW presumptive under 3.309(c)7305 Ulcer, duodenal – also POW presumptive under 3.309(c) – known error with VEB, per VA Pulse, https://www.vapulse.net/message/183337306 Ulcer, marginal (gastrojejunal) – also POW presumptive under 3.309(c)7308 Postgastrectomy syndromes – POW presumptive under 3.309(c)7312 Cirrhosis of the liver, primary biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis – also POW presumptive

under 3.309(c)7315 Cholelithiasis, chronic

7319 Irritable colon syndrome (spastic colitis, mucous colitis, etc.) – POW presumptive under 3.309(c); GW presumptive under 3.317

7322 Dysentery, bacillary – POW presumptive under 3.309(c)7332 / 7333 / 7334 – Rectum and anus: impairment of sphincter control, stricture of, prolapse

Per STAR error reported in September 2010 - The RD granted SC for autonomic neuropathy fecal leakage, and assigned a 10% evaluation based on the Vet's subjective report of fecal leakage. However, QTC rectal exam findings were normal. Therefore, a noncompensable evaluation is warranted for this condition. (38 CFR 4.114 DC 7332)

Rating Note: Only a noncompensable evaluation for fecal leakage is warranted based on a September 2010 STAR error that said only a noncompensable evaluation is warranted for autonomic neuropathy fecal leakage if the veteran reports fecal leakage but the rectal exam findings are normal.

7336 Hemorrhoids, external or internal – III.iv.4.H.3.b VBA Issue Tracker Response – Issue 591 says, for hemorrhoids, do not check anemia if the hemoglobin level is

normal, regardless of what the examiner checked.

7338 Hernia, inguinal – III.iv.4.H.3.a Fanning v. Brown (2/19/93) – cannot give separate, compensable evaluation for a hernia & for the scar

Local Narrative July 2013 suggests “status post inguinal hernia with residual scar,” 7805-7338; can use “A higher evaluation of 10 percent is not warranted unless there is a postoperative recurrent hernia, readily reducible and well supported by truss or belt. A higher evaluation of 10 percent is not warranted unless the scar is considered disabling because of limitation of function of the affected part; or there is at least one scar that is painful or unstable.” (My Notes: Or if no recurrent hernia, do “surgical scar, status post right/left inguinal hernia repair” under 7338-7805 & add “A higher evaluation of 10 percent for the inguinal hernia is not warranted unless there is a postoperative recurrent hernia, readily reducible and well supported by truss or belt.”)

Per QRT/Carlos Rosario, 11/17 - The scar and the hernia are two separate body systems and they have two separate evaluation criteria. That is not pyramiding.  Veterans are entitled to an evaluation based on the hernia and a separate compensable evaluation for tender scar.

Rating Note: Fanning v. Brown is not relevant at this time, as the hernia and scar are noncompensable.

If give separate 10% for painful scar, but hernia already SC, add this to hernia issue just after higher eval discussion:*Please note that you cannot receive a compensable evaluation for your hernia since you are receiving a compensable evaluation for your painful scar, per Fanning v. Brown.

Rating Note: Fanning v. Brown is not relevant at this time, as the hernia is noncompensable.

7343 Malignant neoplasms of the digestive system, exclusive of skin growths – cancers of the gastrointestinal tract are associated with Asbestos

7345 Chronic liver disease without cirrhosis (including hepatitis B, chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug-induced hepatitis, etc., but excluding bile duct disorders and hepatitis C); Hepatitis B- 1965, 5-10% chronic

III.iv.4.H.2.a – need chronic residuals related to hepatitis A infection in order to grant SC

need to send additional notice for hepatitis A or B, or a non-specific form of hepatitis, per III.iv.4.H.2.f

VBMS Tips & Tricks 10.1 - The diagnosis of chronic liver disease without cirrhosis (including Hepatitis B…) under DC 7345, the calculator under-evaluates for the specific combination of symptoms of hepatomegaly and minor weight loss. Currently, it generates a 10% evaluation; however, when taking 38 CFR 4.7 into consideration, it should generate 40%. Workaround: End-Users are to override the 10% evaluation and change it to 40% on the Disability Decision Information (DDI) screen. Select the override reason of “Scenario Not Covered” and enter “Digestive EB Defect 308186” in the override reason textbox.

7354 Hepatitis C (or non-A, non-B hepatitis); Hepatitis C special Issue in VBMS-R –

I.1.B.1.f – need to send additional notice, per III.iv.4.H.2.f III.iv.4.H.2

III.i.3.B.3.d & III.iv.4.H.2.e – need to develop for complete risk factor history, if not provided

An inguinal hernia (7338) is when the contents of the abdomen, such as intestine, protrude through into the inguinal canal (in the lower abdomen just above the leg crease, near or adjacent to the pubic area; in the groin).

A ventral hernia (7339) is a protrusion into the abdominal wall, usually at the site of a previous surgery (also called an incisional hernia & sometimes an umbilical hernia; in the abdomen). Local Narrative Feb 2013 equates epigastric hernia with ventral, postoperative hernia, 7339

A femoral hernia (7340) is a protrusion (of the intestine or other part of the abdominal contents) into the femoral canal (which is next to the point where the blood vessels and nerves pass from the abdomen into the leg; in the groin).

A hiatal hernia (7346) occurs when the stomach protrudes through the esophageal opening in the diaphragm into the mediastinum.

4.115 - 4.115b. The Genitourinary SystemIII.iv.4.I

4.115 Nephritis - III.iv.4.I.1.e, III.iv.4.I.1.f, III.iv.4.I.1.g, III.iv.4.I.1.h – glomerular nephritis comes suddenly with severe infectious diseases- can clear up or become chronic; nephrosclerotic nephritis comes slowly from hypertension or arteriosclerosis; heart disease and nephritis should be evaluated together unless the only renal condition is absence of a kidney, or there is chronic renal disease with regular dialysis; per III.iv.4.I.1.k, nephropathy is not nephritis and 4.115 does not apply (can give heart separate from nephropathy)

4.115a Ratings of the genitourinary system—dysfunction – Renal dysfunction, Voiding dysfunction (including urine leakage, frequency, or obstructed voiding), and Urinary tract infection

4.115b Ratings of the genitourinary system—diagnoses

changed 2/17/94 & 10/8/94 (DCs 7500-7542)*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.115; or in CPKM

III.iv.4.I.3.b –SMC K is still warranted even with use of medication

Rating Note: For a period, we did not grant SMC K if the veteran was using successful treatment, like medication or a vacuum pump, but FAQ 12/3/02 clarified that entitlement to SMC K is not precluded by successful use of medication (which we interpreted to include other treatments). Therefore, under the previous policy, prior Rating Decisions not granting SMC were not CUEs and can be corrected based on policy change.

III.iv.4.I.1.d - creatinine levels above normal (for that particular lab) but less than 4mg% are abnormal & indicate decreased renal function that would warrant a 60% evaluation

III.iv.4.I.1.k - no separate evaluations for renal dysfunction assoc w/ nephropathy & hypertension, even at 80% & 100%

III.iv.4.I.1.b – appliance under voiding dysfunction includes all types of catheters (for leakage, retention, etc), as well as any other assistive device for urination

III.iv.4.I.4.c – kidney donation & expected residuals are NOT subject to SC since it’s an elective surgery & not a disease/injury coincident with service Elective procedure

July 2014 Compensation Service Bulletin (CSB) – Abnormal BUN levels of less than 40mg%, but still higher than the generally normal BUN levels of 20mg%, may not be used to assign a 60 percent evaluation in assigning a rating under renal dysfunction; as such BUN levels are inadequate to demonstrate “definite decrease in kidney function.” Until the appropriate changes can be made in the calculators, unle1ss the BUN value is 40mg% or more, employees should delete the BUN out of the calculator input screen. III.iv.4.I.1.c

7502 Nephritis, chronic7508 Nephrolithiasis7515 Bladder, calculus in7522 Penis, deformity, with loss of erectile power, III.iv.4.I.37527 Prostate gland injuries, infections, hypertrophy, postoperative residuals

7528 Malignant neoplasms of the genitourinary system – prostate cancer is Agent Orange presumptive under 3.309(e) urogenital cancers (except prostate) are associated with Asbestos

III.iv.4.I.2.c – chart for prostate cancer treatments & SMC & permanence

July 2015 Quality Call Notes (this is a staged rating & not a reduction, but they do not mention the RD date) – D1 error on effective date: The Veteran submitted a Fully Developed Claim (FDC) for entitlement to service connection (SC) for prostate cancer on September 27, 2013. As part of its duty to assist the Veteran, the RO requested private records, VA outpatient treatment reports, and a VA examination (VAE). When this evidence was received and reviewed, it indicated the Veteran completed radiation therapy for his prostate cancer on August 23, 2013. Additionally, the VAE report dated November 20, 2014, indicated the prostate cancer was in remission with no known residuals.

Based on this evidence, the RO correctly granted entitlement to SC for prostate cancer, and assigned a 100% evaluation effective September 27, 2012, which is one year prior to the date of receipt of the claim. The 100% evaluation was reduced to 0% effective November 20, 2014, the date of the VAE report, because the evidence showed the prostate cancer was in remission.

The Quality Assurance Consultant conducted a STAR assessment and cited a D1 effective date error because the RO assigned an incorrect effective date for the 0% evaluation. The STAR error narrative indicated the proper date of reduction to 0% is March 1, 2014, which is six months following completion of the Veteran’s radiation treatment for his prostate cancer.

(RO applied for reconsideration, but it was denied)… based on “facts found,” the effective date for the reduction from 100% to 0% should be March 1, 2014, not the date of the VA examination, November 20, 2014. The evidence shows the Veteran completed radiation therapy for his service connected prostate cancer on August 23, 2013. If one were to apply the provisions of the note listed under DC 7528, the 100% evaluation would continue with a mandatory VA examination at the expiration of six months. However, since the VA examination results indicate the prostate cancer is in remission, and since due process to reduce the evaluation is not required under 38 CFR 3.105(e) per the court case of Tatum v Shinseki, the STAR reviewer correctly stated that the reduced 0% evaluation should be effective March 1, 2014.

NEED CLARIFICATION IF ACTIVE & TREATMENT COMPLETED YEARS PRIOR (one examiner clarified that have to have no signs/symptoms for 5 years, but also listed decreasing PSA as evidence of active cancer; plus other examiners have checked remission several months after radiation is completed, so it’s VERY unclear):

for deferral: We need clarification of the DBQ results. *See Claim Notes for more details.

for Claim Note: Claim is not RFD. We need clarification of the DBQ results. The examiner indicates the status of the prostate cancer is active, but that radiation was completed {}. There is no evidence of recurrence. The examiner did not review any records. Please clarify if the prostate cancer is active and the basis for that status. Deferral done.

7530 Chronic renal disease requiring regular dialysis - always use this code if on DIALYSIS (despite diagnosis)!!!

7541 Renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes – added 1/19/94 FY 2012 Quality Call Training – National Grant Rate DC 7101 - Hypertension – microalbuminuria is an

early stage of nephropathy

Persistent albuminuria/proteinuria = 30%

4.116. Gynecological Conditions and Disorders of the BreastIII.iv.4.J

4.116 Schedule of Ratings—Gynecological Conditions and Disorders of the Breast

changed 5/22/95 (DCs 7610-7629)changed 5/13/18 (https://www.gpo.gov/fdsys/pkg/FR-2018-04-09/pdf/2018-07081.pdf, changes name of 7610 to include clitoris; adds note that 7615 includes dysmenorrhea & amenorrhea; adds note under 7619 about paired organs; changes 7621 to pelvic organ prolapse & eval is 10% [can give separate GU, digestive & skin evals, but cannot give more than one 7621]; changes 7627 & 7628 so doesn’t include breast; adds 7630 & 7631 for breast (can get separate eval from other GYN cancer; male veterans cannot get SMC for breast cancer); adds 7632 for FSAD) – NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 5/13/18 (if filed before 5/13/18 or within a year of 5/13/18), AND can’t go one year prior to DOC (if filed more than a year after 5/13/18, but had evidence of increase on 5/13/18, still have to use DOC). However, can use medical evidence of increase to take back to 5/13/18, if filed w/i 1 year & medical evidence shows increase warranted on 5/13/18.*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.116; or in CPKM

6/29/12 DBQ Call – A hysterectomy means removal of the corpus. Ovaries are covered separately. We ask all of the pertinent questions, just not in one place. The Rating Schedule is written poorly.

April 2014 Compensation Service Bulletin (CSB) – discussion of Female Sexual Arousal Disorder (FSAD); per VBMS Tips & Tricks - 7699-7611, do not use EB & use “A noncompensable evaluation is assigned for Female Sexual Arousal Disorder (FSAD). This is the maximum evaluation for this disability.”

III.iv.4.J.1 - Evaluate FSAD analogously using DC 7699-7611 (7632 as of 5/13/18, we need to update the DC on the codesheet) with a 0 percent evaluation.  This is the maximum evaluation available for FSAD.  Grant SMC K for LOU. FSAD is within the scope of a GYN claim if we have a positive medical opinion. Federal Register & TMS training: FSAD under 7632 is separate from a DSM-5 FSAD diagnosis, which should be evaluated under 4.130, FSAD dx by mental examiner cannot be used for SC under 7632; also cannot use FSAD dx in a DM exam, need GYN exam (could use PTRs, if sufficient); “sexual dysfunction” is not a disability if not diagnosed as FSAD

August 2016 Quality Call Notes – cannot do ACE exam for FSAD, an in-person exam is required

Prior to 4/17 (April 2017 Quality Call Notes) gynecomastia was not an actual disability, and gynecomastia surgery scars without unexpected, disabling residuals, was elective surgery; added to III.iv.4.J.3.3 on 5/14/18 – use 7626 (0% max), 7631 or 7804/7805

From: VAVBASDC/RO/VSC Sent: Monday, May 14, 2018 1:11 PMSubject: FW: Q-Tip: Revised Rating Schedule Criteria for Gynecological Conditions & Disorders of the Breast

Q-Tip:  Revised Rating Schedule Criteria for Gynecological Conditions and Disorders of the BreastTarget Audience:  RVSRs and DROsThe Rating Schedule criteria for the Endocrine System, 38 CFR 4.116, was revised effective May 13, 2018.

The revised evaluation criteria can be viewed here (pdf version) and soon at e-CFR (if not so already).

Overview of Changes

Name changes to some diagnostic codes to reflect current medical terminology Added new rating criteria to some diagnostic codes Added notes to some diagnostic codes for further clarification

DC 7619 (Ovary, removal of) – In cases of the removal of one ovary as the result of a service-connected injury or disease, with the absence or nonfunctioning of a second ovary unrelated to service, an evaluation of 30 percent will be assigned for the service-connected ovarian loss – Change made to provide parity to male Veterans rated under DC 7524 (Testis, removal)

Added three new diagnostic codes 7630 – Malignant neoplasms of the breast

Previously combined with malignant neoplasms of the gynecological system under DC 7627 7631 – Benign neoplasms of the breast

Previously combined with malignant neoplasms of the gynecological system under DC 7628 7632 – Female sexual arousal disorder (FSAD)

Previously rated analogous to disease or injury of the vagina under DC 7611 Removed DCs 7622 and 7623 and combined with DC 7621

Name changed to “Complete or incomplete pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy”

Single 10 percent evaluation for condition Note added to define pelvic organ prolapse, identify symptoms/conditions associated with prolapse, and

direct rating personnel to separately evaluate any genitourinary, digestive, or skin symptoms under the appropriate diagnostic code and combine all evaluations with the 10 percent evaluation under DC 7621

Example: A Veteran is service connected for pelvic organ prolapse. Examination shows that, as a result of complete prolapse, the Veteran also experiences urinary incontinence requiring the wearing of absorbent materials which must be changed 2 times per day, impairment of sphincter control resulting in constant slight leakage, and localized dermatitis treated with topical therapy. She may receive the following evaluations for the complete prolapse and each additional chronic residual:

7621 - 10% for complete pelvic organ prolapse 7517 - 20% for requiring the wearing of absorbent materials which must be changed less than 2

times per day 7332 - 10% for constant slight, or occasional moderate leakage 7806 – 0% for no more than topical therapy required, less than 5 percent of exposed skin and

less than 5 percent of body affected

For a more detailed list of the changes, see the student handout from the associated TMS training course on this topic. 

M21-1 Updates

The manual was updated at M21-III.iv.4.J on May 14, 2018 to consider these changes, to include:

Revising the definition of female sexual arousal disorder (FSAD) for consistency with the regulatory revision to 38 CFR 4.118.

Revising the guidance on requesting examinations to reflect updates to the Gynecological Conditions Disability Benefits Questionnaire.

Adding guidance on within scope determinations for FSAD. Updating guidance on evaluating FSAD. Adding guidance on service connection for disorders of menstruation. Incorporating guidance on policy and procedures for evaluating pelvic organ prolapse. Incorporating guidance on malignant neoplasms of the gynecological system; on handling disfigurement due to

benign or malignant neoplasms; on malignant neoplasms of the breast; and on handling disfigurement due to benign or malignant neoplasms of the breast.

Incorporating guidance on gynecomastia that was previously published in the April 2017 Quality Call.

The updates to 38 CFR 4.116 are not liberalizing (M21-1 III.iv.4.J.1.d).

If a Veteran’s claim was pending or there was an Intent to File (ITF) notice received by VA at the time of regulation’s effective date (May 13, 2018), then the claim must be considered under both previous and new rating criteria.  For handling claims when there are regulatory changes, see M21-1 III.iv.5.C.7.m.

DBQs

Updated DBQs for “Gynecological Conditions” and “Breast Conditions and Disorders” were released to VHA Facilities and VBA Contract Vendors on May 13, 2018 to comply with the Rating Schedule updates.  The new DBQs for Contract and Internal Use can be viewed on the DBQ Switchboard.  In the additional exam remarks field in the Examination Request Builder (ERB), continue to enter the intent to file (ITF) date as this will alert the examiner whether historical DBQ information must be provided. 

VBMS-R

VBMS-R was also updated on May 13, 2018 to allow for rating consideration for gynecological and breast conditions across multiple schedules.  However, some issues have been identified including the next higher criteria text not generating or generating improperly for certain DCs.  Here are the workarounds for these problems. 

Training

TMS training on “Introduction to Gynecological & Breast Conditions Rating Schedule Changes” (TMS #4279422) has been added as a required item for RVSRs and DROs with a due date of June 4, 2018.  It is highly recommended that the training be completed as soon as possible for familiarization with the Rating Schedule changes and immediate application.

NOTE: RQRSs will also discuss this topic in upcoming team huddles. Questions on VBMS-R should be referred to your Coach or team Super-User. Questions on the Rating Schedule changes may be referred to your Coach or team SME.

My Notes: The TMS training says if have CFI rec’d 6/22/18 & medical evidence shows does not meet criteria for increased eval as of 7/5/18, but DBQ 7/30/18 shows criteria for increased eval met, eff date is 7/30/18, the date entitlement arose (cannot use 6/22/18, DOC or 5/13/18, date of change in law).

R15.0 UAT Workaround for Core_Awards & Rating Final & R15.0 UAT Release Notes for Core_Awards & Rating Final are saved at H:\VSC\Rating Reference

7628-7613 for uterine fibroids7615 Ovary, disease, injury, or adhesions of - as of 5/13/18, now includes dysmenorrhea & amenorrhea7626 Breast, surgery of – (SMC K for (i) simple/total mastectomy, (ii) modified radical mastectomy & (iii) radical

mastectomy)7627 Malignant neoplasms of the gynecological system, or breast

4.117. The Hemic and Lymphatic SystemsIII.iv.4.K

4.117 Schedule of Ratings—Hemic and Lymphatic Systems

changed 10/23/95 (DCs 7700-7716)*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.117; or in CPKM

7700 Anemia, hypochromic-microcytic and megaloblastic, such as iron-deficiency and pernicious anemia, https://www.vapulse.net/message/52452

March 2016 Quality Call Notes – Normal hemoglobin levels are different for men (13.8-17.2) & women (12.1-15); if above 10mg/dL, can SC if below normal for gender; for compensable eval, need below normal hemoglobin & additional symptom; symptoms hold more weight than lab values (so if have hemoglobin of 10 & dyspnea at rest or high output CHF, assign100%); if there is a diagnosis of anemia that is supported by abnormally low hemoglobin levels (based upon the NIH standards), but above 10, the EB is coded to assign a 0% evaluation if asymptomatic, but no more than a 10% if symptomatic, regardless of the symptoms

My Notes: It seems the VEB gives a 10% based on hemoglobin levels below those normal #s above (13.8-17.2 for men & 12.1-15 for women), so low is 13.7 or lower for men & 12.0 or lower for women.

7703 Leukemia – Chronic Lymphocytic Leukemia (CLL) is Agent Orange presumptive under 3.309(e) & acute nonlymphocytic leukemia is Mustard Gas presumptive under 3.316

III.iv.4.K.2.c – CLL should be 100% with NO future

III.iv.4.K.2.g – no separate evals for CLL under DC 7703 & NHL under 7715

multiple myeloma 7799-7703 is Agent Orange presumptive under 3.309(e) – per III.iv.4.K.2.a – generally multiple myeloma is 100% P&T (rare exceptions)

7705 Thrombocytopenia, primary, idiopathic or immune – in 3.309(a) under Purpura idiopathic, hemorrhagic 7709 Hodgkin's disease – also Agent Orange presumptive under 3.309(e)7714 Sickle cell anemia – III.iv.4.K.1, III.ii.4.A.6 - nonretention of records for sickle cell anemia7715 Non-Hodgkin's lymphoma (NHL) – also Agent Orange presumptive under 3.309(e); 3.313; III.iv.4.K.2.f – only do

review exam if in long-term, stable remission (true for all persistent cancer with a high mortality rate); III.iv.4.K.2.e mycosis fungoides can potentially be evaluated as a skin malignancy under 7715-7818 or NHL under 7715; III.iv.4.I.3.n – no separate evals for CLL under DC 7703 & NHL under 7715

4.118. The Skin

III.iv.4.L

4.118 Schedule of Ratings—Skin

changed 9/30/02 (DCs 7800-7833, scars & skin)changed 10/23/08 (DCs 7800-7805, scars)changed 8/13/18 (https://www.gpo.gov/fdsys/pkg/FR-2018-07-13/pdf/2018-14957.pdf, [scars unchanged]; adds “General Rating Formula for the Skin for DCs 7806, 7809, 7813, 7815, 7816, 7820, 7821, 7822, 7824; revises 7806, 7809, 7813, 7815, 7816, 7817, 7820, 7821, 7822, 7824, 7825, 7826, 7827, 7828, 7829; defines systemic therapy; clarifies that can give separate evals if skin conds involve separate areas of skin… – NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 8/13/18 (if filed before 8/13/18 or within a year of 8/13/18), AND can’t go one year prior to DOC (if filed more than a year after 8/13/18, but had evidence of increase on 8/13/18, still have to use DOC). However, can use medical evidence of increase to take back to 8/13/18, if filed w/i 1 year & medical evidence shows increase warranted on 8/13/18.prior to 9/30/02see “Historic Part 4 Sections” in Rating References Archive*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.118; or in CPKM

The rating criteria for skin was revised effective August 30, 2002.The rating criteria for scars was revised effective October 23, 2008. – III.iv.4.L.2.d - changed 6/22/16, not liberalizing, so do not apply 3.114

“Rule of Nines” – entire head and neck = 9%posterior surface of upper trunk = 9%anterior surface of upper trunk = 9%posterior surface of lower trunk = 9%anterior surface of lower trunk = 9%each entire arm = 9%posterior surface of each leg = 9%anterior surface of each leg = 9%genital area = 1%

if TNTC estimated area is given in cm2, ensure you change the unit selection to “centimeters”

see Eyes for loss of eyebrows & eyelashes (6023 & 6024)

IV.ii.2.B.3.b – (added 7/8/15) - If there is any doubt as to whether the scar is a residual of a wound or injury incurred in service, simply describe the scar, without ascribing it to a specific injury such as a “gunshot wound” or “shrapnel wound.”

Chelte v. Brown (1997) June 2012 Compensation Service Bulletin (CSB) – tenderness is synonymous with painful

FY 2012 Quality Call Training – Inter-Rater Reliability (IRR)/IRR Consistency Questionnaire – add 10% when one or more scars are both painful and unstable

QRT Bulletin April-June 2013 – Evaluation for multiple S/C skin conditions and the Skin DBQ.Discussion: The totality of the evaluated surface area must be known in order to evaluate multiple service connected skin conditions that are based on the total body surface area or exposed areas affected.

The Skin Disease DBQ asks the VA Examiner to report the percent covered for each condition separately. DBQ Call Meeting Minutes dated 08/17/2012, clarified the reasoning for the DBQ asking the VA Examiner to report the percent covered for each condition separately is that the VA Examiner does not know which of the conditions are or will be service connected. 

For example, the VAE shows three conditions, and the VA Examiner reports the following:1. Eczema is less than 5 percent.2. Dermatitis is less than 5 percent.3. Psoriasis is less than 5 percent.

The RVSR makes a decision, and grants S/C for eczema and psoriasis.  S/C for dermatitis is denied.  In this example, the VA Examiner reported eczema is less than 5 percent and psoriasis is less than 5 percent.  Yet, what is the total body surface area or percent of exposed areas affected for eczema and psoriasis? Is it less than 5 percent or at least 5 percent?  Since we do not know the answer, we must defer and ask the VA Examiner. 

Procedural Guidance: If the VAE is insufficient to evaluate the skin conditions, make an interim RD and grant S/C for the skin conditions with a 0 percent evaluation.  Defer the evaluation and ask the VA Examiner to provide the combined percent of the body and/or the exposed areas affected by the S/C conditions.  A final RD will be required once the total percent of the body and or the exposed areas affected is known. 

Continuing with the example above:1. The VA Examiner reports the total body surface area of the eczema and psoriasis is at least 5 percent but less

than 20 percent.  Here, a final RD granting a 10 percent evaluation is warranted.2. The VA Examiner reports the total body surface area of the eczema and psoriasis is less than 5 percent.  Here, a

final RD confirming and continuing the 0 percent evaluation is warranted.

Reference: 38 CFR 4.118; M21-1MR III.iv.5.3.a; DBQ Call Meeting Minutes dated 08/17/2012

Weekly Q-Tip (10/22/13) – This week’s QRT quality tip is to serve as a reminder to consider service connection for a scar that is shown to be related to the service-connected primary condition or as a result of treatment for that service-connected disability.

When a claimed condition warrants service connection, and the DBQ shows a scar that is related to that condition or to the treatment of the claimed condition, the scar should be sympathetically read and considered part of the primary condition.

A scar is to be sympathetically read and considered part of the claim condition as it is proximately due to, or the result of, the claimed condition. The effective date of the scar shall be the same as the effective date of the original claimed condition if the scar existed on that effective date. Otherwise, the effective date of the scar would be the date entitlement arose.

Reference: 38 CFR §3.310(a), M21-1MR III.iv.6.B.3.a, M21-1MR IV.ii.2.B.6.a, M21-1MR IV.ii.2.B.4.c

VBMS Tips & Tricks 6.1 4/21/13 – for 0% scars based on a non-scar DBQ (surgical scar, etc.), enter 0 mm & add this:

Please note that the scar measurements provided to not reflect your actual disability. When a scar is found to have non-compensable symptoms, the VA does not require that the examiner provide exact measurements. Instead, your examiner has stated that your scar is not painful or unstable and measures less than 39 square cm (6 sq. inches).

As of 3/17 (or sometime before), VEB now generates this language for each scar if you enter 0mm x 0mm:

When a scar is found to have non-compensable symptoms, the VA does not require that the examiner provide exact measurements. Instead, the examiner has stated that your scar is not painful or unstable and measures less than 39 square cm (6 sq. inches).

Issue: Entitlement to a separate evaluation for surgical scar,…

Decision: A separate evaluation for surgical scar,… is granted with an evaluation of {} percent effective {}.

Reasons for Decision: A separate evaluation for surgical scar,… has been granted with an evaluation of {} percent from {}, the day VA received your claim. OR the effective date of the original claimed condition since the scar existed on that effective date (My Notes: Although initially advised to use the effective date of the original claimed condition, probably shouldn’t since, although the scars may have been present at that time, it was not policy to consider an unclaimed scar as being within the scope of the claim of the underlying condition until more recently (maybe 2012 or 2013) & since the prior decision is final, we cannot apply current policy/manual guidance to that claim & since there is no CUE in that decision for not addressing the scars, SC for the scars should be established effective date of receipt of current claim, per III.iv.5.C.1.f. ALSO, for new surgical scars, DOC is probably best, or might do date of surgery per III.iv.5.C.5.i & 3.400(o), it’s unclear.)

III.iv.6.B.1.c & III.iv.6.B.2.c – scar from surgical intervention is (1) an issue within the scope of the claim / (2) a complication of the claimed issue

Per QRT/Tom Hendrickson, 6/29/16 - it would be appropriate to separate the scars out as long as the condition is at issue, meaning that we are not required to fix the codesheet if we are not evaluating the condition

III.iv.4.J.1.e & III.iv.4.J.2.f – changed 8/2/16, address unclaimed scars if they are reasonably raised claims; changed to III.iv.4.L.2.e & III.iv.4.L.2.f on 12/21/17 & now says address unclaimed scar if within scope of the pending claim (My Notes: Only discusses head/face/neck scars/disfigurement & painful/unstable scars, does not discuss scars under 7805.)

March 2017 Quality Call Notes -

Question: What is the effective date for SC of noncompensable scars when it is noted on previous exams? This includes routine future exams, claims for increase, and reopened claims. Should decision makers call a CUE to grant a noncompensable scar that was noted on prior exams and not previously separately evaluated?Answer: The scar is considered within the scope of the underlying issue, and generally the effective date rules for the underlying issue (for example a claim for increase or review exam) will guide assignment of the effective date for the scar. No Clear and Unmistakable Errors (CUEs) should be cited for a change in procedure/ manual guidance only. M21-1 Part III.iv.2.B.4

Question: Should a noncompensable scar be inferred if it is noted on the DBQ, but there is no discussion regarding the underlying condition that resulted in the scar? In what situation should development be undertaken for the scar when the exam does not show a clear relationship to the SC condition?Answer: Consistent with M21-1 Part III.iv.6.B.2.c, entitlement to SC for conditions not explicitly claimed should not be put at issue unless entitlement is established. Generally we see clear scenarios such as that in Example 3 at M21-1 Part III.iv.6.B.1.c. It is acknowledged in rare cases, there may be a potential for SC that requires clarification from the examiner, but in general, SC should not be inferred to deny the benefit.

One clue regarding development for scars is exam sufficiency. Most DBQs have a section built-in that elicits specific scar information and instructs the examiner to complete a separate DBQ if certain scar characteristics are documented. If a separate Scar DBQ is needed based on these characteristics and not completed, then the DBQ should be returned as insufficient. M21-1 Part III.iv.3.D.3.a

Question: Does the aforementioned guidance only apply to granting SC for a scar for the first time? Would we consider an increased evaluation for a scar as “within the scope” of the claim if the Veteran claims an increase in the underlying condition? Or should a Request for Application letter be sent?Answer: As referenced in the answer above, generally an issue should not be raised with the intent to deny. Since no benefit is being granted when an evaluation is confirmed and continued, a separately evaluated noncompensable scar that is not explicitly claimed should not routinely be raised if no higher benefit can be granted.

Similarly, a claim should not be solicited unless there is a good probability that the issue in question can be granted. Since a scar would be within the scope of the claim if a benefit could be granted, there would be no need to solicit a claim if an increased evaluation could be granted.

December 2013 Compensation Service Bulletin (CSB) – can assign 10% for 6023 or 6024 (usually from injury, burn, local disease/infection), plus separate eval for loss of all body hair under 7831 (usually from alopecia areata or other analogous, systemic condition)

October 2014 Compensation Service Bulletin (CSB) – Although 7800, Note (1), a scar five inches or more in length may be established by more than one scar, the width of two scars that are narrower than one-quarter inch may not be combined to meet the requirement for a “scar at least one-quarter inch wide at widest part” to satisfy the requirement for a characteristic of disfigurement under Note (1) of DC 7800. The regulation specifically requires that the scar must be at least one-quarter inch wide at its widest part. Thus, if no singular scar is one-quarter inch wide at its widest point, the widths of multiple scars cannot be combined to meet the criteria of “at least one-quarter inch wide at widest part.”

July 2015 Quality Call Notes –

There are several skin disorder diagnostic codes (DCs) in 38 CFR Part 4.118 that do not have rating criteria. These codes include 7807, 7808, 7809, 7813, 7820, and 7821. Because these DCs direct the decision-maker to rate the disorder under a different DC, these six DCs can never be a primary code as the primary code must reflect the code that the disorder is being evaluated under; i.e., the DC with the actual rating criteria that is being used by the decision-maker. These DCs that direct the decision-maker to another DC must also be a hyphenated code; for example, DC 7813-7806 and DC 7820-7800. Decision-makers must not use overrides in the Evaluation Builder (EB) calculator to make these six DCs the primary codes, and they should not submit any pyramiding overrides to keep one of these codes separate from another code. Any override that conflicts with this guidance will be considered invalid.

Shows (with screen snap-shots) how to evaluate dermatophytosis under 7813-7806 & under 7813-7800

Per VA Pulse, https://www.vapulse.net/thread/6810, separate evaluations for each diagnosis are permissible when the evaluation is based on disability due solely to the individual diagnosis … if… the medical evidence clearly indicates that the percentages affected are due solely to each individual diagnosis. As an example, the medical evidence must clearly indicate that skin condition X alone affects 6% of the exposed skin while skin condition Y alone affects 12% of the exposed skin. In this scenario, separate evaluations may be assigned.

III.iv.4.L.1.f – as of 10/5/15 - The term “systemic therapy such as corticosteroids or other immunosuppressive drugs” that is contained in certain DCs under 38 CFR 4.118, refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder.” Example, Dapsone, is an antibiotic. Reference (added 12/21/17) says does not include topical corticosteroids. In April 2016, Carlos said antivirals, antihistimines are okay, anything systemic. *Please note that this is a change in policy & previously (in November 2011 & July 2012) policy was that Acyclovir/Valtrex (valacclovir) were considered antivirals, not immunosuppressive, and did not qualify as “systemic therapy.”

April 2016 Quality Call Notes – confims that Cetrizine/Zyrtec (oral antihistime) prescribed by MD (& taken by mouth or injected) = 60%

From: VAVBASDC/RO/VSC Sent: Tuesday, June 14, 2016 1:38 PMSubject: Q-Tip Inferring Scars from Claimed Primary Condition : Target Audience: RVSRs and DROs

Attention all RVSRs and DROs:

Q-Tip:  Inferring scar from claimed primary conditionThe station received a couple of STAR errors in the past couple of months relating to failing to infer and address a scar shown to be associated with a claimed SC disability.  The following Q-Tip is provided on this topic:

M21-1 III.iv.6.B.1.a. states, “When preparing a rating decision, the decision maker must recognize, develop, clarify, and/or decide all issues and claims, whether they are expressly claimed, reasonably raised, or unclaimed subordinate issues and ancillary benefits.”

M21-1 III.iv.6.B.1.c. notes that that a reasonably raised claim “encompasses such things as entitlement to any ancillary benefits that arise as a result of the adjudication decision, and additional benefits for complications of an expressly claimed condition.”  It provides the following example relating to inferring/addressing a residual scar from a claimed primary condition:

Example 3:  The Veteran submits a claim for SC for right knee strain.  The evidence of record, including the resulting examination, shows that SC for the knee strain is warranted.  The examination also reveals a knee scar that resulted from a post-service arthroscopy procedure.  The examination indicates the arthroscopy was associated with the SC right knee strain.  The examination also shows that the scar is not painful or unstable and is less than 6 square inches. 

Result:  In the event that the examination is otherwise sufficient for rating purposes, the decision maker awards SC for the knee condition and separate SC for the noncompensable knee scar as within the scope of the claim for SC for right knee strain.

The manual was updated on January 11, 2016 to include the above scenario in which raters are required to infer/address an unclaimed scar associated with a SC disability as a reasonably raised claim.

If there are any questions relating to this topic, please contact the QRT or your Coach.

III.iv.4.L.3.b (previously III.iv.4.J.2.b) changed 6/22/16, need objective evidence of pain/tenderness to give 10% under 7804; Supposedly scars DBQ updated 9/13/16 to ask if “tender to palpation” and “unstable upon inspection” (version online unchanged & got one from VAMC that also does not show these questions); changed again 9/27/16, examiner has to indicate “tender to palpation” for 10%

Scars DBQs updated 3/22/17 & 8/13/18 ( the 8/13/18 one still says “Updated on: March 22, 2017” ) have this question under each body area (RUE, LUE, RLE, LLE, anterior trunk, posterior trunk) under Section I, “2. Physical Exam for Scars on the Truck and Extremities”:

And this question under Section II, “2-1. Details of Scar or Disfigurement for the Head, Face and Neck”:

Add to Reasons for Decision: Please note that the DBQ shows no objective indication supporting subjective reports of pain.

III.iv.4.L.1.a - do not give a 10% for dermatitis under 7806 with a 0% for scarring under 7800 through 7805, only the 10% for 7806 is warranted

From: VAVBASDC/RO/VSC Sent: Wednesday, March 01, 2017 8:54 AMSubject: FW: Q-Tip Inferring Scars from Claimed Primary Condition - Target Audience: RVSRs and DROs

RVSRs and DROs:

Due to a recent error trend noted by STAR nationwide, we are re-issuing the Q-Tip below on the requirement to address an unclaimed scar associated with an SC disability.

M21-1 III.iv.B.1 (My Notes: It’s III.iv.6.B.1) now refers to inferred or reasonably raised issues as issues “within the scope” of an expressly claimed issue, such as

complications of the claimed condition, or

unclaimed subordinate issues and ancillary benefits.

A scar associated with a claimed primary SC condition continues to be considered an issue with the scope of the claim and must be addressed, per M21-1 III.iv.6.B.1.c.

Consideration for complications of an expressly claimed issue is discussed at M21-1 III.iv.B.2.c (My Notes: It’s III.iv.6.B.2).  Complications of a claimed issue include, but is not limited to:

complications of diabetes mellitus

residuals of cancer

scars as the result of surgical intervention for an SC disability

neurological disabilities related to the spine

complications of progressive disorders, such as

o ALS, or

o multiple sclerosis (MS), or

constitutional symptoms caused by systemic disorders, such as

o rheumatoid arthritis, or

o ankylosing spondylitis.

Febuary 2017 Quality Call Notes – the first four characteristics of disfigurement under Diagnostic Code 7800 can be satisfied by only a scar. On the contrary, the last four characteristics of disfigurement can be satisfied by either a scar or an area of disfigurement.

III.iv.3.d.4.l (added 5/14/18) - sufficiency of exam reports of skin & scars

…

7801 deep & nonlinear; My Notes: Per Note 2, can assign separate evaluations for each extremity, anterior trunk & posterior trunk.

7802 superficial & nonlinear; My Notes: Per Note 2, can assign separate evaluations for each extremity, anterior trunk & posterior trunk.

7804 My Notes: If an exam is done soon after a surgery & the scar is painful, it’s probably best to do a 0% & get another DBQ in a few months (explain, in the narrative, that it seems the pain is due to the recent surgery, but we will do a RFE to determine if the scar is still painful; if it is still painful, can take the 10% back to the original eff date).

Switchboard shows Scars DBQ updated 8/13/18 (but it still says “Updated on: March 22, 2017” on the actual PDF). The changes are, for each body area (RUE, LUE, RLE, LLE, anterior trunk, posterior trunk), the questions change from:

To (removed separate sections for “linear,” “superficial non-linear,” & “deep non-linear):

7806 III.iv.4.L.1.b, III.iv.4.L.1.c & III.iv.4.L.1.d - separate evaluations for each diagnosis are permissible when the evaluation is based on disability due solely to the individual diagnosis (either on exposed areas, entire body or medication) (this is a change, as we were previously directed that all skin only warrants one evaluation)

III.iv.4.L.1.e – a single eval is allowed for separate diagnoses if it gives a higher benefit or if symptoms/area affected can’t be separated

Rating Note: Separate evaluations under 7806 can be assigned, per III.iv.4.L.1.b (which does not make a distinction for 0% evaluations).

7815 Bullous disorders (including pemphigus vulgaris, pemphigus foliaceous, bullous pemphigoid, dermatitis herpetiformis, epidermolysis bullosa acquisita, benign chronic familial pemphigus (Hailey-Hailey), and porphyri cutanea tarda) – Agent Orange presumptive under 3.309(e)

7818 Malignant skin neoplasms (other than malignant melanoma) –scar formation & squamous cell carcinoma of the skin are Mustard Gas presumptive under 3.316

7821 Cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis, and dermatomyositis)

7825 Urticaria, 3.3807833 Malignant melanoma7829 Chloracne – Agent Orange presumptive under 3.309(e)

4.119. The Endocrine SystemIII.iv.4.M

4.119 Schedule of Ratings—Endocrine System

changed 6/6/96 (DCs 7900-7919, 7910 removed)

changed 12/10/17 (added 7906 for thyroiditis, added new rating criteria & notes to some DCs, name changes to reflect current medical terminology, added clarification regarding injection of insulin to 7913), https://www.ecfr.gov/cgi-bin/text-idx?SID=a89bbbfed89969856b699368523f31a1&mc=true&node=20171102y1.3 – NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 12/10/17 (if filed before 12/10/17 or within a year of 12/10/17), AND can’t go one year prior to DOC (if filed more than a year after 12/10/17, but had evidence of increase on 12/10/17, still have to use DOC). However, can use medical evidence of increase to take back to 12/10/17, if filed w/i 1 year & medical evidence shows increase warranted on 12/10/17.https://www.vapulse.net/thread/42668 - discusses “Rating Period Start” box (should be date you begin evaluating the issue, i.e. date of claim, date of ITF, date of RFE); December 2017 Quality Call Notes – removed 10% for continuous medication required for control for 7900, 7903 & 7905; 7913 – insulin requirement is now “one or more daily injection”

*see below for more info on changes (modified from handout on TMS Training, Introduction to Endocrine Conditions Rating Schedule Changes, that handout had multiple errors, My Notes are in Arial)*you can find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.119; or in CPKM

Code Change Description7900Hyperthyroidism, including, but not limited to, Graves' disease

Now includes Graves’ disease- evaluation criteria begins with 30% evaluation for 6 months, followed by a mandatory evaluation. Rate residuals of disease or complications with the appropriate DC within the appropriate body system.My Notes: So, if residuals are diarrhea & constipation, do 7900-7319, 30%. 7901 doesn’t say anything about an exam, but we need a RFE 6 months following initial diagnosis.

7901 Thyroid enlargement, toxic& 7902Thyroid enlargement, nontoxic

Name changes only, from toxic adenoma to enlargement, toxic and from non-toxic adenoma to enlargement, non-toxic

7903Hypothyroidism

Veterans presenting with myxedema are given a 100 percent or without myxedema are given a 30 percent evaluation. Six months following initial diagnosis, a future examination should be conducted to determine residuals, which are rated under the appropriate body system. The 30 percent evaluation is not a mandatory minimum evaluation.

7904Hyperparathyroidism

The 100 percent evaluation is only for application for six months from the date of discharge following surgery. The 60 percent evaluation is based entirely on objective laboratory values – hypercalcemia. The 10 percent evaluation is largely similar to the old evaluative criteria of continuous medication required for control, but also adds consideration for symptomatic individuals not receiving medication.

7905Hypoparathyroidism

New evaluation criteria: 100 percent evaluation following initial diagnosis followed by a VA examination

7906 Thyroiditis

New code, 0% or use 7900 or 7903

7907 new evaluation criteria – the criteria has been clarified to be based

Cushing's syndrome on the severity and extent of muscle weakness and comorbidities, and the 60 percent criteria no longer requires enlargement of the adrenal or pituitary gland. Evaluation for 6 months after initial diagnosis followed by a VA examination. Then residuals evaluated under the appropriate body system.

7908Acromegaly

New criteria, removal of sella turcica symptom requirement for 30 percent evaluation

7909Diabetes insipidus

New evaluation criteria based on initial diagnosis for 3 months followed by a VA examination.

7911Addison's disease (adrenocortical insufficiency):

Name change only

7912Polyglandular syndrome (multiple endocrine neoplasia, autoimmune polyglandular syndrome)

Name change only

7913Diabetes Mellitus

Clarification stating one or more daily injection of insulin in the 20, 40, and 60 percent criteria

7914Neoplasm, malignant, any specified part of the endocrine system

No change

7916 – 7919Hyperpituitarism (prolactin secreting pituitary dysfunction)&Hyperaldosteronism &Pheochromocytoma &C-cell hyperplasia of the thyroid

New evaluation criteria. Evaluate as malignant or benign neoplasm

C-cell hyperplasia of the thyroid - evaluate as either malignant neoplasm or hypothyroidism, depending on treatment

Per QRT/GiaBao Nguyen, 12/1/17 - When there is any change in the evaluation criteria for a disability applicable to a pending claim where an otherwise sufficient examination was already completed and the rating was not completed prior to the release of the new VASRD criteria, then an addendum to the examination is needed and if not possible, then a new examination should be requested as the examination of record would be insufficient to evaluate the condition as of the date of the law change. Supporting citations for this stance would include: M21-1 III.iv.3.D.3.a; M21-1 III.iv.3.D.3.b (Barr v. Nicholson); and 38 CFR 3.159(c)(4).

Since we will be in a period of overlap with the old and new rating criteria, there are many Veterans who have claims pending for Endocrine System conditions that require exams. If a Veteran’s claim was filed or we received their Intent to File before the regulation’s effective date, then the Veteran will be considered under both rating criteria. See M21-1 III.iv.5.C.7.k. If the new provision is more favorable, unless explicitly made retroactive, the new criteria are applicable only as of the effective date of the change of law.

III.iv.3.D.3.c (updated 12/12/17) discusses the above issue of addendums

November 2017 Compensation Service Bulletin (CSB) – If a Veteran’s claim was filed or we received their Intent to File before the regulation’s effective date, then the Veteran will be considered under both rating criteria and we will use the criteria that is most advantageous to the Veteran keeping in mind the provisions of M21-1, Part IV, Subpart ii,

2.K.6.b which states that “if the new provision is more favorable, unless explicitly made retroactive, the new criteria are applicable only as of the effective date of the change of law.”… When there is any change in the evaluation criteria for a disability applicable to a pending claim where an otherwise sufficient examination was already completed, however, the rating was not completed prior to the release of the new VASRD criteria, then an addendum to the examination is needed and if not possible, then a new examination should be requested as the examination of record would be insufficient to evaluate the condition as of the date of the law change. . Supporting citations for this stance would include: M21-1 III.iv.3.D.3.a; M21-1 III.iv.3.D.3.b (Barr v. Nicholson); and 38 CFR 3.159(c)(4).

Endocrinopathies are all presumptive under 3.309(a)!!!

7900 Hyperthyroidism – if also has hyperthyroid heart disease or psychiatric manifestations, see III.iv.4.F.3; Graves disease; per III.iv.4.G.3.i, evaluate hypertension as part of hyperthyroidism if it is the cause, no separate evaluation for hypertension is allowed; III.iv.4.M.3

7903 Hypothyroidism – Tatum v. Shinseki (9/28/09) - if have 2 of the 3 symptoms required for the next higher, must consider 4.7 (for all disabilities with successive criteria), plus consider 4.13 if have a separate, related diagnosis with common symptomatology

From: VAVBASDC/RO/VSC Sent: Friday, January 12, 2018 12:09 PMSubject: FW: VBMS-R Evaluation Error for Hypothyroidism

VBMS-R evaluation error for hypothyroidism

Target Audience:  RVSRs and DRos

The Rating Schedule criteria for the Endocrine System, 38 CFR 4.119, was revised effective December 10, 2017.

VBMS-R is currently generating an incorrect 100% for hypothyroidism, without myxedema, when “mental disturbance” selected.  100% is not warranted unless there is myxedema. 

The Evaluation Builder will be updated.  Please refer to VBMS Tips and Tricks Release 14.0 for the workaround regarding this issue, which directs end-users to not select ‘mental disturbance’ as a symptom under hypothyroidism (DC 7903).

January 2018 Quality Call Notes – reiterates error on hypothyroidism with myxedema (9703)

7913 Diabetes mellitus – Type II is also Agent Orange presumptive under 3.309(e)

III.iv.4.M.1.f – complications are within the scope of a claim for DM

III.iv.4.M.1.g – table on which DBQs to request with DM & claimed complications; if claiming increase in DM, can also address any new complications or any increase in already SC complications even if not expressly listed

III.iv.4.M.1.h – addresses FTRs for DM-related claims (if claims increase in DM & FTR, CCEVAL for DM & all separate complications)

III.iv.4.M.2 – complications, incl that they are a worsening/increase claim rather than a secondary claim

March 2016 Quality Call Notes clarifies that solicitation of a claim for increase is required for diabetes mellitus & it’s complications (if DM &/or that specific complication(s) NOT claimed, but another complication was claimed; My example: eyes claimed,but TRs show nephropathy diagnosed/worsened, DM not claimed, so other

complications not within scope) (also says, in Q&A, if claimed PTSD & increase in DM shown in TRs, could consider soliciting CFI, seems not to be required in this case); AND reiterates that we do not apply 3.157 for complications shown (diagnosed) in TRs after 3/24/15, but can go 1 year prior to DOC; reminder that do not need specific claim for complications if have claim for primary disability, as “reasonably raised” & 3.155(d)(2)’s “VA will also consider all lay and medical evidence of record in order to adjudicate entitlement to benefits for the claimed condition as well as entitlement to any additional benefits for complications of the claimed condition, including those identified by the rating criteria for that condition in 38 CFR Part 4, VA Schedule for Rating Disabilities.” [per QRT/GiaBao Nguyen, 5/25/17, if see worsening in SC cond in DBQ, can solicit claim & if claim within one year, can use date of DBQ for effective date]

…

Can use with borderline diabetes or an unclear diagnosis:Since you do not have a clear diagnosis of diabetes mellitus type II based on (1) classic symptoms of hyperglycemia plus a casual/random plasma glucose greater than/equal to 200 mg/dL, (2) fasting plasma glucose greater than/equal to 126 mg/dL on 2 or more occasions, (3) glucose greater than 200 mg/dL after 75 g glucose load OR 2 hour plasma glucose of greater than/equal to 200 mg/dL on glucose tolerance test, or (4) A1C of 6.5 percent or greater on 2 or more occasions, we cannot establish service connection for diabetes mellitus type II.

regulation of activities:III.iv.4.M.1.e*have to have INSULIN & regulation of activities to get 40%

DM2

Add this, if needed:The DBQ shows you require regulation of activities as part of medical management of diabetes mellitus (DM), but the example of how you regulate your activities does not meet the criteria for regulation of activities, and there is no competent medical evidence that you are required to avoid strenuous occupational and recreational activities due to problems with glucose control.

Please note that although the DBQ shows you are restricted in your ability to perform strenuous activities / you should avoid strenuous activity to prevent hypoglycemic reaction, [it was noted to be because you tire easily and not due to medical necessity; OR the statement was based on your subjective reports only; OR it is a general statement put in most VA contracted examinations], and there is no competent medical evidence that you are required to avoid strenuous occupational and recreational activities due to problems with glucose control.

The DBQ you provided shows you require regulation of activities as part of medical management of diabetes mellitus (DM), but no example was provided of how you must regulate your activities, and the treatment records show no competent medical evidence that you are required to avoid strenuous occupational and recreational activities due to problems with glucose control.

DBQ lists these recognized complications: Diabetic peripheral neuropathy (per DBQs, diabetic peripheral neuropathy evaluated under musculospiral (radial)

(8514/8614/8714), median (8515/8615/8715), ulnar (8516/8616/8716); sciatic (8520/8620/8720), anterior crural/femoral (8526/8626/8726); VEB does sciatic (8520/8620/8720) as of sometime before 12/17, changed to external popliteal nerve (common peroneal) (8521) if you choose peripheral neuropathy, lower extremity; radial (8514/8614/8714) if you choose peripheral neuropathy, upper extremity; *III.iv.4.N.4.g says use 8514 & 8521 if the examiner is unable to specify the affected nerve(s) & there is no other evidence adequately documenting the affected nerveRating Note: III.iv.4.N.4.g says use 8521 if the examiner is unable to specify the affected nerve & there is no other evidence adequately documenting the affected nerve. VEB also uses 8521 when you choose "peripheral neuropathy, lower extremity."

Diabetic nephropathy/renal dysfunction (caused by DM) (7541) Diabetic retinopathy (6040, previously 6006)

DBQ lists these conditions as choices due to DM: Erectile dysfunction Cardiac condition(s) (7005) Hypertension (in the presence of diabetic renal disease) Peripheral vascular disease (7114, ulcers 7121) Stroke Skin condition(s) Eye condition(s) other than diabetic retinopathy Other

DBQ lists these conditions as choices aggravated by DM: Cardiac condition(s) Hypertension (7101) Renal disease (7541) Peripheral vascular disease (7114, ulcers 7121) Eye condition(s) other than diabetic retinopathy Other

March 2016 Quality Call Notes – Distinguishes arteriosclerotic manifestations secondary to hypertension (& depression secondary to hearing loss) from diabetic neuropathy as a natural progression of the complicated metabolic disorder of diabetes. 3.157 does not apply to secondary disabilities.

Diabetes mellitus, diabetic nephropathy and hypertension

III.iv.6.B.2.b

III.iv.4.M.2.e, III.iv.4.M.2.f, III.iv.4.M.2.g

If not claimed, but diagnosed AFTER dx of DM w/diabetic nephropathy & there is an increase in BP readings (or change in treatment) & you are doing a partial grant:*Select At Once exam under diabetic nephropathy (if it is separated from DM; if diabetic nephropathy is 0% & not separated, do the At Once exam under DM). Add this note to the issue: We are requesting a Disability Benefits Questionnaire to confirm your current level of disability.*Do NOT defer the issue of hypertension on the rating, as it was not claimed & it’s possible we’ll get a negative aggravation opinion.*If the opinion is positive, evaluate diabetic nephropathy (or DM, if applicable) & include hypertension.*If the opinion is negative, C&C the diabetic nephropathy evaluation (or the DM evaluation, if applicable).

http://epss.vba.va.gov/mepss/ - MEPSS has discussion of diabetes and hypertension

7914 Neoplasm, malignant, any specified part of the endocrine system 7915 Neoplasm, benign, any specified part of the endocrine system

From: VAVBASDC/RO/VSC Sent: Monday, December 11, 2017 2:32 PMSubject: Q-Tip: Revised Rating Schedule Criteria for the Endocrine System

Good afternoon VSC,

The Rating Schedule criteria for the Endocrine System, 38 CFR 4.119, was revised effective December 10, 2017.

Overview of Changes

Added one new diagnostic code (7906) for thyroiditis

Added new rating criteria to diagnostic codes Hyperthyroidism, including, but not limited to, Graves’ disease Thyroid enlargement, toxic Thyroid enlargement, non-toxic Hypothyroidism Hyperparathyroidism Hypoparathyroidism Cushing’s Syndrome Acromegaly Diabetes Insipidus

Added notes to diagnostic codes for further clarification Name changes to several diagnostic codes to reflect current medical terminology

Hyperthyroidism changed to Hyperthyroidism, including, but not limited to, Graves’ disease Thyroid gland, toxic adenoma of changed to Thyroid enlargement, toxic Thyroid gland, non-toxic adenoma of changed to Thyroid enlargement, non-toxic Addison’s disease (Adrenal Cortical Hypofunction) changed to Addison’s disease (adrenocortical

insufficiency) Polyglandular syndrome changed to Polyglandular syndrome (multiple endocrine neoplasia, autoimmune

polyglandular syndrome) Added clarification regarding injection of insulin (from “Requiring insulin” to “Requiring one or more daily injection

of insulin”) to diagnostic code 7913 Diabetes Mellitus (this did not require a change to the Diabetes Mellitus DBQ)

The revised evaluation criteria can be viewed here (pdf version) and soon at e-CFR (if not so already).

M21-1 Updates

The manual was updated at M21-III.iv.4.M on December 11, 2017 to consider these changes, to include:

Updated diabetes mellitus criterion Updated the definition of hyperthyroidism Added a definition for hypothyroidism Added a new block with guidance on evaluating thyroid disabilities Updated guidance on rating nontoxic thyroid enlargement Added a new block with a definition for myxedema Added a new block with guidance on disability evaluations and changes in the endocrine rating schedule, to

include a note that the new rating schedule changes are not considered liberalizing

If a Veteran’s claim was pending or there was an Intent to File (ITF) notice received by VA at the time of regulation’s effective date (December 10, 2017), then the claim must be considered under both previous and new rating criteria.  For handling claims when there are regulatory changes, see M21-1 III.iv.5.C.7.k.

DBQs

Updated DBQs for “ENDO Endocrine Miscellaneous” and “ENDO Thyroid & Parathyroid” were scheduled to be pushed to VHA C&P sites on December 10, 2017.  The new DBQs for Contract and Internal Use can be viewed on the DBQ Switchboard.  In the additional exam remarks field in the Examination Request Builder (ERB), continue to enter the intent to file (ITF) date as this will alert the examiner whether historical DBQ information must be provided. 

VBMS-R

VBMS-R was also updated on December 10, 2017 to allow for rating consideration for endocrine conditions across multiple schedules.  See slides 2-5 of the training deck.

Please note: RQRSs will also discuss this topic in upcoming team huddles. Questions on VBMS-R should be referred to your Coach or team Super-User. Questions on the Rating Schedule changes may be referred to your Coach or SME.

4.120 - 4.124a. Neurological Conditions and Convulsive DisordersIII.iv.4.N

4.120 Evaluations by comparison – rate in proportion to motor, sensory or mental impairment4.121 Identification of epilepsy – need neurological observation in hospital if there is doubt to the nature, seizure needs

to be witnessed or verified by a Physician, III.iv.4.N4.122 Psychomotor epilepsy – seizures and chronic psychiatric disturbance4.123 Neuritis, cranial or peripheral – loss of reflexes, muscle atrophy, sensory disturbances, and constant pain,

maximum rating is SEVERE; if no organic changes then maximum rating is MODERATE, or MODERATELY SEVERE if sciatic

4.124 Neuralgia, cranial or peripheral – dull and intermittent pain, maximum rating is MODERATE

4.124a Schedule of Ratings—Neurological Conditions and Convulsive Disorders

changed 10/23/08 (DC 8045), see “Historic Part 4 Sections” in Rating References Archive*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.124; or in CPKM

ORGANIC DISEASES OF THE CENTRAL NERVOUS SYSTEM8000 Encephalitis, epidemic, chronic8002 Brain, new growth of, Malignant, RFE is 2 years (not 6 months)8003 Brain, new growth of, Benign8004 Paralysis agitans; Parkinson’s disease - bradykinesia is slowness of motion, dyskinesia is diminished voluntary movements with involuntary movement

III.iv.6.E.2.d

Example of how to code, the most disabling effect is first & is “Presumptive,” subsequent are coded as “Secondary” to the first:8004-7542 Parkinson’s disease with incontinence7399-7319 constipation8516 right upper extremity tremor, bradykinesia/slowed motion, muscle rigidity/stiffness and loss of automatic movements [Audrey Reid uses 8510]8516 left upper extremity tremor, bradykinesia/slowed motion, muscle rigidity/stiffness and loss of automatic movements [Audrey Reid uses 8510]8521 right lower extremity tremor, bradykinesia/slowed motion, muscle rigidity/stiffness and loss of automatic movements [Camp Lejeune training uses 8520]8521 left lower extremity tremor, bradykinesia/slowed motion, muscle rigidity/stiffness and loss of automatic movements [Camp Lejeune training uses 8520]8212 speech changes7299-7203 difficulty chewing/swallowing 6275 loss of sense of smell

8005 Bulbar palsy8007 Brain, vessels, embolism of8008 Brain, vessels, thrombosis of – POW presumptive under 3.309(c)8009 Brain, vessels, hemorrhage from – POW presumptive under 3.309(c)8010 Myelitis8011 Poliomyelitis, anterior8012 Hematomyelia8013 Syphilis, cerebrospinal8014 Syphilis, meningovascular8015 Tabes dorsalis8017 Amyotrophic lateral sclerosis – eff 9/23/08 anytime after service if had at least 90 days of service, 100% minimum, consider SMC, 3.114 applies

III.iv.4.N.6 3.318 February 2018 Quality Call Notes

8018 Multiple sclerosis – 7 year pres period; III.iv.4.N.58019 Meningitis, cerebrospinal, epidemic8020 Brain, abscess of8021 Spinal cord, new growths, Malignant8022 Spinal cord, new growths, Benign8023 Progressive muscular atrophy – III.iv.4.N

8024 Syringomyelia8025 Myasthenia gravis8045 Residuals of traumatic brain injury (TBI) – includes traumatic encephalopathy –

3.310(d) has TBI severity table

DBQs are for internal VA use only, see DBQ at http://vbacodmoint1.vba.va.gov/bl/21/dbq/default.asp

III.iv.4.D.4, III.iv.4.N.1.e, III.iv.4.N.2.i – vertigo

III.iv.4.N.2.f seems to imply that we only need an opinion if “medical evidence of record does not show a clear-cut etiology for a sign or symptom claimed as a delayed effect,” but Geoff Sauer said direct medical opinions are needed to grant SC.

III.iv.4.N.2.h – table for manifestations, separate eval if distinct dx

III.iv.4.N.2.i – table for evaluating co-morbid symptoms/conditions, incl headaches, tinnitus, vertigo, cognitive/behavioral/emotional residuals

III.iv.4.N.2.j – if have TBI & mental dx, with sx that cannot be delineated, plus have physical TBI sx w/o distinct physical dx, give mental under 93## & physical under 8045

III.iv.4.N.2.k – need medical opinion evidence on whether TBI and mental disorder are distinct and can be separately evaluated (from either TBI or mental examiner); per Suzanne Burkett, 9/2/16, if SC for PTSD & claims TBI, so only get TBI exam, can ask TBI examiner to differentiate

III.iv.4.N.2.q - need TBI corporate flash for all TBI claims (added through SHARE, includes sympathetic claims (i.e. head injury, concussion) per III.iv.4.N.2.e); keep if TBI is granted, remove if TBI is denied

III.iv.4.N.3.g,h&i – five diagnosable illnesses secondary to TBI , per 3.310(d) 12/17/13; 1) Parkinsonism/Parkinson’s disease, (2) unprovoked seizures, (3) dementias (presenile dementia of the Alzheimer’s type, frontotemporal dementia, and dementia with Lewy bodies), (4) depression (w/i 3 years of mod/sev or 12 mos of mild), (5) disease of hormone deficiency that result from hypothalamo-pituitary changes (w/i 12 mos) associated with mod/sev (determined by initial severity) TBIs, eff 1/16/14, 3.114 applies

April 2012 TBI training – migraines and tension headaches qualify for separate evaluations; tinnitus only qualifies for separate evaluation if diagnosed at audio exam; delete information on each facet that does not apply to veteran; heterotopic ossification is myositis ossificans 5023 (rate based on 5003 or LOM of joint); cognitive impairment or post-concussive syndrome diagnoses are under TBI (8045) NOT mental unless examiner says cannot determine, then can do with mental if needed

Notes from January 2016 TBI Training (Carlos Rosario & John Trunick):

mental symptoms without diagnosis, under 8045; but mental diagnosis – need to know if symptoms can be differentiated (if unclear, request clarification); if cannot differentiate , need reason; III.iv.4.N.2.i

if mental examiner can differentiate symptoms, but not occupational impairment (or vice versa), III.iv.4.N.2.h says do one evaluation (under 8045 or a mental DC, whichever is higher) since “manifestations” cannot be clearly separated (My Notes: Prior Quality Call said have to be able to separate symptoms & impairment for separate evals, confirmed by 9/29/16 update.)

physical issues likely under separate evaluation, III.iv.4.N.2.d; apraxia – disconnect between brain & motor function

if have diagnosis, rate separately (i.e. migraines, tinnitus (My Notes: I guess they mean it’s reported on a HL/tinnitus DBQ since tinnitus isn’t diagnosed on DBQs.), III.iv.4.N.2.h says tinnitus can be physical or subjective, but do separately as physical unless gives higher combined eval if do under subjective

heterotopic ossification is due to blast, bone issue where doesn’t belong, 5023 myositis ossificans

dizziness & vertigo – always under 8045, subjective (unless diagnosed in service, as separate from TBI); if already separate, leave it & can even increase; III.iv.4.N.1.e, III.iv.4.N.2.h

even if diagnosed, can rate under 8045 ifgives veteran a higher evaluation (My Notes: I do not see this in the Live Manual, but the example in the hand-out confirms.)

cognitive & behavioral/emotional signs/symptoms – might overlap with any mental diagnoses

III.iv.4.N.3.a, 3.114 applies, eff 1/16/14 – 5 diagnoses automatically secondary to TBI depending on initial severity of TBI; RVSR determines initial severity per III.iv.4.N.3.b&c&d; unless have contradicting evidence, no secondary opinion is needed; if not specifically claimed & TBI is not at issue in claim, invite if found

o Parkinsonism (mod or sev)

o unprovoked seizures (mod or sev)

o dementias (w/i 15 years of mod or sev)

o depression (w/i 3 years of mod or sev or w/i 1 year of mild)

o diseases of hormone deficiency from hypothalamo-pituitary changes (w/i 1 year of mod or sev)

must have in-service event

SMC T (if at 100% for TBI & at L for A&A for TBI, then if need higher level of care & would need nursing/hospital care, pays at R2 level), only need paragraphs for L & R2, add note on codesheet: SMC(t) = (r)(2); IV.ii.2.H.11, 3.350 updated 5/8/18 with new paragraph (j), 3.352 updated 5/8/18 with new paragraph (b)(2)

be careful with effective dates when changing from TBI w/PTSD with one evaluation, to separate evaluations (and vice versa)

Policy Letter 21-16-13 – Review of Traumatic Brain Injury (TBI) Claims / TBI Equitable Relief Review (veteran flash) / TBI Exam Review (claim-specific special issue indicator on TBI issue/contention) -

Per letter, need Initial TBI exam conducted by psysiatrist, psychiatrist, neurosurgeon or neurologist; only developed, rated & authorized by Togus, Nashville, St. Paul, San Diego and Muskogee; veteran has one year from 5/3/16 letter to request a new exam

Per Beth, 8/30/16, all should go to a prior SpecOps RVSR to rate (email Beth if get one to rate, or one where exam is warranted); as of 10/16, also email Sally

Determining Evaluation Criteria for Rating Residuals of Traumatic Brain Injury (TBI) [RVSR Job Aid], TBI, Case Law and Nehmer Timeline [spreadsheet with 8045 TBI Facets & Info] & TBI_Policy_Letter_21-16-03.pdf are saved at H:\VSC\Rating Reference

October 2017 Consistency Study said can give separate 10% for tinnitus even if not on audio exam

TBI denial (need Long Form Narrative, per III.iv.6.C.7.a):

Service connection for traumatic brain injury may be granted when there is evidence establishing a clear diagnosis of the condition, credible supporting evidence that the traumatic brain injury actually occurred, and a nexus or link established by medical evidence, between symptomatology and the in-service traumatic brain injury. Occurrence of a traumatic brain injury in service is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event: any period of loss of or a decreased level of consciousness; any loss of memory for events immediately before or after the injury; any alteration in mental state at the time of injury (confusion, disorientation, slowed thinking, etc); neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphagia, etc.) that may or may not be transient; or intracranial lesion.

NIS STRs You denied any head injury, memory loss or amnesia, as well as a period of unconsciousness or concussion, on your {} separation examination and the clinical evaluation showed normal neurological findings. / Your neurological findings were noted to be normal on the clinical evaluation of your {} separation examination.

ACK_SX The treatment records show evidence of {}. OR NODX The treatment records show no current medical evidence of {}. / There is no current medical evidence of {}.

8046 Cerebral arteriosclerosis (rate vasovagal syndrome analogous, 8099-8046; Dr. Corey at C&P at VAMC San Diego said to use a CNS DBQ)

MISCELLANEOUS DISEASES8100 Migraine – III.iv.4.N.7, III.iv.4.N.7.f – very frequent completely prostrating = 50%My Notes: 8100 says “very frequent completely prostrating and prolonged attacks,” DBQ says “very frequent prostrating and prolonged attacks”

HA1

THE CRANIAL NERVES8205    Fifth (trigeminal), paralysis. 8207    Seventh (facial), paralysis. 8209    Ninth (glossopharyngeal), paralysis. 8210    Tenth (pneumogastric, vagus), paralysis. 8211    Eleventh (spinal accessory, external branch), paralysis. 8212    Twelfth (hypoglossal), paralysis. 8305    Neuritis, fifth cranial nerve. 8307    Neuritis, seventh cranial nerve. 8309    Neuritis, ninth cranial nerve.

8310    Neuritis, tenth cranial nerve. 8311    Neuritis, eleventh cranial nerve. 8312    Neuritis, twelfth cranial nerve. 8405    Neuralgia, fifth cranial nerve. 8407    Neuralgia, seventh cranial nerve. 8409    Neuralgia, ninth cranial nerve. 8410    Neuralgia, tenth cranial nerve. 8411    Neuralgia, eleventh cranial nerve. 8412    Neuralgia, twelfth cranial nerve.

THE PERIPHERAL NERVES – Per QRT/GiaBao Nguyen, 9/8/17, policy on giving 10% based on subjective complaints came out in mid/late September 2013 & prior to that RVSRs would combine the sciatica/radiculopathy with the back (if there were only subjective complaints for the extremities) based on this note at the beginning of the spine rating criteria, “With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.” It is not a CUE.

III.iv.4.N.4.aIII.iv.4.N.4.b – if only sensory, use mild or at most moderate

use mild if sensory symptoms are (1) recurrent but not continuous, (2) assigned a lower medical grade reflecting less impairment, (3) affecting a smaller area in the nerve distribution

use moderate if sensory symptoms are (1) continuous, (2) assigned a higher medical grade reflecting greater impairment, (3) affecting a larger area in the nerve distribution

III.iv.4.N.4.c – mild, moderate, moderately severe, severeIII.iv.4.N.4.e – LEs allowed separated evals for different nerve branches (also see boxes below for the five groups)

SCIATIC (includes sciatic [8520], external popliteal/common peroneal [8521], musculocutaneous/superficial peroneal [8522], anterior tibial/deep peroneal [8523], internal popliteal/tibial [8524], posterior tibial [8525])

FEMORAL (includes anterior crural/femoral [8526], internal saphenous [8527]) OBTURATOR [8528] EXTERNAL CUTANEOUS [8529] ILLIO-INGUINAL [8530]

POW presumptive under 3.309(c)8515/8615/8715 - carpal tunnel syndromeEarly-onset peripheral neuropathy is Agent Orange presumptive under 3.309(e)8510    Upper radicular group, paralysis. 8511    Middle radicular group, paralysis. 8512    Lower radicular group, paralysis. 8513    All radicular groups, paralysis. 8514    Musculospiral nerve (radial), paralysis. 8515    Median nerve, paralysis. 8516    Ulnar nerve, paralysis. 8517    Musculocutaneous nerve, paralysis. 8518    Circumflex nerve, paralysis. 8519    Long thoracic nerve, paralysis.

8520    Sciatic nerve, paralysis. 8521    External popliteal nerve (common peroneal), paralysis. 8522    Musculocutaneous nerve (superficial peroneal), paralysis. 8523    Anterior tibial nerve (deep peroneal), paralysis. 8524    Internal popliteal nerve (tibial), paralysis. 8525    Posterior tibial nerve, paralysis.

8526    Anterior crural nerve (femoral), paralysis. 8527    Internal saphenous nerve, paralysis.

8528    Obturator nerve, paralysis.

8529    External cutaneous nerve of thigh, paralysis.

8530    Ilio-inguinal nerve, paralysis.

8540    Soft-tissue sarcoma (Neurogenic origin). 8610    Neuritis, upper radicular group. 8611    Neuritis, middle radicular group. 8612    Neuritis, lower radicular group. 8613    Neuritis, all radicular groups. 8614    Neuritis, musculospiral (radial) nerve. 8615    Neuritis, median nerve. 8616    Neuritis, ulnar nerve. 8617    Neuritis, musculocutaneous nerve. 8618    Neuritis, circumflex nerve. 8619    Neuritis, long thoracic nerve.

8620    Neuritis, sciatic nerve. 8621    Neuritis, external popliteal (common peroneal) nerve. 8622    Neuritis, musculocutaneous (superficial peroneal) nerve. 8623    Neuritis, anterior tibial (deep peroneal), nerve. 8624    Neuritis, internal popliteal (tibial) nerve. 8625    Neuritis, posterior tibial nerve. 8626    Neuritis, anterior crural (femoral) nerve. 8627    Neuritis, internal saphenous nerve. 8628    Neuritis, obturator nerve. 8629    Neuritis, external cutaneous nerve of thigh. 8630    Neuritis, ilio-inguinal nerve. 8710    Neuralgia, upper radicular group. 8711    Neuralgia, middle radicular group. 8712    Neuralgia, lower radicular group. 8713    Neuralgia, all radicular groups. 8714    Neuralgia, musculospiral nerve (radial).

8715    Neuralgia, median nerve. 8716    Neuralgia, ulnar nerve. 8717    Neuralgia, musculocutaneous nerve. 8718    Neuralgia, circumflex nerve. 8719    Neuralgia, long thoracic nerve. 8720    Neuralgia, sciatic nerve. 8721    Neuralgia, external popliteal nerve (common peroneal). 8722    Neuralgia, musculocutaneous nerve (superficial peroneal). 8723    Neuralgia, anterior tibial nerve (deep peroneal). 8724    Neuralgia, internal popliteal nerve (tibial). 8725    Neuralgia, posterior tibial nerve. 8726    Neuralgia, anterior crural nerve (femoral). 8727    Neuralgia, internal saphenous nerve. 8728    Neuralgia, obturator nerve. 8729    Neuralgia, external cutaneous nerve of thigh. 8730    Neuralgia, ilio-inguinal nerve.

from http://www.neuroexam.com/content.php?p=29

Muscle Strength0/5: no contraction 1/5: muscle flicker, but no movement 2/5: movement possible, but not against gravity (test the joint in its horizontal plane) [SEVERELY DECREASED STRENGTH]3/5: movement possible against gravity, but not against resistance by the examiner [MODERATELY DECREASED STRENGTH]4/5: movement possible against some resistance by the examiner (sometimes this category is subdivided further into 4–/5, 4/5, and 4+/5) [SLIGHTLY DECREASED STRENGTH]5/5: normal strength

Deep Tendon Reflexes0: absent reflex1+: trace, or seen only with reinforcement [also called hypoactive]2+: normal 3+: brisk [also called hyperactive without clonus]4+: nonsustained clonus (i.e., repetitive vibratory movements) [also called hyperactive with clonus]5+: sustained clonus

per 4.124 (also noted above) - for neuralgia (dull and intermittent pain) - the maximum rating is moderate per 4.123 (also noted above) - for neuritis (loss of reflexes, muscle atrophy, sensory disturbances, and constant

pain) – the maximum rating is SEVERE, and if there are no organic changes, the maximum rating is MODERATE (or MODERATELY SEVERE if sciatic)

Please note: Musculocutaneous (superficial peroneal, lower), Anterior tibial (deep peroneal), Internal saphenous, Obturator, External cutaneous nerve of thigh, and Ilio-inguinal, all start with 0% for MILD

Rating Note: The DBQ shows moderate involvement of the {} nerve, but muscle strength and reflexes were normal, and sensation was only decreased (not absent, and not significantly disabling or affecting a large area), so mild involvement most accurately reflects the level of disability based on only subjective complaints and sensory findings.

Rating Note: The DBQ shows moderate involvement of the {} nerve, but muscle strength, reflexes and sensation were all normal, so mild involvement most accurately reflects the level of disability based on only subjective complaints.

Rating Note: Although the VA examiner did not indicate the severity of the peripheral neuropathy under 5b { Although the DBQ shows mild involvement}, there is 4/5 strength on the right, 5/5 strength on the left, decreased and absent reflexes, and some decreased (not absent) sensation, all of which generally indicate the severity is moderate.

Rating Note: Although the DBQ shows severe involvement of the sciatic nerve, 8520 says "Severe, with marked muscular atrophy" and the DBQ shows no muscle atrophy, normal muscle strength and normal reflexes, with the only objective finding being decreased sensation to light touch in the lower leg/ankle and foot/toes, plus subjective complaints (severe constant pain, paresthesias/dysesthesias and numbness). It seems the "severe" is indicated based on the subjective complaints, but mild most accurately reflects the level of disability since the only objective finding is decreased sensation.

Check Peripheral Nerve Evaluation Matrix on Rating Job Aids page

Notes from March 2018 Training Provided by Central Office by Andrew Grey (Site Visit Training) on Peripheral Nerves:

use answers to all questions prior to examiner’s assessment (subjective symptoms, muscle strength testing, reflex exam, sensory exam), rather than solely using the assessment of the severity (as the examiner’s assessment does not apply the law)

Sensory only = mild (possibly moderate)

Question from the room at the end of the training was about the amputation rule with neuropathy and foot drop associated with neuropathy.Answer: When determining whether the amputation rule applies to a neurological condition, you must determine the etiology of the neurological condition. When peripheral nerve disabilities are not associated with a musculoskeletal injury, such as diabetic neuropathy, the amputation rule does not apply. However, if the peripheral nerve disability is associated with a musculoskeletal injury or amputation, the provisions of 38 CFR 4.68 and M21-1 III.iv.4.A.13.d (My Notes: as of 4/13/18, it’s III.iv.4.A.8.e) would apply. If the foot drop is caused by the neuropathy, the amputation rule would not apply as the etiology is neurological in nature, not musculoskeletal.

San Diego RVSR Training (Version 2).pptx, recorded training & email message with answers to questions are saved at H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18\2018 Site Visit Training

THE EPILEPSIESIII.iv.4.N

4.125 - 4.130. Mental Disorders

III.iv.4.Oalso see MD1 & MD2

4.125 Diagnosis of mental disorders – diagnosis has to conform to DSM-IV and be supported by findings, if diagnosis has changed, need to determine (or ask) if progression, correction of error or development of new and separate condition

4.126 Evaluation of disability from mental disorders – consider frequency, severity and duration, as well as length of remissions and ability to adjust during remission, consider both social and occupational impairment

4.127 Mental retardation and personality disorders – no service connection for mental retardation or personality disorders

4.128 Convalescence ratings following extended hospitalization – if at 100% for hospitalization of 6 months or more, give a total 100% and schedule a examination 6 months after discharge, if decrease- give due process

4.129 Mental disorders due to traumatic stress – if discharged for mental condition, give 50% or more and schedule examination within 6 months of discharge, III.iv.4.O.1.h

4.130 Schedule of Ratings—Mental Disorders

changed 11/7/96 (DCs 9201-9211, 9300-9327, 9400-9413, 9416-9417, 9421-9425, 9431-9435, 9440, 9520 & 9521)*you can also find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.130; or in CPKM

Training documents are under “PTSD / Other Psychiatric Conditions” at http://hvnc.gdit.com/lc/

III.iv.3.A.8.b send the claims folder for review for "mental health exams" – “any case involving a request for mental disorders examination” reiterated by December 2012 Compensation Service Bulletin (CSB)

III.ii.4.A.6 - nonretention of records for alcohol or drug abuse

III.iii.2.A.1.b & IV.ii.1.D.2.a - Note says clinical records / mental health records are not in STRs & are destroyed after 5 years of inactivity; III.iii.2.A.2.b has table for storage of clinical records

III.iv.4.O – III.iv.4.O.1.a&b – sympathetic reading of mental claims (per Robinson v. Shinseki (2/25/09) & Clemons); III.iv.4.O.5.a – must send file for examiner to review for PTSD

III.iv.4.O.1.e - consider incremental reductions for proposals (except if FTR for RFE - then can reduce to 0%, per IV.ii.3.B.1.a)

III.iv.4.O.1.i (?added 6/14/18) – somatic symptom disorder

III.iv.4.O.1.k (added 6/14/18) – neurodevelopmental disorders (ie.e ADD, ADHD, Autism Spectrum Disorder, Specified Learning Disorder, Tic Disorder, Child-Onset Fluency Disorder/Stuttering, Intellectual Disability/Intellectual Developmental Disorder) are not diseases/injuries under 3.303(c) & are not generally subject to direct SC unless (1) developed as a result of an in-service injury like TBI, or (2) there is progression at an abnormally high rate during service as discussed in IV.ii.2.B.4&6, then consider aggravation

III.iv.4.O.1.l (added 6/14/18) – SC for primary insomnia is allowed if there is no other underlying etiology/disease/injury/mental disorder & there is an event in service (i.e. diagnosis of primary insomnia), a current dx of primary insomnia & a nexus

IV.ii.2.K - alcohol (also 3.301, 3.310, Allen v. Principi (2/2/01))

Mauerhan, 16/436 - NP rating criteria symptoms are no exhaustive list - “such as”

Moore v. Derwinski, 1 Vet.App. 356, 358 (1991) -GAF scores @ 15

Jandreau v. Nicholson (7/3/07) – “lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.”

Clemons v. Shinseki (2/17/09) – “a service connection claim that only identifies post traumatic stress disorder (PTSD) cannot only be limited to that diagnosis, but must be considered a claim for any mental disability that may be reasonably raised by several factors, to include the veteran’s description of the claim and/or symptoms and any information and evidence submitted by the veteran or obtained by VA. The Court explained that because a veteran

was reasonably requesting benefits for symptoms of a mental condition that he was not competent to medically identify, the adjudication of the claim does not end in the face of currently diagnosed mental conditions that are different from his lay hypothesis on the claim form. The Court noted that it is generally within the province of medical professionals to diagnose or label a mental condition, not the claimant. “ says will update III.iv.4.O.32.j (now III.iv.4.O.6 & it says “If a VA medical examination fails to establish a diagnosis of PTSD and no other mental diagnosis is made, deny the claim on that basis. Note: If the existence of a stressor has not been determined, do not include the discussion of the alleged stressor in the rating decision.”) see July 2015 PTSD Training under PTSD section for more notes

Per STAR error reported in November 2010 - D1 Error. Vet was granted SC for depression and anxiety with an effective date based on the date of his VAE. The case is based on the Vet claiming PTSD 4 months earlier. The effective date should have been the date of claim for PTSD and not the date of the VAE. While the Vet was not dx with PTSD at the VAE, the VAE dx depression and anxiety and opined that the conditions started in service. ---Veterans are not required to dx themselves. Our take-away should be that when a Vet claims a mental health condition, it’s essentially a claim for any possible mental health condition. (NOTE: PTSD was denied separately.)

March 2015 Quality Call Notes – discusses case where PTSD, anxiety & depression were all claimed, but only PTSD was denied. Anxiety & depression were not addressed at all. Confirms that also need to separately address anxiety & depression [unless they are claimed as symptoms, then can use “(also claimed as anxiety and depression)”]; additional Q&A says: “In the scenario presented in this question, if anxiety and depression were listed on the “decision line” or in the “Reasons for Decision,” a STAR A1 error most likely would not have been cited since the specifically claimed issues would have been “addressed.””

May 2015 Compensation Service Bulletin (CSB) – Final Rule – Schedule for Rating Disabilities – Mental Disorders and Definition of Psychosis for Certain VA Purposes; based on DSM-5 nomenclature, but does not change how mental disorders are evaluated; effective March 19, 2015; see III.iv.3.A.8.e (now III.iv.3.A.6) & III.iv.4.O

https://mhreference.org/dsm-codes/dsm-category/

Weekly Q-Tip (6/12/15) – This week’s Quality Tip involves best practices for rating mental conditions. Please review the following rating scenarios and best practices for properly disposing of claims for service connection for various mental conditions. For all scenarios below, assume service connection is warranted and all development actions completed.

Example #1:

Veteran claimed service connection for PTSD, depression and anxiety.  VA exam diagnosed PTSD and checked boxes indicating symptoms of depressed mood and anxiety.

Best Practice:  Grant service connection for “PTSD (also claimed as/with depression and anxiety).” Do not deny depression and anxiety, as these are symptoms of PTSD.

Acceptable practice:  Grant service connection for PTSD while ensuring evaluation builder-generated texts reflects symptoms of depressed mood and anxiety.  [NOTE: Be sure to address all claimed contentions in one way or another.]

Example #2:

Veteran claimed service connection for PTSD, depression and anxiety.  VA exam diagnosed PTSD and did not check boxes for symptoms of depressed mood and anxiety.

Best Practice:  Grant service connection for PTSD and separately deny service connection for depression and anxiety citing reason of no diagnosis. 

NOTE: Be sure to address all claimed contentions in one way or another.

Example #3:

Veteran claimed service connection for PTSD, depression and anxiety.  VA exam diagnosed Major Depressive Disorder and checked boxes for symptoms of depressed mood and anxiety.

Best Practice:  Grant service connection for “Major Depressive Disorder (also claimed as/with anxiety)”; and, separately deny service connection for PTSD.

Example #4:

Veteran claimed service connection for PTSD, depression and anxiety.  VA exam revealed no diagnosis.

Best Practice:  Separately deny service connection for PTSD, depression and anxiety.

Acceptable practice: Deny them all as a single decision.

NOTE: Be sure to address all claim contentions in one way or another.

TAKE AWAY NOTE:  Ensure that all claimed contentions are reflected in the Rating Decision.  If claimed contentions are attributed to the service-connected Axis I diagnosis as symptoms, separate denials of service connection are improper as the symptoms are, in effect, service-connected.

References: March 2015 Quality Call Notes38 CFR 3.304(f)

My Notes (thoughts):

A veteran claims PTSD, anxiety & depression; PTSD is the only diagnosis & service-connectable disability but symptoms include anxiety & depression. Grant PTSD & add “(also claimed as anxiety and depression)” to the decision line. Correct per Weekly Q-Tip (6/12/15). A veteran claims PTSD, anxiety and depression; PTSD is the only diagnosis & service-connectable disability & symptoms DO NOT include anxiety & depression. Grant PTSD; deny anxiety & depression SEPARATELY for no diagnosis. Ref: Weekly Q-Tip (6/12/15)A veteran claims PTSD, anxiety and depression; MDD is diagnosed & service-connectable w/symptoms of anxiety & depression. Grant MDD & do “(also claimed as anxiety and depression)”; deny PTSD SEPARATELY for no diagnosis. Ref: Weekly Q-Tip (6/12/15) OR, address PTSD in the MDD issue narrative, indicating that it cannot be granted. It is not an error to deny it separately, but addressing it within the MDD issue is most appropriate.

A veteran claims PTSD, anxiety and depression; no mental disability is diagnosed. Deny PTSD, anxiety & depression SEPARATELY for no diagnosis. Correct per Weekly Q-Tip (6/12/15). A veteran claims PTSD & bipolar disorder; PTSD is the only diagnosis & service-connectable disability; grant PTSD & deny bipolar disorder SEPARATELY (since bipolar disorder is a disability & cannot be interpreted as merely symptoms of the SC disability).

Rating Note: Bipolar disorder was separately denied since it is a diagnosable disability & cannot be interpreted as a symptom of the SC PTSD/mental disability.

Mental Disorders, Initial PTSD and Review PTSD DBQs Revised (5/24/2018) On May 24, 2018, three revised Disability Benefits Questionnaires (DBQs) were released to VHA Facilities and VBA Contract Vendors. The Initial PTSD, Review PTSD, and Mental Disorders DBQs required examiners to differentiate the portion of occupational and social impairment attributable to each diagnosis when more than one mental disorder is diagnosed or when TBI is also diagnosed, and also to differentiate the portion of symptoms attributable to each diagnosis when more than one mental disorder is diagnosed or when TBI is also diagnosed. The term “portion” was having the unintended result of C&P examiners providing percentages and it has been noted that some exam requests are specifically requiring examiners to provide a percentage in response to those questions. Accordingly, the affected questions in these DBQs were re-worded (and the word portion was removed). On the Mental Disorders DBQ, the changes affect 2b and 2d, 3b and 3c. On the Initial PTSD and the PTSD Review DBQs, the changes affect 3b and 3d and 4b and 4c.

Also, in the Initial PTSD DBQ, the following note was added to Section 2, Part 2. HISTORY as follows:

NOTE: Initial examinations require pre-military, military, and post-military history. If this is a review examination, only indicate any relevant history since prior exam.

…

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS – 3.384POW presumptive under 3.309(c)III.iv.6.B – consider SC for treatment only if deny psychosis as related to wartime service

DELIRIUM, DEMENTIA, AND AMNESTIC AND OTHER COGNITIVE DISORDERS

ANXIETY DISORDERS – POW presumptive under 3.309(c)

DISSOCIATIVE DISORDERS

SOMATOFORM DISORDERS: 9421- “Somatization disorder is a chronic condition in which there are numerous physical complaints. These complaints can last for years, and result in substantial impairment. The physical symptoms are caused by psychological problems, and no underlying physical problem can be identified.”- Medline Plus“Somatization Disorder was formerly called hysteria. Primarily affecting women, it generally has its onset in adolescence or early adulthood and lasts for years. Its symptoms usually include a combination of pain, pseudoneurological, digestive and sexual complaints.”- PlanetPsych.com9422- “Pain disorder is persistent and chronic pain at one or more sites in which psychological factors are thought to play a role.”- Medline Plus“Pain Disorder is diagnosed when the primary symptom is pain and psychological factors are presumed to be important in the etiology, maintenance or exacerbation of the condition.”- PlanetPsych.com 9423- “Undifferentiated Somatoform Disorder is a milder form of Somatization Disorder lasting at least six months.”- PlanetPsych.com9424- “Conversion Disorder is characterized by unexplained sensory motor deficits which are judged to be psychogenic.”- PlanetPsych.com [if manifests with paralysis/loss of use of legs, cannot get separate 100% under 5110,

just one 100% under 5110-94249425- “Hypochondriasis is the fear illness in the absence thereof or exaggeration of symptoms or bodily sensations into serious illness.”- PlanetPsych.com

MOOD DISORDERS – POW presumptive under 3.309(c)

CHRONIC ADJUSTMENT DISORDER

EATING DISORDERS – Per QRT, rate separately, confirmed per VA Pulse, https://www.vapulse.net/message/122384

Post Traumatic Stress Disorder -

3.304(f) Post-Traumatic Stress Disorder – (PTSD)9411 Post-traumatic stress disorder – added 4/11/80

Initial PTSD DBQ is for internal VA use only, see DBQ at http://vbacodmoint1.vba.va.gov/bl/21/dbq/default.asp

Training documents are under “PTSD / Other Psychiatric Conditions” (& more, search “PTSD” and/or “MST”) at http://hvnc.gdit.com/lc/

PTSD Knowledge Aid (from 2014) is saved at H:\VSC\Rating Reference

Manual References: III.iv.4.O –

III.iv.4.O.3 & IV.ii.1.D.5 – personal trauma

III.iv.4.O.4.b - “In order to conclude that a Veteran “engaged in combat with the enemy,” the evidence must establish that the Veteran was present during an encounter with a military foe either as a combatant or as a service member performing duty in support of combatants.”

III.iv.4.O.4.d – “Primary evidence, such as the Veteran’s DD Form 214, Certificate of Release or Discharge From Active Duty, and other service records showing deployments, relevant awards or decorations, receipt of Combat/ Imminent Danger/ Hostile Fire Pay, and other conditions of service, will be key to proving service in an area of potential or actual hostile military or terrorist activity.” Used to say, “While confirmation of receipt of Combat/Imminent Danger/Hostile Fire Pay through the VIS alone does not constitute verification of a combat-related stressor, it may, in combination with other evidence, "tip the scales" in favor of the Veteran's assertion of his/her involvement in combat.”

IV.ii.1.D –

as of 10/17/17, formal finding / PTSD memo is no longer needed

IV.ii.1.D.1.f – (added 10/17/17, modified 6/14/18) if have sufficient evidence to corroborate a claimed stressor, mark subject line with “[Nature of stressor], pg. [#]”

IV.ii.1.D.2.i says to send “PTSD-Need stressor details/med evid personal trauma incdnt” which is this paragraph:

We need specific details of the personal trauma incident(s) that resulted in post-traumatic stress disorder (PTSD). It is important that you read the following information and respond to our request within 30 days from the date of this letter. If you do not respond, VA may deny your claim. Complete and return the enclosed questionnaire. We realize that this may be a difficult subject for you to discuss, but the information will be safeguarded and used only in support of your claim. If you are not able to provide the exact date of the incident, please indicate the location and approximate time (a 2-month specific date range) of the stressful event(s) in question. Give us reports of private physicians, if any, who have treated you for this condition since discharge. The reports should include clinical findings and diagnosis. If you have been treated for this condition at a VA medical facility, furnish the date(s) and place(s). We will obtain the report(s). If you have been treated in the Vet Center, tell us the dates of treatment and the address of the Vet Center. We will request the records. Identify any possible sources of

information and evidence such as police reports or medical treatment records for assault or rape. Send us supporting statements from any individuals with whom you may have discussed the incident. Furnish copies of correspondence you may have sent to close friends or relatives in which you related information about the incident. If you did not discuss the incident with anyone, send us supporting statements from service persons, friends, family or clergy who may have observed any changes in your behavior as it may have related to the incident.

Should also include “PTSD Notice-free treatment for PTSD personal assault”:

You may be able to receive free counseling and medical care for problems associated with personal assault whether or not you are receiving compensation. If you want information about counseling and treatment or you want to discuss these services before deciding, please contact the nearest VA medical facility or community based outpatient clinic (CBOC) or Vet Center. Also, the counselors at these facilities will be helpful to you in documenting the details of the stressful event that can be used to support your claim.

IV.ii.1.D.3.c (added 2/3/16, updated 1/30/17) – have to make permanent note in VBMS called “Stressor Verification” (including whether stressor is verified, why it is or is not verified, list of sources reviewed)

IV.ii.1.D.3.g – Examples of Service in Areas of Hostile Military or Terrorist Activity – Korean DMZ since 1953; ship in “blue waters” of Vietnam or in Thailand with VSM or VCM

IV.ii.1.D.3.m – Stressors That Cannot Be Verified

IV.ii.1.D.6.b - “When evidence of exposure to stressors related to combat, experience as a POW, or a fear of hostile military or terrorist activity is established by a Veteran’s individual decoration(s) or other military records, include a statement to that effect in the Remarks section of the examination request. This evidence allows VA (including the examiner) to accept the Veteran’s own description of the specific events without further corroboration.” III.iv.4.O.5.b used to say: “If the claimed stressor is related to a fear of hostile military or terrorist activity, add the following language to the examination request:  Examiner, In addition to the other information provided in the examination report, please specifically state whether or not the claimed stressor is related to the Veteran’s fear of hostile military or terrorist activity.

“event” - Per 3.303 & III.iv.4.O.4.k, we need to attempt to verify the reported event(s), as we have a non-PTSD diagnosis.

for deferral: We need to attempt to verify the reported event(s)/stressor(s) on the 0781(s)/DBQ. *See Claim Notes for more details.

for Claim Note: Claim is not RFD. The Initial PTSD DBQ shows a diagnosis of unspecified anxiety disorder linked to Stressor #1. We cannot grant SC for unspecified anxiety disorder based on fear under 3.304(f)(3), but must use 3.303, which requires a verified event. We need to attempt to verify the reported event(s)/stressor(s) on the 0781(s)/DBQ. III.iv.4.O.4.k. Deferral done.

From: VAVBASDC/RO/VSC Sent: Monday, March 13, 2017 10:48 AMTo: VBASDC_VSC EmployeesSubject: Q-Tip PTSD Stressor Development/VA Form 21-0845 process Attn: VSRs

Question: How do VSRs properly document PTSD stressor development in VBMS?1. M21-1 IV.ii.1.D.1 General Information on Developing Claims for SC for PTSD

-then-2. M21-1 IV.ii.1.D.1.n. Documentation of Stressor Development

Change Date January 30, 2017Fully document all sources of evidence obtained for purposes of stressor verification in the claims folder.

At the time of initial claims folder review, insert a permanent claim-level note in the Veterans Benefits Management System (VBMS), entering Stressor Verification in the first line of the note, and include the following information:

whether stressor can be verified at this stage an explanation of why stressor is or is not considered verified, and a listing of the sources reviewed to include, but not limited to, personnel records, lay statements, medals or

citations, and web sites.

When the stressor is not verified at the time of initial claims folder review but is subsequently verified during the development process, insert a permanent claim-level note in VBMS, entering Stressor Verification in the first line of the note, and include the following information:

an explanation of why the stressor is considered verified, and a listing of the source of evidence for verification of the stressor.

References:  For more information on

development to the Veteran for stressor information and development for evidence of in-service mental health treatment, see M21-1 IV.ii.1.D.2

requesting corroboration of an in-service stressor, see M21-1 IV.ii.1.D.3 and, completion of a formal finding of a lack of information required to document the claimed stressor(s), see M21-1

IV.ii.1.D.4

PTSD Rating Job Aids - http://vbaw.vba.va.gov/bl/21/rating/rat06.htm; VA-sanctioned websites are under “Helpful Website Links”

Stressor Verification Database on C&P Website - http://vbaw.vba.va.gov/bl/21/rating/stressor/general.htmIn VA Pulse, https://www.vapulse.net/groups/jsrrc, JSRRC – Central Clearing House, with:

https://www.vapulse.net/docs/DOC-13968, document on How to Search Deck Logs on the NARA website

https://www.vapulse.net/docs/DOC-13974, document with excerpts from the official report of the C-5 Galaxy crash at Ramstein Air Base (Germany) 29 Aug 1990

https://www.vapulse.net/docs/DOC-13973, Navy SeaBee Museum contact

& more…

Receipt of any of the following decorations will be considered evidence of participation in a stressful episode/combat (per IV.ii.1.D.1.e):

Air Force Achievement Medal with “V” DeviceAir Force Combat Action MedalAir Force Commendation Medal with “V” deviceAir Force CrossAir Medal with “V” deviceArmy Commendation Medal with “V” device Bronze Star Medal with “V” device“C” device, denoting combat conditions, when affixed to other awards for meritorious service or achievement (as of 10/17/17)Combat Action Badge (CAB) Combat Action Ribbon (CAR) (Note: Prior to February 1969, the Navy Achievement Medal with “V” Device was awarded.)Combat Aircrew Insignia (as of 3/04)Combat Infantry/Infantryman Badge (CIB)Combat Medical BadgeDistinguished Flying CrossDistinguished Service CrossFleet Marine Force (FMF) Combat Operations InsigniaJoint Service Commendation Medal with “V” deviceMedal of HonorNavy Commendation Medal with “V” deviceNavy CrossPurple Heart (HECPurpleHeartTeam@med.va.gov -Purple Heart Registry)Silver Star

Verified combat veterans (i.e. has one of the decorations above)- word is truth with regard to stressor or injuries incurred in combat!!!

JSRRC Stressor Verification Guide shows the Air Force Combat Action Medal as evidence of participation in combat

III.iv.4.O.3.d – The receipt of military awards such as, but not limited to, the Vietnam Service or Campaign Medal, Kuwait Liberation Medal, Iraq

Campaign Medal, and Afghanistan Campaign Medal is generally considered evidence of service in an area of potential hostile military or terrorist activity.

The receipt of service medals such as the National Defense, Armed Forces, and Global War on Terrorism (GWOT) Service Medals does not indicate service in locations that involve exposure to hostile military or terrorist activity, because these are general

medals that do not denote service in a particular area or campaign. If the Veteran served in an area of potential hostile military or terrorist activity, he/she would have received a more specific medal for such service.

NEED PTSD DBQ:

for deferral: An Initial PTSD DBQ is warranted. *See Claim Notes for details.

for Claim Note: Claim is not RFD. The veteran served in the Army in Vietnam, indicating he was in a location that would involve “hostile military or terrorist activity.” An Initial PTSD DBQ is warranted. 3.304(f)(3), III.iv.4.O.3.d. Deferral done.

How to enter in Exam Request Builder (ERB):In description box, put veteran’s reports, plus *one of the below statements:

Select “Service connection w/o MO”:

We do NOT need a medical opinion (do NOT select “Direct MO”), as the link is addressed in the DBQ (usually under #4 / Criterion I):

Exam Request Builder (ERB) will generate:

The Veteran is claiming service connection for PTSD due to the claimed stressor of {add veteran’s reports

here PLUS *one of the below statements}. Please examine the Veteran for a chronic disability related to his or her claimed condition and indicate the current level of severity.

If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder.

If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event.

*The veteran is in receipt of a Vietnam Service Medal, indicating he was in a location that would involve “hostile military or terrorist activity.”

*The veteran served in the Army/Marines in Vietnam, indicating he was in a location that would involve “hostile military or terrorist activity.”

*The veteran is a combat veteran, in receipt of a Combat Action Ribbon.

*The veteran’s service in Kwuait and Iraq in 2003 is verified, indicating he was in a location that would involve “hostile military or terrorist activity.”

*The veteran's involvement in the evacuation in Lebanon in June 1976 is verified.

*The veteran’s involvement in the December 2004 Indian Ocean/South Asia/Indonesian tsunami rescue efforts is verified. – Indonesia, Sri Lanka, India, Thailand, Maldives, Somalia, Malasia, Myanmar

Operation Restore Hope, Mogadishu, Somalia 12/8/92 to March 1993; http://www.history.army.mil/html/documents/somalia/SomaliaAAR.pdf, p5-8

Operation Continue Hope 3/93-3/94, p8-14

III.iv.3.D.2.h.The following credentialed mental health professionals are qualified to perform initial C&P mental disorder examinations:

board-certified or board-eligible psychiatrists licensed doctorate-level psychologists, or the following other mental health professionals, under the close supervision of a board-certified or board-

eligible psychiatrist or licensed doctorate-level psychologist: o doctorate-level mental health providerso psychiatry residents, ando clinical or counseling psychologists completing a one-year internship or residency.

Note:  “Close supervision” means that the supervising psychiatrist or psychologist met with the Veteran and conferred with the examining mental health professional in providing the diagnosis and the final assessment.  The supervising psychiatrist or psychologist must co-sign the examination report. 

Important:  For a claim for posttraumatic stress disorder (PTSD) based upon a stressor related to the Veteran’s fear of hostile military or terrorist activity, 38 CFR 3.304(f)(3) directs that the examination must be conducted by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted.

Reference:  For more information on the qualifications of examiners for specific examinations, to include initial mental disorders examinations, PTSD, and eating disorders, see DBQ Switchboard.

VA policy says the following credentialed mental health professionals are qualified to perform initial mental disorder examinations: board-certified or board-eligible psychiatrists; licensed doctorate-level psychologists; doctorate-level mental health providers, psychiatry residents and clinical or counseling psychologists completing a one-year internship or residency under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.

III.iv.3.D.2.i.

The following credentialed mental health professionals are qualified to perform C&P mental disorder review examinations or examinations in claims for increased evaluations of service-connected (SC) mental disorders:

mental health professionals qualified to perform initial mental disorder examinations per M21-1, Part III, Subpart iv, 3.D.2.h, or

other mental health professional under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist, including

o licensed clinical social workerso nurse practitionerso clinical nurse specialists, ando physician assistants.

Reference:  For more information on the qualifications of examiners for review examinations for PTSD, see the PTSD DBQ in the DBQ Switchboard.

VA policy says the following credentialed mental health professionals are qualified to perform review mental disorder examinations: board-certified or board-eligible psychiatrists; licensed doctorate-level psychologists; doctorate-level mental health providers, psychiatry residents, clinical or counseling psychologists completing a one-year internship or residency, licensed clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.

Older References: Mauerhan, 16/436 - NP rating criteria symptoms are not exhaustive list - “such as”

Moore v. Derwinski, 1 Vet.App. 356, 358 (1991) -GAF scores @ 15

Moreau v. Brown (9/12/96) - PTSD examiner cannot rely on vet's stmt to establish the occurrence of the stressor. Vet's own statement is NOT "credible supportive evidence" (must be independent evid to be 'supportive'). Vet's stmt does not become credible because Examiner repeats it.

Gaines v. West (8/6/98) – combat v. non-combat MOS

Fossie v. West (10/30/98) - stressors for non combat veteran are too vague to send to ESG

Pentecost v. Principi 16/124 (2002) - stressor is corroborated by a preponderance of the evidence; if veteran was at Danang when it was documented there had been rocket attacks, it is not necessary to document the veterans proximity to the point of attack

10/29/08 change to 3.304(f) - if the evidence shows that the veteran's PTSD was diagnosed during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor.

November 2008 Compensation Service Bulletin (CSB) – reiterates elimination of requirement for evidence corroborating the occurrence of a claimed in-service stressor if PTSD is diagnosed in service, new 3.304(f)

More Recent References:: March 2010 Compensation Service Bulletin (CSB) –

“V” Device Combat Awards in PTSD CasesIn claims for posttraumatic stress disorder, per 38 CFR 3.304(f)(2), sufficient evidence that the Veteran “engaged in combat with the enemy” can establish the occurrence of a stressor related to that combat with the Veteran’s lay statement alone. Combat participation may be established when the Veteran has received a combat decoration or award, such as those listed in M21-1 Manual Rewrite (MR) IV.ii.1.D.13.d. When a “V” device for valor is attached to an individual award, it is generally accepted as proof of the Veteran’s combat participation. However, when the “V” device is attached to a unit award, such as the Air Force Outstanding Unit Award, it does not necessarily indicate combat participation by an individual member of that unit. In addition, this award may go to a unit that supported combat activity rather than participated in combat activity. Therefore, although a unit award with “V” device may be credible evidence supporting a Veteran’s claimed stressor, it is not, by itself, sufficient to establish combat

participation.

Lionesses – Women in Combat - The Team Lioness program refers to women who serve in combat support missions. These Veterans have encountered difficulty receiving proper recognition for their combat support when seeking disability benefits or health care from the VA because of the lack of documentation on the DD Form 214 and other records. They have had to rely on an outside organization to provide the witnesses and documentation needed to establish their combat experience.

In August, the DoD issued instructions for uniform documentation of a member’s participation in contingency operations in Block 18a on DD Form 214s. This should provide VA with adequate information for development of claims involving combat and support of combat mission members. However, all women who have supported combat missions prior to these instructions need VA to help verify their combat service. Be aware that there are no limitations as to the type of evidence that may be accepted to confirm engagement in combat. Any evidence that is probative of (serves to establish the fact at issue) combat participation may be used to support a determination that a Veteran engaged in combat.

For more information see M21-1MR III.iv.4.O.29.b and IV.ii.1.D.13.c for a definition of "engaging in combat." Also, see M21-1MR III.iv.4.O.29 and IV.ii.1.D.13 on verifying combat service based on primary and secondary sources of evidence. For more information about the “Lionesses,” visit http://www.lionessthefilm.com.

3.304(f)(3) change eff 7/13/10, per July 2010 Compensation Service Bulletin (CSB)

States that a Veteran’s lay statement alone may establish stressor occurrence when the stressor: (1) relates to a fear of hostile military or terrorist activity; (2) is consistent with the places, types, and circumstances of the Veteran’s service; and (3) is determined by a VA psychiatrist or psychologist to be the cause of the Veteran’s current PTSD symptoms.

Applies to all claims received from the effective date of publication forward and all claims that were pending before the VA on the date of publication. Additionally it applies to Veterans of any period of service, not just the current conflicts in Iraq and Afghanistan.

Regional Office (RO) personnel must still determine whether the Veteran’s service is consistent with the places, types, and circumstances of hostile military or terrorist activity. This criterion could be met by service records showing service in any past or present area of hostile military or terrorist activity.

Once this is established, a VA PTSD examination should be scheduled. In these cases, there is no longer a requirement to establish the occurrence of the stressor before scheduling an examination as the threshold for scheduling is low. It will be up to VA examiners to determine whether the claimed stressor is the cause of the current symptoms and relates to a fear of hostile military or terrorist activity. Rating decisions will be based on the results of the PTSD examination report.

This new regulation applies only when the specified criteria are met. Other parts of § 3.304(f) will apply in PTSD claims based on combat status, former prisoner-of-war status, in-service diagnosis of PTSD, personal assault, or any other stressor unrelated to hostile military or terrorist activity. C&P Service has developed a training letter that will explain in detail this new regulation and its effect on PTSD claims.

We can use the date of claim for the effective date on any claim pending on 7/13/10.  We must use the new date of claim for any claim received on or after 7/13/10 (including those previously denied and final, as well as those previously denied but not yet final).

April 2011 Compensation Service Bulletin (CSB) – discussion of PTSD examinations in cases based on the new “fear” stressor regulation, VSM and/or VCM sufficient even for service aboard a ship offshore, or for service in Thailand

don’t use “PTSD-Combat – Fear-Easing Standard” or “PTSD-Non-Combat – Other Stressor Verification”

Can use:

PTSD – Combat Combat Medal or Other Stressor Verification

PTSD – Non-Combat Fear-Easing Standard or Stressful Event

From Geoff Sauer, 3/13/12 (reference is “straight from the TOP”) –

Question (1) : If the Veteran only states PTSD without associating the PTSD to fear of hostile military or terrorist activity, but is in receipt of the Campaign Medal or Vietnam Service Medal, are we required to wait for the veteran to provide a stressor statement (or VA Form 21-0781), or should we proceed with scheduling an exam?

Answer: In the above question the Veterans' claim would follow the traditional development path for development of an in-service stressor. We would not schedule an exam without the verified stressor. M21-1MR IV.ii.D.13 (My Notes: I believe the reference is IV.ii.1.D.13)

Question (2): If the Veteran provides a statement indicating he was "in fear of hostile military terrorist activity" but provides no further elaboration (or VA Form 21-0781), but is in receipt of the Campaign Medal or Vietnam Service Medal, should we proceed with scheduling an exam?

Answer: Yes, the veterans statement and receipt of the Campaign Medal and/or Vietnam Service Medal is sufficient for us to order an exam. TL-10-5, M21-1MR IV.ii.1.D.13.g, Compensation Service Bulletin April 2011.

Per March 2012 Compensation Service Bulletin (CSB) & QRT Bulletin March 2012 - Non-PTSD mental disorders cannot be service-connected under 3.304(f), but need to use 3.303 and need to have the condition or proof of an “event” in service, plus a medical nexus between the diagnosis and the in-service condition/event [3.304(f) requires fear-related “stressor” not fear-related “event”].

July 2012 military sexual trauma (MST) Training - threshold for examination is LOW (& III.iv.4.O); McLendon v. Nicholson, 20 Vet.App. 79 (2006) - liberal approach to scheduling VA exam; Patton v. West, 1999 – served as basis for current personal assault regulations, two markers identified, says we don’t need an actual event in service, just marker/credible supporting evidence, many markers are possible and should not be viewed as normal behavior, but rather in the context of supporting the claim; always notify the veteran about alternative sources; includes active duty for training and drill weekends (per an unnamed FAQ); as of March 2012, according to the Privacy Act of 1974, we can request the “alleged” perpetrator’s or a buddy’s records (service personnel records or CAPRI records) in an attempt to corroborate the incident to adjudicate a claim for benefits; if veteran has diagnosis of another mental disorder (besides PTSD, cannot use markers, need an event (see above March references); never do a formal finding of lack of information required to corroborate stressor in personal trauma cases [can do a formal finding of Federal record unavailability if Federal records could not be obtained, but this should not mention the event/stressor/markers/etc]

April 2013 Compensation Service Bulletin (CSB) – The Veterans Benefits Administration (VBA) will amend 38 C.F.R. § 3.304(f) to clarify that service connection may be granted for PTSD when first manifesting in service and is related to a pre-service stressor.

Regional offices (ROs) may grant service connection for PTSD when first manifesting in service and related to a pre-service stressor under the 38 U.S.C. § 1110, which is the statute containing the general criteria for establishing service connection for a chronic disability.

When PTSD first manifests in service as the result of a pre-service stressor, do not cite 38 C.F.R. § 3.304(f) , as the current language of the regulation clearly limits establishing service connection for PTSD to an in-service stressor. See Arzio v. Shinseki, 602 F.3d 1343 (Fed. Cir. 2010). Also, reference to 38 C.F.R. § 3.303(a) should not be made in pre-service stressor PTSD claims. Accordingly, we are rescinding Fast Letter (FL) 99-85, Service Connection for Posttraumatic Stress Disorder (PTSD) diagnosed In-Service, which contains such instructions.

The existence of a pre-service stressor does not rebut the presumption of soundness under 38 U.S.C. § 1111 for a claim involving an in-service diagnosis of PTSD. The mere existence of a pre-service stressor is insufficient to clearly and unmistakably establish that PTSD existed prior to service and was not aggravated by such service.

IV.ii.1.D.1.g – Schedule an examination if there is evidence of a PTSD diagnosis or symptoms, and the Veteran’s DD Form 214, Certificate of Release or Discharge From Active Duty, or other service records, shows service in an area of potential hostile military or terrorist activity.

The receipt of military awards such as, but not limited to, the Vietnam Service or Campaign Medal, Kuwait Liberation Medal, Iraq Campaign Medal, and Afghanistan Campaign Medal is generally considered evidence of service in an area of potential hostile military or terrorist activity.

The receipt of military awards such as the National Defense Service Medal, Armed Forces Service Medal, and Global War on Terrorism (GWOT) Service Medal generally does not indicate service in locations that involve exposure to hostile military or terrorist activity, because these are general medals that do not denote service in a particular area or campaign. If the Veteran served in an area of potential hostile military or terrorist activity, he/she would have received a more specific medal for such service.

May 2014 Rating Quality Call Notes & July 2014 Rating Quality Call Notes– 38 CFR 3.304(f) applies only to a true diagnosis of post-traumatic stress disorder (see Arzio v Shinseki). Any other mental disorder diagnosis, including subtypes of PTSD, is only adjudicated under 38 CFR 3.303. For example, a DSM-5 diagnosis of “Other stress-related disorder” that has been attributed to “fear of hostile military and terrorist activity” is adjudicated under 38 CFR 3.303.

May 2014 Rating Quality Call Notes – Per the Arzio court decision, 38 CFR 3.304(f) applies only to Axis I diagnoses of PTSD. Any other Axis I mental disorder diagnosed is adjudicated under 38 CFR 3.303. “Other stress-related disorder” is not PTSD.

Trauma and Stress-Related Disorders in DSM-5 is saved at H:\VSC\Rating Reference (My Notes: Use 9499-9440 or 9499-9410)

other specified trauma/stressor-related disorder

other specified trauma-related disorder

other specified stressor-related disorder

other trauma-related disorder / other trauma related disorder

other stress-related disorder / other stress related disorder

July 2015 PTSD Training (John Trunick) –

Training documents are under H:\VSC\Training\NTC Class Material\PTSD RVSR_DRO_RQRS July 2015

III.iv.4.O – Mental Disorders Mittleider v. West (1998) - if it is not possible to differentiate the veteran’s symptoms between a service-

connected and NSC disability, the symptoms should be deemed related to the service-connected disability and rated accordingly

Allen v. Principi (2/2/01) – substance abuse can be secondary to or caused by (or a symptom of) a SC cond [& can grant diseases secondary to substance abuse (because the disease is really related to PTSD)]

Forcier v. Nicholson (1/25/06) – veteran did not have a diagnosis of PTSD, so there was no reasonable possibility that any further assistance in verifying the alleged in-service stressor (personal assault case) would aid in substantiating the claim; Court did criticize BVA’s speculations about misconduct and lack of aptitude

Buchanan v. Nicholson (6/14/06) – even if there is no treatment in service, buddy statements are credible & competent, they cannot be rejected unless biased, there is conflicting evidence, etc.; buddy statements should be weighed against the absence of medical records

McClain v. Nicholson (6/21/07) – even if diagnosis resolves by the time we make a decision, the Court said SC is warranted as long as it existed when a claim was pending

Clemons v. Shinseki (2/17/09) – also see discussion of case under Mental section

Arzio v. Shinseki (4/19/10) – The specifics of 3.304(f) take precedence over the general rule of 3.303 [if 3.304 is not met, then can’t meet 3.303]

also see STAR error reported in November 2010 & Weekly Q-Tip (6/12/15) for details/thoughts on disabilities vs. symptoms; but PowerPoint showed:

(1) FAQ, p54 - Regarding Clemons v. Shinseki & Arzio v. Shinseki, if a PTSD claim is pending and we receive an exam and can grant SC for anxiety disorder, PTSD does NOT have to be separately denied. Grant “anxiety disorder (claimed as PTSD).”

(2) FAQ, p55 - Per Mittleider v. West, if a veteran is 30% for PTSD, the exam shows new diagnoses & the examiner says they are not related to the PTSD, but it is not possible to separate the symptoms, use all the symptoms to evaluate PTSD but do not code the others as SC.

ERB has “If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder.”

(3) If the examiner provides multiple diagnoses & links them to PTSD, grant all (i.e. “PTSD with depression and alcohol abuse”).

(4) If the examiner provides multiple diagnoses, but there is no discussion or delineation of symptoms, DEFER & ask the examiner to discuss the relationship between mental conditions.

My Notes (thoughts) on Clemons:

o Veteran claims PTSD d/t fear. Diagnosis is generalized anxiety disorder (or any non-PTSD dx). Per Clemons, have claim for BOTH. Nothing in STRs & event cannot be verified. Need denial of both PTSD (no diagnosis)

& generalized anxiety disorder (“reasonably raised from claim for PTSD,” nothing in-service). And add one of these notes:

Rating Note: {Generalized anxiety disorder} is reasonably raised, per Clemons. There is no evidence of treatment for or complaints of mental symptoms in service and SC cannot be granted for {generalized anxiety disorder} based on 3.304(f), but rather has to be considered under 3.303. The reported “event” is not verified or verifiable.

OR

Rating Note: {Generalized anxiety disorder} is reasonably raised, per Clemons. There is no evidence of treatment for or complaints of mental symptoms in service and SC cannot be granted for {generalized anxiety disorder} based on 3.304(f), but rather has to be considered under 3.303. No further development is needed since {generalized anxiety disorder} was not linked to the reported stressor (i.e. "event" per 3.303) and the reported stressor is insufficient for a diagnosis of PTSD.

OR

Rating Note: {Generalized anxiety disorder} is reasonably raised, per Clemons, but is not being deferred since it was not specifically claimed. No further development is needed since {generalized anxiety disorder} was not linked to the reported stressor (i.e. "event" per 3.303) & the reported stressor is insufficient for a diagnosis of PTSD.

o Veteran claims PTSD d/t fear. Diagnosis is anxiety disorder (or any non-PTSD dx). Event IS verified. Grant of anxiety disorder (claimed as PTSD). Ref: PowerPoint for July 2015 PTSD training, per Clemons & Arzio & April 2011 Compensation Service Bulletin (CSB) *For combat veterans or those with a verified stressor, just need the opinion to link the non-PTSD diagnosis to the combat event or verified event in order to grant under 3.303. [see “Non-PTSD diagnosis & verified event” and “Non-PTSD diagnosis & verified combat veteran” under Free Text]

o Veteran claims PTSD d/t fear. No mental diagnosis is provided by the DBQ. Deny PTSD for no diagnosis & do not discuss alleged stressor. Ref: III.iv.4.O.6.i

o Veteran claims PTSD d/t fear. Diagnoses are PTSD & generalized anxiety disorder. Per Clemons, have claim for BOTH. PTSD can be granted, but generalized anxiety disorder was indicated to be separate from PTSD. It’s best to address generalized anxiety disorder in the PTSD issue narrative, indicating that it cannot be granted. It is not an error to deny it separately, but addressing it within the PTSD issue is most appropriate. If don’t deny separately, add a variation of one of these notes:

use this if symptoms were also differentiated:Rating Note: {} is/are not included in the PTSD evaluation, as the DBQ indicates those symptoms are related to {}, but {} is not linked to PTSD. Since PTSD is being granted, {} is not being inferred to be denied.

use this if symptoms were not differentiated:Rating Note: Since PTSD is being granted, {} is not being inferred to be denied.

*or see below for more notes…

My Notes (thoughts) on disabilities vs. symptoms (John Trunick agrees): If symptoms & impairment CAN be differentiated, don’t include the new diagnoses (or non-PTSD dx) w/PTSD unless the examiner independently says they’re related. And if the examiner CANNOT differentiate, include at least the symptoms, maybe also the diagnoses unless the examiner independently says they’re NOT related:

o Veteran is SC for PTSD & now has additional mental diagnoses, but the examiner says they are not related to PTSD (would have to be an independent statement from the examiner, as this is not actually included in the DBQ…), but CANNOT differentiate symptoms. Use all symptoms in PTSD eval (do not list additional mental diagnoses in name of disability). Ref: PowerPoint for July 2015 PTSD training, per Mittleider.

o Veteran is SC for PTSD & now has additional mental diagnoses, but the examiner does NOT say whether or not they are related to PTSD & CANNOT differentiate symptoms. Use all symptoms in PTSD eval (do not list additional mental diagnoses in name of disability).And add this note:

Rating Note: The examiner states the symptoms and impairment cannot be differentiated because the

symptoms overlap, but does not indicate if the mental diagnoses are related, so all mental symptoms are included in the PTSD evaluation, but the diagnosis of {generalized anxiety disorder} is not included in the disability name.

o Veteran is SC for PTSD & now has additional mental diagnoses, but the examiner does NOT say whether or not they are related to PTSD & DIFFERENTIATES the symptoms. Use only the PTSD symptoms in the PTSD eval. And add this note:

Rating Note: {} is/are not included in the PTSD evaluation, as the DBQ indicates those symptoms are related to {}, but {} is not linked to PTSD. Since PTSD is being granted, {} is not being inferred to be denied.

Rating Note: The DBQ also shows a diagnosis of {} with symptoms of {}, which are differentiated from the symptoms of PTSD, and are not listed under “5. Symptoms.” {} is not linked to PTSD, and since PTSD is being granted, {} is not being inferred to be denied.*It appears Clemons is mostly concerned with if we’re denying the claimed mental disorder. If we’re granting the claimed mental disorder, seems we do not need to infer to deny the other, unrelated diagnosis (but can do “claimed as…” if needed …

***See III.iv.4.O.1

o Veteran is SC for PTSD & now has additional mental diagnoses, which the examiner says are related to PTSD. Use all symptoms & add the diagnoses to the disability name. Ref: PowerPoint for July 2015 PTSD training.

o Veteran is SC for PTSD & now has additional mental diagnoses, but the examiner does NOT say whether or not they are related to PTSD & does NOT differentiate the symptoms. Defer for discussion of relationship between mental conditions (really the DBQ only asks for differentiation of symptoms under #3b and differentiation of impairment under #4b). Ref: PowerPoint for July 2015 PTSD training

o If other diagnosis is Alcohol Use Disorder & the DBQ provides no link, but differentiates symptoms & impairment, use below Rating Note:

Rating Note: Alcohol Use Disorder is not included with PTSD, as the DBQ does not link Alcohol Use Disorder to PTSD PTSD & the DBQ differentiates the symptoms & impairment.

Rating Note: The veteran claimed depression/major depression. The DBQ shows diagnoses of Unspecified Depressive Disorder and Social Anxiety Disorder. The examiner noted that the onset of the Social Anxiety Disorder was childhood. However, no mental symptoms/disabilities are listed on the 2/02 entrance / enlistment exam. The examiner differentiated the symptoms attributable to each diagnosis (depressed mood, anxiety, sense of failure and insomnia/chronic sleep impairment linked to Unspecified Depressive Disorder; fear of rejection and criticism and relationship issues/difficulty in establishing and maintaining effective work at social relationships to Social Anxiety Disorder), but could not differentiate what portion of the level of occupational and social impairment is attributable to each diagnosis without resorting to speculation. The medical opinion clearly links just the "mood changes" (i.e. depression) to service. Per Clemons, “any co-existing mental condition identified by the evidence(must) be considered and a determination of service connection be made.” Because (1) the examiner could not differentiate the level of occupational and social impairment, (2) there is no mention of social anxiety disorder on the 2/02 entrance / enlistment exam, (3) the VATRs show the veteran's reports that depression and anxiety began 8 years prior, and (4) the VATRs show some of the insomnia is reportedly linked to anxiety, Unspecified Depressive Disorder and Social Anxiety Disorder and considered intertwined.

Good for exam request: If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder.

o In-Service – 3.304(f)(1), III.iv.4.O.2, November 2008 Compensation Service Bulletin (CSB), April 2013 Compensation Service Bulletin (CSB)

o Combat – 3.304(f)(2)

o III.iv.4.O.3.b – “Engaging in combat with the enemy means personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such

events either as a combatant, or service member performing duty in support of combatants, such as providing medical care to the wounded.”

o Drone aircraft crew members - III.iv.4.O.3.a, III.iv.4.O.3.e, October 2014 Compensation Service Bulletin (CSB) says they’ve seen “extensive combat action”

o IV.ii.2.B.3.d – combat-related disabilities

o Fear – 3.304(f)(3)

o POW – 3.304(f)(4)

o Personal Assault – 3.304(f)(5) – per MUST notify the veteran about alternate sources of evidence (III.iv.4.O.3 says Personal Trauma), only need “marker,” not verification of event; need to list marker on exam request w/this sentence: Please provide an opinion as to whether the marker can be associated with occurrence of a stressor and, if so, whether current PTSD symptoms are related to that in-service stressor. (My Notes: III.iv.4.O.5.a says request opinion, but does not have that specific statement.)

o Non-Combat – many types, need more than veteran’s statement or repeating of veteran’s statement by MD or other person

o Can’t use fear under 3.304(f)(3) for any non-PTSD diagnosis, but per Clemons v. Shinseki (2/17/09) any “acquired psychiatric disability” = ALL MENTAL, so you have to address the other diagnosis somehow

My comments:

VA needs to make a distinction between "non-combat/personal trauma" & "personal assault or military sexual trauma (MST).” Using "personal trauma" for both (although the Manual does not do this, the training did) blurs the line.

We also should use "stressor" only for PTSD. If we're talking about a non-PTSD diagnosis, then we should use "event" rather than "stressor.”

VSRs rarely list stressors on exam requests.

Was John’s ariel photograph example non-combat or fear?

John says you may be able to grant PTSD due to death of a family member, is this non-combat? [can’t do fear based on learning of the death of another person when such death occurred remote from the veteran, see PowerPoint]

VA Pulse, https://www.vapulse.net/thread/7776, supports Clemons instead of Request for Application (RFA) if claim & diagnosis are different mental diagnoses, plus need to develop for stressor (probably should have said “event”) with non-PTSD diagnosis

Per Clemons, “any co-existing mental condition identified by the evidence (must) be considered and a determination of service connection be made.”*It appears Clemons is mostly concerned with if we’re denying the claimed mental disorder. If we’re granting the claimed mental disorder, seems we do not need to infer to deny the other, unrelated diagnosis…

From: VAVBASDC/RO/VSC Sent: Friday, March 10, 2017 2:49 PMSubject: FW: SD MST CoordinatorsGood Afternoon VSC,The following employees are assisting our office with MST claims.  We are providing the email for situational and operational awareness. Alishea Flores is the primary MST coordinator for the San Diego RO.  Ms. Jacque Hartz is now the alternate MST coordinator.The following VSRs are also assisting in the adjudication of MST claims:1. Nicolette Dominguez2. Karla Marmolejo3. Albert Arguilla (Male MST claims)4. Ann Newcomb (Pre-Discharge MST claims)ThanksVSC Front Office

From: VAVBASDC/RO/VSC Sent: Thursday, June 29, 2017 8:19 AMSubject: FW: Proper Procedures for Routing Claims Related to Military Sexual Trauma (Monthly Reminder)Good day,

As a reminder if you identify an assigned claim as MST related, you should discontinue processing, and forward the claim information to your Coach for routing to the appropriate party.  *You should not update the pending claim in any manner (avoid adding tracked item(s), updating Claim Status or Suspense Date, etc.), nor should you process any non-MST related contentions, as this may result in the claim being recalled to NWQ, without appropriate action being taken.  It is of the utmost importance that these highly sensitive claims are processed according to prescribed law.  If you have any questions on this matter, please contact your immediate supervisor.As a reminder, the San Diego Women’s Veteran Coordinator is Alishea Flores, CORE PRE Team 3, and the Male Veteran point of contact is Albert Arguilla, CORE PRE Team 2.*unclear if this is just for development, or for rating too.

February 2018 Quality Call Notes - Q # 1: Please clarify whether a virtual MST team is still a requirement or is the expectation that any RVSR who has had PTSD-MST training can rate the claim?A: ROs should establish VBMS assignment rules to ensure that MST claims are not routed to employees who have not yet completed the requisite MST training. ROs should ensure MST claims are routed to employees that have completed the PTSD-MST training.

Q # 2: Please clarify if markers can be used as alternative evidence in personal trauma claims not related to MST, as suggested by IV.ii.1.D.4.m - Problems Associated With Development in Claims Based on Personal Trauma.A: Yes that section of the manual is referring to personal trauma to include MST.

Q # 3: Please clarify what constitutes a “military setting.” Does the fact that the Veteran is in the military suffice? For example, if a military service member is walking down the street and is sexually assaulted by civilians, does this constitute as MST? (M21-1 IV.ii.1.D.4.a - General Information on Personal Trauma)A: If the Veteran is on active duty, it does not matter if he/she is off duty when the assault occurs. It would still constitute MST because the event occurred during active duty.

Useful websites for PTSD claims:

Combat Action Ribbon Recipients: https://www.manpower.usmc.mil/pls/apex/f?p=102:1:3777234332515950

Here is the direct site for casualties from Korea & Vietnam from the NARA website. You can search by state, home of record, alphabetically by name, etc.:http://www.archives.gov/research_room/research_topics/korea_&_vietnam_casualties.html

Air Force casualty information can be found at:http://www.afpc.r&olph.af.mil/sascasstats/search_for_deceased.asp

The Army publishes this list with links to cover every war period & many of the incidents where troops were deployed:http://www.cs.amedd.army.mil/history/battles.html

Verifying stressors aboard ship for Navy or even USMC is a challenge & the Naval Historical Center website can provide Ship’s Deck Logs to verify particular events. Providing a narrow time frame is good because some Logs can be lengthy--like if you wanted an entire months worth. This site is good to just print out & keep as a reference. A written request is required & can take as long as a CURR request (please see Agent Orange for who has deck logs):http://www.history.navy.mil/faqs/faq73-1.htmIV.ii.1.H.2.j

There is another site that is not a government site. It provides a quick way to find Vietnam casualties with, sometimes detailed information, involving the veteran’s death:http://www.thewall-usa.com/

VBMS-R System-Generated TextAll 3 choices below have these 2 paragraphs, plus No Diagnosis (PTSD) and No Link (PTSD) have additional reasons

Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred.

If the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, the Veteran's lay statement alone may establish the occurrence of the stressor. The available evidence is not sufficient to confirm that the Veteran actually engaged in combat with the enemy. Receipt of an award or medal related to combat or other documentation of combat has not been established. When determining whether to grant service connection for PTSD, VA considers all potential in-service stressors reported by the Veteran or raised by the evidence. The stressors can include combat, non-combat, fear of hostile military or terrorist activity, or personal assault. VA was unable to corroborate combat or any other in-service stressor.

No Combat Stressor (PTSD) - nothing additional

No Diagnosis (PTSD)

A diagnosis of posttraumatic stress disorder must meet all diagnostic criteria as stated in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The evidence does not show a confirmed diagnosis of posttraumatic stress disorder which would permit a finding of service connection.

No Link (PTSD)

The available medical evidence is insufficient to confirm a link between current symptoms and an in-service stressor.

also see MD3fear of hostile military or terrorist activity, July 13, 2010

denyptsdfear (need Long Form Narrative, per III.iv.6.C.7.a):

lay testimony stressor conceded & had VAE, but no dx (choose No Diagnosis and No Diagnosis (PTSD))- STRs PTSD_C You have reported {}/multiple stressors in {}/fear while serving in {}. Your lay testimony is adequate to establish occurrence of the claimed stressor. The claimed stressor is consistent with the places, types and circumstances of service in which fear of hostile military or terrorist activities is ongoing. The SPRs show {service in an area of hostile military or terrorist activity/you were in Bagdad, Iraq on this date.} OR Your DD214 verifies service in an area of hostile military or terrorist activity, as evidenced by your Iraq Campaign Medal/Afghanistan Campaign Medal/Vietnam Service Medal. NODX The VA examiner has not provided a current Axis I psychiatric diagnosis of PTSD that is directly related to {fear of hostile military or terrorist activity/this incident}. The VA examiner indicated that you do not have a diagnosis of PTSD that conforms to DSM-5 criteria, as your symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria.

not consistent with service, no dx & no link- NIS STRs PTSD_NC You have reported {}. The STRs, SPRs and DD214 do not show any in-service stressor. We do not have evidence {that you are a combat veteran or} that you served in an area in which fear of hostile military or terrorist activities is ongoing. {You did not return the PTSD questionnaire with the details we requested. OR Your lay testimony is not consistent with the places, types and circumstances of your service.} {The treatment records show multiple reported stressors, including pre-service and post-service stressors.} NODX NONEX There is no confirmed diagnosis of post traumatic stress disorder with a link to a consistent in-service stressor.

combat veteran, but no dx (choose No Diagnosis and No Diagnosis (PTSD))- STRs PTSD_C You are a combat veteran in receipt of a {}. NODX The VA examiner has not provided a current Axis I psychiatric diagnosis of post traumatic stress disorder that is directly related to your combat service. The VA examiner indicated that you do not have a diagnosis of PTSD that conforms to DSM-5 criteria, as your symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria.

denyptsd (can also use for fear, if have vague stressor)-

unknown stressor - no details from veteran/no medal/peacetime veteran, nothing in STRs or 201, no dx & no link:

NIS STRs PTSD_NC The STRs, SPRs and DD214 do not show any in-service stressor. You did not return the PTSD questionnaire or provide any lay testimony to establish occurrence of an in-service stressor. NODX NONEX There is no confirmed diagnosis of post traumatic stress disorder with a link to a consistent in-service stressor.

MST (no need for Memo) (need Long Form Narrative, per III.iv.6.C.7.a, does not say need for other personal trauma denials, just MST):

Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. The evidence does not show an event, disease or injury in service. Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.

NIS STRs You did not return the PTSD questionnaire. The STRs and SPRs show no credible supporting evidence that would establish reasonable doubt and allow us to concede that you were, in fact, assaulted. {The SPRs only shows that you were repeatedly disciplined throughout your military service}. There is no confirmed diagnosis of post traumatic stress disorder with a link to a confirmed in-service stressor. NODX The VA examiner has not provided a current Axis I psychiatric diagnosis of PTSD that is directly related to {fear of hostile military or terrorist activity/this incident}. The VA examiner indicated that you do not have a diagnosis of PTSD that conforms to DSM-5 criteria, as your symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria.

USE VBMS-R System-Generated Text or:"Credible supporting evidence that the claimed in-service stressor occurred" means that there is a legal standard that must be met and that the veteran's report of the incident must be supported by service or civilian documentation of the incident, or if that is not available, there must be other evidence that would lead to the reasonable conclusion that the incident occurred. Such other evidence would generally include military or civilian documentation of behavioral changes after the incident which could reasonably be expected from a person who had undergone a personal assault. Such changes include, but are not limited to: sudden requests for other duty assignments without justification, obsessive behavior (such as over, or under, eating), increased disrespect for military or civilian authority etc.

MST w/non-PTSD diagnosis, choose no credible stressor, keep VBMS-R System-Generated Text, then add:However, service connection for a non-PTSD diagnosis, like {diagnosis on DBQ}, is different than service connection for PTSD, as it requires a verified in-service event.

NIS STRs There is no confirmed diagnosis of post traumatic stress disorder with a link to a confirmed in-service stressor. The Initial PTSD DBQ does not show an Axis I psychiatric diagnosis of PTSD, but rather shows a diagnosis of {diagnosis on DBQ}. The STRs and SPRs show no verification of the reported event.

GAF RATING SCHEDULE

0-10 - Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

11-20 - Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).

21-30 - Behavior is considerable influenced by delusions or hallucinations OR serious impairment in communication of judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).

31-40 - Some impairment in reality testing or communication ( e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family, relations, judgment thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work, child frequently beats up younger children, is defiant home and is failing at school.

41-50 - Serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job.)

51-60 - Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

61-70 - Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social occupation, school functioning (e.g., occasional truancy, or theft with the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

71-80 - If symptoms are present, they are transient and expectable reaction to psychosocial stressor, (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

81-90 - Absent or minimal symptoms (e.g., mild anxiety before and exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

91-100 - Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or hers many positive qualities. No symptoms.

Total occupational and social impairment...100

Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood...70

Occupational and social impairment with reduced reliability and productivity...50

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)…30

Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication...10

A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication...0

1702

IX.ii.2.5 3.384 – Psychosis

Note: We should not grant treatment under 1702 for personality disorders, or willful misconduct such as alcohol abuse or drug/cannabis abuse. Note added to IX.ii.2.5.c on 2/18/18 says “Gulf War Veterans who manifest primary diagnoses of substance abuse disorders within the applicable timeframes described above will be entitled to mental health treatment for those disorders under 38 U.S.C. 1702 even though the laws administered by VA prohibit awards of monetary benefits for conditions of misconduct etiology.”

Don’t consider 1702 for personality disorder, as it is not subject to service connection, even if given an Axis I diagnosis (see 3.303(c) & 4.9 & 4.127 - personality disorder is not a disease for compensation purposes)

QRT Bulletin August 2012 & Q&A Session emphasized that it says “within two years after discharge or release from military service”

December 2012 Compensation Service Bulletin (CSB) – NO LONGER INFER TO DENY (need to ensure previous decisions did not miss an entitlement grant; grant only needs to be addressed once)

TR1 & 1702?

HISTORIC PART 4 SECTIONS can be found in Rating References ARCHIVEor at Regulation Citator at http://vacoappbva2.dva.va.gov; or in CPKM

Improvement, Future Examinations (Routine Future Examination / RFE) and Reductions –

VE2

3.327 Reexaminations – 3.327(b)(2) Do not request reexaminations in cases when: the disability is static there is no material improvement for five+ years disability is permanent, without likelihood of imrprovement the veteran is over 55 years of age (except in unusual circumstances) – per III.iv.3.B.2.d, changed 12/19/17,

need to explain unusual facts found in the Special Notation box (or as a VBMS note, if no rating is being prepared)

the evaluation is the prescribed schedular minimum (My Notes: This refers to DCs that have “Minimum” or “Minimum rating” listed, like 5054, 5055, 6029, 7018, see My Notes on next page for entire list.)

the combined evaluation would not change even if the reexamination resulted in a reduced evaluation for one or more disabilities

III.iv.3.B.2.b – RFEs ONLY when absolutely necessary (if it’s an acute exacerbation, still recuperating following hospitalization and/or improvement/recovery can be anticipated)

III.iv.3.B.2.c - RFE – 5 3 years from date of rating; then if improvement is shown, another future 18, 24, or 30 months from the date of the new rating; (5/5/17, this is a change) – 3 years for anticipated improvement (III.iv.3.B.2.i says we need to correct dates on codesheet/Master Record even if reviewing unrelated claim); 18, 24 or 30 months to monitor for sustained improvement; 6-12 months for 4.28; within 6 months for 4.129; 6 months after treatment for malignancy stops (5012 – 1 year, 8002 or 8021 – 2 years); mandatory as established by regs

III.iv.3.B.2.d – NO RFEs when: the disability is static, without material improvement over 5 years (this combines I & ii from 3.327(b)(2)) the disability is permanent in character and of such nature that there is no likelihood of improvement the veteran is over 55 years of age (except under circumstances that are required by regulation, such as

convalcence after surgery), changed 12/19/17 to say - (except under unusual circumstances or where required by regulation)

the evaluation is the prescribed schedular minimum within its diagnostic code (My Notes: This refers to DCs that have “Minimum” or “Minimum rating” listed, like 5054, 5055, 6029, 7018, 8002, 8017, 8018, see My Notes on next page for entire list.)

the evaluation is 10 percent or less (My Notes: This is not listed under 3.327(b)(2)) the combined evaluation would not change even if the reexamination resulted in a reduced evaluation for

one or more disabilities

Rating Note: The {date} RFE has been cancelled for {disability} because III.iv.3.B.2.d says we are not to do RFEs if the evaluation is 10 percent or less.

III.iv.3.B.2.e – table on if over 55 years of age (consider age at time of RFE, do not schedule RFE if 55 when 810 expires, delete RFE from codesheet/Master Record even if reviewing unrelated claim; per CO, grant Ch35/DEA, if applicable, effective the date of review, based on difference of opinion)

Rating Note: The {date} RFE for {disability} has been cancelled, per III.iv.3.B.2.e, because the veteran {is age 55 or older / will be age 55 or older by the time the RFE is conducted} and there are no specific regulations requiring an RFE, nor any unusual circumstances involved in this case.

III.iv.3.B.2.i – changing RFEs from 5 years to 3 years, or cancelling them

Rating Note: The {date} RFE for {disability} has been {changed to {}, per III.iv.3.B.2.i / cancelled, per III.iv.3.B.2.i, because it was not warranted per III.iv.3.B.2.a & III.iv.3.B.2.b}.

Rating Note: The {date} RFE for {disability} has been cancelled because the combined evaluation would no longer change even if the reexamination resulted in a reduced evaluation, per III.iv.3.B.2.d.

Rating Note: The {date} RFE for {disability} has been changed to an At Once exam, per III.iv.3.B.2.i, as the prior RD is more than three years old and the RFE needs to be conducted now.

III.iv.3.B.2.l as of 3/18/16, says “If it is determined that a future examination should be canceled and … the disability for which the review examination was requested is not totally disabling, prepare a rating decision

establishing permanence”; as of 12/19/17, says “If it is determined that a future examination should be canceled and the Veteran’s combined evaluation reflects total disability (100% schedular or IU), then prepare a rating decision establishing permanence by awarding (DEA/Ch35).” AND “If it is determined that a future examination should be canceled and the Veteran’s combined evaluation does not reflect total disability, then prepare a rating decision establishing permanence by confirming and continuing the existing evaluation of any disability for which review examination was originally scheduled, and identifying the disability(ies) as static, warting no additional or future examination.”

III.iv.3.D.5.a – if an RFE shows worsening, increase from date of exam

III.iv.3.D.5.b – if an RFE shows additional residual / complication / secondary disabilities (per Part 4 or other official guidance) or surgical scar, grant SC from date of exam; if medical evidence says it’s related but it’s not a common complication / residual / secondary disability (per Part 4 or other official guidance), solicit claim [but if veteran says they want SC at the exam, it’s an RFA]

III.iv.5.B.3 IV.ii.8.D.1 Mandatory Routine Future Exams by Diagnostic Code

RFE in 2yrs6701670267036704672167226723672480028021

RFE in 1yr50015012601063046311651567306731673270197331735175057525753177107811

RFE in 6mos5327532960146208630063016302630463056306630763086317681970117016711071117123734375287627770277037709771577167818783379147919800080078008800980118012801980208540

My Notes:

Under 3.327(b)(2), the phrase "the evaluation is the prescribed schedular minimum" refers to the "Minimum rating" under: 5051 to 5056, ALL prosthetic implants - 20% or 30% 6029, aphakia - 30% 7018, implantable cardiac pacemakers - 10% 7019, cardiac transplantation - 30% *Note that under the old cardiac regulations (prior to 1998), 30% was

the minimum rating after a heart attack. 7500, removal of one kidney - 30% *If there is nephritis, infection or pathology of the other kidney, rate as

renal dysfunction, but the minimum is still 30%. 8000, chronic epidemic encephalitis (10% if there are ascertainable residuals) 8002, malignant brain growths - 30% 8003, benign brain growths (10% if there are ascertainable residuals) 8004, paralysis agitans - 30% 8007 to 8009, strokes (10% if there are ascertainable residuals) 8010, myelitis - 10% 8011, anterior poliomyelitis (10% if there are ascertainable residuals) 8012, hematomyelia (10% if there are ascertainable residuals) 8017, ALS - 100% 8018, MS - 30% 8019, epidemic cerebrospinal meningitis (10% if there are ascertainable residuals) 8020, brain abscess (10% if there are ascertainable residuals) 8021, malignant spinal cord growths - 30% 8022, benign spinal cord growths (10% if there are ascertainable residuals) 8023, progressive muscular atrophy - 30% 8024, syringomyelia - 30% 8025, myasthenia gravis - 30% Please note that the 10% evaluations under some of the organic disease of the nervous system are only allowed if there are ascertainable residuals. 

These prescribed schedular minimums should never have a routine future examination / RFE, as we would never reduce.

September 2014, Rich Osborne (Comp Service Quality Review & ConsistencyTeam) : Routine future exams / RFEs – Age (specifically youth) is not a factor We should only be doing futures if we evidence the disability might improve or evidence of improvement We will almost always get routine future exams / RFEs for prostate cancer (6 months to 1 year out) unless

they’ve been doing no treatment/watchful waiting for an extended period, or they are on hormones and do not plan to do surgery, then might be able to make them permanent.

“L2: Restore Disability Ratings Following Hospitalization/Convalescence: T1: Rate Claims Following Hospitalization/Convalescence” training in TMS says:

Less Than Five Years - Decreases to disability evaluations when an evaluation has been in effect for less than five years may be done provided there is sufficient medical evidence demonstrating improvement of the condition warranting the decrease. Review 38 CFR 3.327(b)(1) for additional information.

Between Five and Twenty YearsIf a disability evaluation has been in effect more than five years, but less than twenty years, you may decrease the evaluation if improvement is sustained. However, you may not reduce based on the medical evidence from one exam. In these situations, you must continue the evaluation regardless of the examination results and schedule a future exam in 18, 24, or 30 months to determine if improvement is sustained. At this point, if the medical evidence still supports the decrease, you may take action to reduce. Review 38 CFR 3.327(b)(2)(ii) and 38 CFR 3.344 for additional information.

Beyond Twenty Years

Disability evaluations that have remained unchanged for over twenty years are considered "protected" and cannot be decreased regardless of medical evidence provided, unless there is evidence of fraud. Note that if a protected disability evaluation is increased after twenty years, only the lower disability evaluation remains protected against decreases in evaluation. Review 38 CFR 3.951(b) for additional information.

Other ConsiderationsYou should not make drastic (i.e., more than one rating percentage increment) reductions in rating evaluations at any given time for Posttraumatic Stress Disorder (PTSD) and other mental health disabilities, if a reduction to an intermediate rate is more in agreement with the degree of disability. For example, a Veteran that is 70% service-connected for PTSD could not be reduced beyond one increment (50%) regardless of the medical evidence provided. Review M21-1MR, Part III, Subpart IV, Chapter 4, Section H, 27(b) for additional information.

March 2016 Quality Call Notes – If routine future was not done on cancer, but remission shown in TRs, get DBQ & rate on residuals

Per QRT/Melvin Moore, 7/27/16 – can remove inappropriate routine future exams / RFEs (even if not rating that issue) [also said if at eval for 5 years & exam shows improvement, we aren’t required to schedule another exam; see III.iv.3.B.2.l for actions needed

Per QRT/Carlos Rosario, 8/24/16 – if 810 diary incorrect, 310 established incorrectly & RFE requested incorrectly (veteran already P&T w/Ch. 35 granted), can cancel the 310 (even with exam results on file) [inside the 310, click on “Go to Work Item”; under Actions drop-down, choose Complete Work Item; Claim State: CANCELLED; Reason: Established in error; make a Permanent Note that:

The 810 diary should have been cleared when the {} RD removed the future exam and granted Ch. 35. The 310 was established & RFE requested in error. No action needed, per QRT, even though we have the RFE results on file.

May 2017 Quality Call Notes –

Questions: If a RFE was conducted and shows improvement, but the evaluation is in effect for more than 5 years, and the Veteran is over 55 years old, are we required to schedule another RFE (under 3.344b) or not (under 3.327b)?Veteran submitted a claim for increase for a condition, and the examination shows improvement. The evaluation has been in effect over 5 years. 3.327 indicates to not reexam if Veteran is over 55 or if the combined evaluation does not change, while 3.344 notes to schedule another RFE. Which CFR applies?An evaluation has been in effect more than 5 years. We receive a review exam which shows improvement. Veteran will be 55 years old in one year. Should or shouldn’t we schedule another examination in 18/24/30 months? Just let the improvement go without action since the Veteran will be 55 by time we get another exam?38 CFR 3.327 provides the general regulatory standard for determining whether further reexamination is or is not appropriate, whereas 38 CFR 3.344 addresses factors associated with disability evaluation stabilization, including the potential need for multiple examinations to ensure improvement in certain situations. The former reference indicates that periodic reexaminations should not, under normal circumstances, be requested in cases of Veterans over 55 years of age; it makes no effort to differentiate between initial routine future examinations and reexaminations requested in the interest of substantiating sustained improvement. Therefore, in instances where one examination portrays improvement in the evaluation of a Veteran who has reached age 55 (or will have reached age 55 by the time a prospective reexamination is carried out), notwithstanding any other specific requirement in the VASRD, reexamination should not be conducted.

Question: In instances where the initial RFE is requested prematurely (before the 3 years, or previously 5 years standard) and the examination shows improvement, should a reduction still be adjudicated although it was requested too soon?Answer: The fact that a reexamination was ill-timed or prematurely scheduled bears no impact on the corresponding report’s evidentiary or probative value. Once an examination is conducted and demonstrates improvement in a service-connected disability, it becomes an indelible entry in the evidentiary record and must be considered in the context of M21-1, Part III, Subpart iv, 8.D.1.b and 38 CFR 3.344(c). If a reduced evaluation is in order, rating action should be taken to implement it.

IX.ii.2.1.m & IX.ii.2.1.n – effective date is date of exam establishing permanency (i.e. no routine future exam / RFE was ordered), or date new evidence warranting cancellation of routine future exam / RFE, or date of review when a routine future exam / RFE was cancelled, or

Rating Note: Per IX.ii.2.1.n, the examination control was set up in error (veteran was over 55 years of age at the time of the prior RD, and there were no unusual circumstances involved in the case), so the date of P&T disability is as if the future examination control was never established.

Rating Note: Per IX.ii.2.1.n, there is a difference in judgment in the examination control, so the date of P&T disability is the date of review (i.e. the date of this rating).

Rating Note: Per IX.ii.2.1.n, there is new evidence that changes the prior assessment, so the date of P&T disability is the date the new evidence was received.

From: VAVBASDC/RO/VSC Sent: Monday, June 11, 2018 11:09 AMSubject: FW: Q-Tip: Determining the Need for Review Examinations

Attention all DROs/RVSRs:

Please review the attached synopsis for determining the need for review examinations. 

Question: Is a future/review examination required or necessary when granting or evaluating the service-connected condition?

Answer: Central Office has concerns with the amount of future examinations created by San Diego VA Regional Office (along with other offices across the country). During Central Office last visit to San Diego, they emphasized to schedule future/routine examinations only when necessary.

Recent Trend Analysis show San Diego RO continues to schedule a large number of unnecessary future/review examinations.

M21-1 III.iv.3.B.2.a. state to request a review examination whenever: there is a need to verify either the continued existence or the current severity of a disability it is likely that a disability has improved evidence indicates there has been a material change in a disability the current rating may be incorrect, or it is otherwise required by the regulation or diagnostic code (DC) under which the Veteran is service

connected.Note: Do not request a review examination solely to confirm evidence listed in 38 CFR 3.326(b) and (c) that is otherwise adequate for rating.

M21-1 III.iv.3.B.2.b. states:Exercise prudent judgment and refer to 38 CFR 3.327(b) in determining the need for review examination. It is the policy of VBA to request future examinations only when absolutely necessary, and every effort should be made to limit cases where future examinations are requested. Consider whether: the Veteran’s current condition is an acute exacerbation the Veteran is still recuperating following hospitalization, and improvement or recovery can be anticipated.

M21-1 III.iv.3.B.2.c. provides examples of when a routine future examination is appropriate: monitor for anticipated improvement in an SC disability (in 3 years) monitor for evidence of sustained improvement (in 18, 24, or 30 months) reevaluation of pre-stabilization ratings under 4.28 (6-12 months) evaluate post-therapeutic residuals of malignancies (6 months following cessation of treatment – ** there

are exceptions which would warrant a date of more than 6 months)

M21-1 III.iv.3.2.d. (My Notes: It’s III.iv.3.B.2.d) states not to request future reexaminations in cases when: the disability is static, without material improvement over five years the disability is permanent in character and of such nature that there is no likelihood of improvement the Veteran is over 55 years of age (except under circumstances where required by regulation, such as

convalescence after surgery.) the evaluation is the prescribed schedular minimum within its diagnostic code the evaluation is 10 percent or less, or the combined evaluation would not change even if the reexamination resulted in a reduced evaluation for

one or more disabilities.

Important:  When deciding if a disability is static or not, only order a future examination if there is objective evidence stating clearly a disability is likely to improve.

Ref: 38 CFR 3.327 and M21-1 III.iv.3.B.2.a-d.

3.330 Resumption of rating when veteran subsequently reports for Department of Veterans Affairs examination

3.344 Stabilization of disability evaluations – III.iv.3.B & III.iv.8.D(c) says “paragraphs (a) and (b)… apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.”

Rating Note: 3.344c says disabilities which have not become stablized & are likely to improve (not at level for 5 years) warrant reduction in rating if reexam shows improvement.

(a) [as above, only applies to ratings 5+ years] says be careful that the exam is full/complete/sufficient and improvement will be maintained under the ordinary conds of life; and do not reduce on one exam if (1) disease is subject to temporary/episodic improvement (bipolar, psychosis, epilepsy, ASHD, asthma, ulcer, skin, etc), or (2) disease improves with rest (phlebitis, ASHD, etc)

(b) [as above, only applies to ratings 5+ years] says if doubt remains, reexamine in 18, 24 or 30 months

Schafrath v. Derwinski, 1 Vet. App. 589 (1991) – reductions must be based upon review of the entire history of the veteran’s disability.

Lehman v. Derwinski, 1 Vet. App. 339 (1991) - unless all the evidence of record establishes that a claimant's condition has undergone sustained material improvement, a total disability rating that has existed for five years or more may not be reduced on any one examination (the 5-year requirement is a guideline)

Hohol v. Derwinski, 2 Vet. App. 169 (1992) - If the symptoms improved because of rest, and not under the ordinary conditions of life... a veteran's total disability cannot be reduced until “reexamination after a period of employment (3 to 6 months).”

Dofflemyer v. Derwinski 2 Vet. App. 277 (1992) – similar to Hohol above

Rossiello v. Principi, 3 Vet. App. 430 (1992) - rating reductions in general (3.343 and/or 3.344), are not applicable where the reduction is mandated by expiration of a time period set forth in the rating schedule

Murincsak v. Derwinski (4/24/92) - reductions in 100% evaluation under 3.344 and 3.343

Brown v. Brown, 5 Vet.App. 413, 421 (1993) - a rating reduction cannot be made effective for a minimum of 120 days after it is proposed in writing to the veteran, and also reiterates need for review of the entire record

Olson v. Brown, 5 Vet.App. 430 (1993) - failure to apply 3.344 equals CUE

Ternus v. Brown, 6 Vet.App. 370, 376 (1994) - failure to apply 3.344 equals CUE

Kitchens v. Brown, 7 Vet.App. 320, 325 (1/19/95) - a reduction that is not in accordance with 3.344 is a CUE, and where there is doubt of whether a veteran’s condition has materially improved, the rating should be continued pending reexamination

Hayes v. Brown (1996) – VA bears the burden of proof in reduction cases, if there is any doubt, continue the rating & reexamine in 18, 24 or 30 months

Faust v. West, 13 Vet. App. 342 (2000) - can use nonmedical evidence for reductions, so if a veteran is getting IU and an examiner only notes increased income, but does not see any changes in the veteran’s condition, that is sufficient to support a rating reduction. However, need to show “actual employability,” not just actual employment (substantially gainful employment), see 3.343

Sorakubo v. Principi, 16 Vet. App. 120 (2002) - failure to apply 3.344 equals CUE

O’Connell v. Nicholson, 21 Vet. App. 89 (2007) - 3.105(e) does not apply in the context of the assignment of a staged rating where the veteran’s disability rating is not reduced, for any period of time, to a level below what was in effect previously, as not considered a reduction in evaluation

Stelzel v. Mansfield, 508 F.3d 1345 (2007) – no need to propose if compensation not reduced

Reizenstein v. Peake, 22 Vet.App. 202 (2008) – staged ratings do not need an examination showing material improvement

III.iv.8.D.1.e – do not need to propose to reduce under 3.105(e) on initial staged ratings (example is cancer in

remission)

III.iv.8.D.1.f – example of reduction not affecting combined evaluation, so do not need to propose to reduce

3.655 Failure to report for Department of Veterans Affairs examination – FTR for RFE - Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc.

proposereduc - proposed reduction

3.655 / FTR for reexamination / FTR for RFE – please note that this is different than 3.105(e)Go straight to the Disability Decision Information (DDI) – manual entry screen, choose “Stage,” choose “Decrease Issue,” add new percentage (with no date) & choose “Proposed Reduction under 38 CFR 3.655(c)(2),” then probably select “Static Disability (No Exam)”

III.iv.8.E.1.c – RD must address lack of good cause or lack of reason for FTR (My Notes: III.iv.8.E.16 used to say good cause includes, but is not limited to: illness or hospitalization of the claimant, serious illness or death of an immediate family member, weather related impediments, or a previously scheduled/paid for commitment such as a vacation)

IV.ii.3.B / IV.ii.3.B.1 – 3.655 – Failure to report for Review Examination – good cause includes, but is not limited to: illness or hospitalization of the claimant, death of a family memberIV.ii.3.B.2 – RSVP

if FTRSVP for RFE:maybe use Special Determination Requested & date rating is completedfor Evidence: Report of inability to contact you to schedule VA examination (RSVP), received {}

Intro: We have received notice that you failed to report for a reexamination scheduled for {}.

Reasons for Decision:use VBMS-R System-Generated Text

FTROR if FTRSVP for RFE: We have been informed that you did not respond to attempts to schedule a VA examination in support of your claim. As a result, medical evidence that could have been used to support your claim was not available to us. Please notify us when you are ready to report for an examination, or you may submit a DBQ which must be completed and signed by a physician.

A continued evaluation of {} percent is not warranted because the evidence does not show:[add Eval Builder info for current evaluation]

If the proposed reduction takes effect, your combined evaluation will be {} percent.If proposing to reduce multiple issues: If the proposed reductions take effect, your combined evaluation will be {} percent.

IV.ii.3.B.3.c says notification must include when discontinued/reduced payment will be effective, so probably best to include this in narrative:As this is a proposed action, you will have 60-days from the date of this notification letter to provide additional evidence to support why this action should not be taken or request a hearing. If we do not receive a request for a hearing or additional evidence supporting the continued evaluation or entitlement to service connection for this condition, a new rating will be sent finalizing this proposed rating. The effective date assigned will be the first of the month following 60-days from the date of the proposed action notification letter, or the date of last payment, whichever is later.*verbiage in italics added from paragraph above for 3.105(e)

November 2017 Quality Call Notes - When proposing a reduction/discontinuance under 38 CFR 3.655, for Failure to Report (FTR) for a Routine Future Exam (RFE), the notification letter should provide a proposed effective date of reduction which is the first of the month following 60 days from the letter. For example, if sending the notification letter on 11/1/17, the proposed effective date should be 2/1/18. If the Veteran does not

respond, the final rating assigns an effective date which is the date of last payment (or the date communicated in the predetermination notice, whichever is later). See M21-1 Part III.iv.8.E.1 and M21-1 Part IV.ii.3.B.VSR: This is a proposed reduction under 3.655. Per III.iv.8.E.1, IV.ii.3.B & November 2017 Quality Call Notes, the notification letter should provide a proposed effective date of reduction which is the first of the month following 60 days from the letter.

III.iv.8.D.4.a – procedures for addressing individual unemployability when a schedular 100-percent evaluation is proposed to be reduced

Reductions (need Long Form Narrative, per III.iv.6.C.7.a; also, ensure correct proposal was done, either 3.105(e) or 3.655):III.iv.8.D

3.655 / FTR for reexamination / FTR for RFE - final reduction is 60 days after proposal letter or date last paid (DLP), III.iv.8.E.1.g says DLP or the date indicated in the notice

Evidence:Rating Decision, and all evidence contained therein, dated {}, and notification letter to you dated {}

Issue: Evaluation of {} currently evaluated as {} percent disabling.

Decision: Evaluation of {}, which is currently evaluated {} percent disabling, is decreased to {} percent effective {}.

Reasons for Decision:The evaluation of {} is decreased to {} percent effective {}, the first of the month following the 60-day period after notification of this decision. // OR if 3.655, you need to check the notification letter for the date used & indicate that date, or DLP, whichever is later - The evaluation of {} is decreased to {} percent effective {}, {the first of the month following the 60-day period after notification of the proposed action OR the date of the last payment}.

The previously considered evidence shows…improvement OR that you failed to report to two requested review examinations. There is no current objective medical evidence to support the continuation of the {} percent evaluation. The {} percent evaluation is based on:

…

Your new combined evaluation will be {} percent.

OR (if improvement within 5 years & reduction does not affect combined):The evaluation of {} is decreased to {} percent from {}, the date of the DBQ showing improvement. You have been evaluated at {} percent for fewer than 5 years, the DBQ shows improvement, and there is no other evidence to support a {} percent evaluation.

This reduction does not reduce your combined evaluation.

March 2014 Compensation Service Bulletin (CSB) – if sever or reduce to 0%, check the Share corporate record for an active Ch 31 flash & notify VSR (in a note on the codesheet) if there is a flash – VSR: Please notify VR&E that SC has been severed/the evaluation has been reduced to 0%.

From: VAVBASDC/RO/VSC Sent: Friday, June 15, 2018 10:35 AMSubject: FW: Reminder to Utilize GAO for Reduced Evaluations

VSC employees,

As a reminder to all Regional Offices, ratings that sever or reduce service connection may require an override in the Awards application.

VETSNET and VBMS Awards do not apply Omnibus correctly when processing ratings that sever or reduce service connected disabilities.  RVSRs should not adjust the rating effective date to resolve this issue as a

workaround.  When an inappropriate effective date is generated in VETSNET or VBMS Awards for a rating reduction or termination, the VSR should use the Generate Award Override (GAO) function in the Awards application to apply the proper date for the reduced evaluation.

If you have any questions, please reach out to your Coach/Assistant Coach.

Modified RE1 (if still at 100% combined, but no longer 100%+60%; My Notes: VBMS-R does not allow you to do a proposed change for SMC without entering a date (which is incorrect), so I guess just address the SMC within the Reasons for Decision for the disability (have to propose to reduce the disability even if it doesn’t affect the combined since it affects the SMC level) & maybe add the below line to the Decision line):If the proposed reduction takes effect, your combined evaluation will be unaffected, but you will no longer be entitled to special monthly compensation at the housebound rate, and will only be entitled to special monthly compensation based on the loss of use of a creative organ.

Decision: The assignment of special monthly compensation is proposed to be decreased to the loss of use level.

OR do the issue as Free Text

OR try this, from VA Pulse, https://www.vapulse.net/thread/36790:make SMC an issue in the issue management tab.  Once entering the decision in the paragraph section, edit one of the SMC paragraphs but change nothing and accept.  Then go to the code tab and edit the most recent code line and choose proposed reduction/discontinuance in the supplementary drop down.  If you don't edit a paragraph first, it usually says that a corresponding paragraph was not entered or something to that affect. 

reduction from housebound to loss of use of creative organ only:Entitlement to the current level of special monthly compensation is no longer shown because you no longer have a single service-connected disability rated 100 percent and a separate service-connected disability or disabilities independently rated 60 percent or more. A lower level of special monthly compensation based on loss of use of a creative organ is established from {}.

RVSR Q-Tip: Final Reduction Effective Date (provided to at least one team on 3/26/15)

When taking a final reduction in evaluation, follow the guidelines under 3.105(e):

The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. If additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires.

For reductions in evaluations, the rule is 60 + 60.  We allow 60 days for due process when we propose to reduce, then allow an additional 60 days before the final reduction takes place.

Please Note: This rule does not apply to other due process issues such as failure to return VAF 4140 or incompetency rating.

Example: The Veteran is service-connected with a combined evaluation of 70 percent. A 60 percent evaluation is assigned for chronic obstructive pulmonary disease and a 30 percent evaluation is assigned for gall bladder removal. The current evidence supports a 10 percent evaluation for the gall bladder removal. You are required to prepare a proposal rating because a reduction decision will reduce the combined evaluation from 70 to 60 percent (the monthly payment will be reduced). On January 9, 2015, you prepare and send a proposal rating and a notification letter on the same date, giving the Veteran 60 days to reply.  On March 18, 2015 you review the claim folder. As no additional evidence was submitted, you prepare and send a final rating and a notification letter on the same date, reducing the gall bladder evaluation to 10 percent effective and the combined evaluation to 60 percent.

Answer: June 1, 2015, the date of reduction of evaluations. This effective date is based on the assumption that the award will be processed in March 2015 and the notification letter will be sent the same month.

References:  38 CFR §3.105(e) Revision of decisions; Reduction in evaluation-compensation

OTHER DECISIONS –

Individual Unemployability (IU) –

3.340 Total and permanent total ratings and unemployability –

III.iv.5.C.5.c & III.iv.5.C.5.d – effective dates for IU under 3.400(o)(2)

III.iv.6.B – inferred issues, do not infer to deny

III.v.8.A.2.b – IU & incarceration (deny if would first become effective will incarcerated for felony)

IV.ii.2.F -

o IV.ii.2.F.1.d & IV.ii.2.F.1.e – marginal employment

o IV.ii.2.F.2.e – still have to rate evaluations & IU even without work history

o IV.ii.2.F.2.f - if there is an entry that covers fewer than 5 years, assume it is the entire work history unless inconsistent with other evidence (if inconsistent, call to clarify)

o IV.ii.2.F.2.g - send 21-4192 to employer(s) during last year of employment (no need to send 4192 if veteran says they are no longer in business), also says follow up if returned form says veteran RETIRED (ask if retired by reason of disability & if so, ask to identify nature of disability); unemployable if stop working from disability & unable to secure further employment, even if tried & was unsuccessful; 15 days for initial & 15 for follow-up; appeals with IU / intertwined, https://www.vapulse.net/message/34973 (also see IV.ii.2.F & notes under “Appeals References”)

o IV.ii.2.F.2.h – if just says “ALL SC disabilities,” address all or call to clarify; NSC issues listed on 8940 are a Request for Application (RFA), then updated 1/17/17 & 8/1/17 treat as reconsideration if notified of denial within last year (different if filed before 3/24/15, see chart)

o IV.ii.2.F.2.j – need to get VR&E records (unless veteran does not return 8940)

o IV.ii.2.F.4.i – temporary or permanent 100% evals with IU (don’t close-out IU unless discontinuance warranted under 3.343, which is only if they have gainful employment)

o IV.ii.2.F.9.b – poverty thresholds

The veteran reported self-employment from {}. We need to request his self-employment information, per IV.ii.2.F.3.a.

Moore v. Derwinski (1991) - The term “substantially gainful occupation” refers to, at a minimum, the ability to earn a living wage.

Wood (Clarence) v. Derwinski (1991) - An application for unemployability compensation is an application for increased compensation within the meaning of 38 U.S.C. § 5110(b)(2).

Blackburn v. Brown (1993) - Entitlement to TDIU compensation must be established solely on the basis of impairment arising from service-connected disabilities.

Hattlestad v. Brown (1993) - In determining entitlement to TDIU evaluations, a clear explanation requires analysis of the current degree of unemployability attributable to the service-connected condition as compared to the degree of unemployability attributable to the non-service connected condition.

Parker v. Brown (1994) – “…determination of the veteran’s entitlement to TDIU is considered in the context of the individual veteran’s capabilities regardless of whether an average person would be rendered unemployable under the same circumstances.”

Norris v. West (6/9/99) – When VA is considering a rating increase claim from a claimant whose schedular rating meets the minimum criteria of § 4.16(a) and there is evidence of current service-connected unemployability in the claims file or under VA control, evaluation of that rating increase must also include an evaluation of a reasonably raised claim for TDIU.

Faust v. West (2000) - The Court held that the definition of a substantially gainful occupation is as follows. One that provides annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the veteran actually works and without regard to the veteran’s earned annual income prior to his having been awarded a 100% rating based on individual unemployability. The Court held that such employment constitutes, as a matter of law, a substantially gainful occupation and thus “actual employability” for the purposes of 38 C.F.R. § 3.343(c)(1). In determining entitlement to a TDIU rating, VA must consider the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. A determination of whether a person is capable of engaging in a substantially gainful occupation must consider both that person’s abilities and employment history.

Hurd v. West (2000) - A TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation apply to a TDIU claim.

Roberson v. Principi (2001) - Once a Veteran submits evidence of a medical disability, makes a claim for the highest rating possible, and submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim “identify the benefit sought” has been satisfied and VA must consider whether the Veteran is entitled to TDIU.

Bowling v. Principi (5/8/01) - Court noted that "The term 'substantially gainful occupation' is not defined by VA regulation; however, the Court has held that the term refers to, at a minimum, the ability to earn 'a living wage'.

VAOPGCPREC 12-2001 (7/6/01) - Roberson v. Principi held that once a veteran submits evidence of a medical disability, makes a claim for the highest rating possible and submits evidence of unemployability, the requirement in 38 CFR 3.155(a) that an informal claim “identify the benefit sought” has been satisfied and VA must consider whether the veteran is entitled to total disability based upon individual unemployability (TDIU); and a veteran is not required to submit proof that he or she is 100% unemployable in order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 CFR 3. 340(a).

Bradley v. Peake (11/26/08) - The provisions of 38 U.S.C. § 1114(s) do not limit a “service-connected disability rated as total” to only a schedular 100-percent rating. A TDIU rating may serve as the “total” service-connected disability, if the TDIU entitlement was solely predicated upon a single disability for the purpose of considering entitlement to SMC at the (s) rate. SMC S based on IU if IU is based on a single disability and the veteran is housebound due to that disability, or has additional SC disabilities that combine to 60% or more. 4.16 does not apply for the IU based on a single disability (it truly has to be a single disability).

Comer v. Peake (Fed. Cir. 2009) - A claim for a total disability evaluation due to individual unemployability (TDIU) is implicitly raised whenever a pro se Veteran (unrepresented), who presents cogent evidence of unemployability, seeks to obtain a higher disability rating, regardless of whether the Veteran specifically states that he is seeking TDIU benefits.

Rice v. Shinsek (5/6/09) – A request for a total disability evaluation on the basis of individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate claim for benefits, but involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for increased compensation, if entitlement to the disability upon which TDIU is based has already been found to be service connected. There is no freestanding TDIU claim. IU is not a separate or freestanding claim, but is part of the initial adjudication of a claim or part of a claim for increased compensation.

The effective date for IU & Ch. 35 should be the date the increase was granted if the claim for IU was received w/in 1 yr. of the notification of the RD granting the increase (& when the schedular criteria were met for IU) if the veteran was not working on the date of the increase. (Two June 2009 STAR Errors), only reference is 3.400(o)(2))

Buie v. Shinseki (3/23/10) - a total disability rating due to individual unemployability (TDIU) that is based on more than one underlying disability does not satisfy the first requirement of 38 U.S.C. § 1114(s) that a veteran have “a service-connected disability rated as total” for the purpose of establishing entitlement to special monthly compensation (SMC) at the (s) rate. VA must assess the SC disabilities to see if any combo allows for SMC S.

QRT Bulletin August 2012 & Q&A Session & 8/3/12 – Procedural Guidance: Identifying and Processing Reasonably Raised Claims for Individual UnemployabilityIssue: To ensure consistency on identifying and processing reasonably raised claims for IU, we are providing the following guidance.

Discussion: M21-1 MR IV.ii.2.F.25.h and M21-1 MR IV.ii.2.F.25.i provide our references for how to identify a reasonably raised claim of IU and how to process them when applicable. A properly identified claim may be observed either with an original claim or an increased claim if these two criteria are met:1. The veteran meets the minimum schedular criteria under 38 CFR 4.16(a), and 2. there is evidence of current s/c unemployability in the Veteran's claims folder or under VA control

Cases should only be placed at issue if they only meet both requirements above. The manual specifically provides that we are not to consider IU a reasonably raised claim, or defer entitlement, or send the vet an 8940 if there is no evidence of s/c unemployability.

o If the Veteran meets the minimum schedular criteria under 38 CFR 4.16(a), but there is no evidence of current s/c unemployability in the Veterans claims folder or under VA control, RVSRs should put the following note on the codesheet: "Note to File: The Veteran meets the minimum schedular criteria under 38 CFR 4.16(a), however there is no evidence the Veteran is unemployable due to S/C conditions at this time. Therefore, IU is not being put at issue."

o If the Veteran meets both criteria outlined above, and the RVSR does not have enough evidence to grant on the current rating decision, the RVSR must infer the IU issue and defer for further development. This means the RVSR must place IU as an issue on the rating decision, identify the issue as deferred and instruct the VSR what development is needed for the IU issue. From this point forward, if the case is called for a quality review and the issue of IU is not properly inferred and deferred on the rating decision, it will be considered an A2 critical error for missing the inferred issue.

o Development for Reasonably Raised IU: IU is not considered a freestanding claim. Therefore, if the issue of IU is reasonably raised on a rating decision, a separate VCAA development letter is not required and sending the WTEMS is not required. The Post VSR will complete whatever development is needed (i.e. send the Veteran 21-8940). According to 38 USC 5103 (Duty to Notify) and 38 USC 5103A (Duty to Assist), our duty to notify/assist is only enacted when we have received a claim. A inferred issue of IU has not been claimed by the Veteran, but reasonably raised by the evidence of record by the RVSR and therefore does not require VCAA development or WTEMS.

September 2012 Compensation Service Bulletin (CSB) – info on follow-up when employer only gives statement that the Veteran’s employment can be verified through www.theworknumber.com/socialservices or other related websites. – see IV.ii.2.F.2.g

May 2013 Compensation Service Bulletin (CSB) - The responsibility for deciding whether or not service-connected disabilities render a Veteran unable to secure and follow gainful employment is not within the realm of the examining physician, but is an adjudicative issue that rests solely with the rating activity (see 38 CFR 4.16(a)). If the facts of the case require VA to examine the Veteran, do not ask the examiner to opine as to whether or not the Veteran is unemployable due to his service-connected disabilities, but simply request that the examiner comment instead on the functional impairment caused solely by the service-connected disabilities subject to examination. This guidance will soon be implemented with the release of the new FL.

VETSNET Awards Super User Call July 16, 2013 The correction to FL 13-13 is still pending. In the interim, please do not follow step 1 on page 3 where the instructions are to complete a Benefit Eligibility Decision using the reason “Failure to Furnish Requested Evidence” unless you intend to remove all eligibility for the Veteran retroactively to the first date of entitlement.The two options available at this time are:

The RVSR can complete a rating to deny IU for failure to furnish requested evidence. The VSR can administratively deny via award letter.

September 2013 Compensation Service Bulletin (CSB) – Volunteer work alone is not sufficient basis to warrant reduction of TDIU evaluation unless it demonstrates the veteran is capable of employment. Faust v. West, 13 Vet.App. 342 (2000), provided guidance in defining employability in holding that employment in a substantially gainful occupation that showed actual employability is as follows: “One that provides annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the veteran actually works and without regard to the veteran’s earned annual income prior to his having been awarded a 100 percent rating based on individual unemployability.”

December 2013 Compensation Service Bulletin (CSB) – if the employer refers us to www.theworknumber.com/socialservices or another related website, it is the equivalent of returning the VA Form 21-4192 with necessary information omitted and we must follow-up with the employer and again request that the form be completed, allowing an additional 10 days for response. Also notify the veteran. – see IV.ii.2.F.2.g

Weekly Q-Tip (1/24/14) – Based on a trend noted throughout FY2013, the following reminder regarding properly disposing of IU as an issue is disseminated.

TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation.

The rater is required to consider evidence of unemployability as far back as one year prior to the date of the underlying claim. The effective date is governed by 38 CFR 3.400(o)(2).  Since this is a claim for increase, staged rating applies to the IU also.

In other words, the Rater must address the entitlement to IU for the entire period of eligibility.

Specifically, if the Veteran is awarded a schedular 100 percent evaluation, entitlement to IU must be addressed for the period between the date of claim for IU (or the date the IU claim is reasonably inferred), and prior to the effective date of the schedular 100 percent.  If a Vet’s claim for IU is received within one year from their last date of employment and entitlement is shown, the effective date for IU can predate the date of receipt of claim.  As such, there are several scenarios in which IU will need to be addressed for the period prior to the effective date of the schedular 100 percent evaluation.  If entitlement is not shown for any period after the date of claim and prior to date of the schedular 100 percent, it must be properly denied, and not merely “vacated” or deemed moot due to the grant of the schedular 100%.

Example: Vet is s/c for migraines at 50% from 2/7/2004, anxiety at 30% from 2/7/2004 and tinnitus at 10% from 4/10/2010.  Vet submitted VA Form 21-8940 that was received on 11/1/2013.  On VAF 8940, Vet reported last date of employment was 7/1/2013.  Upon VA examination, Vet warranted a schedular 100% for s/c anxiety.  There is no evidence of record (no CAPRI tx recs, private treatment records, etc) to warrant an increased evaluation under 38 CFR 3.157.  Vet’s previous employer returned VAF 4192 and indicated that Vet’s employment was terminated due to inability to work with others due to social anxiety.  How do you rate this case?

Answer: Grant IU from 7/2/2013, the day following last date of employment. IU should be discontinued as of date of effective date of schedular 100%, which is 11/1/2013, date of receipt of claim.  Address entitlement to ancillary benefits and competency.

References: ·       FL 13-13: Claims for Total Disability Based on Individual Unemployability (TDIU) (effectively rescinds TL 10-07)·       38 CFR 3.157(b) Report of examination or hospitalization as claim for increase or to reopen·       38 CF3.400(o)(2)  Effective dates; Increases·       Mayhue v. Shinseki, Application of 38 CFR 3.156 (c) ·       Hart v Mansfield, Staged Ratings

March 2014 Compensation Service Bulletin (CSB) – When the Veteran’s record shows that he/she has been awarded disability benefits by SSA and a VA Form 21-8940 is of record, ROs should obtain the SSD records. However, ROs are not required to request SSD request when a Veteran fails to return VA Form 21-8940. In those cases, the claim is not substantially complete and no further development action is needed.

ADL SOP March 2014 – IU When There Is No Complete VA Form 21-8940 – see details under VBMS-R Free Text section of this same title

From: VAVBASDC/RO/VSC Sent: Tuesday, June 24, 2014 1:22 PMSubject: FW: TDIU as an inferred issue

Employees, please be reminded of the following guidance regarding claims for Total Disability Individual Unemployability (TDIU). 

Fast Letter 13-13 states that “if the evidence reasonable raises the issue of TDIU, the RVSR will infer and defer the issue on the Rating decision.  In these cases, authorize but continue the end product (EP).  The TDIU claim must be worked as part of the EP pending when the RVSR inferred the issue . . . at that point, send the Veteran a TDIU-specific Section 5103 notice for all TDIU claims.  Include any disability the Veteran specifies causes I.U. in the notice as the claim for increase.”

An EP 930 is not warranted for the scenario above, nor is it efficient to reassign the deferred issue to a Pre VSR on the Team to send a separate 5103 notice to the Veteran for TDIU.  The preferred method is for the Post VSR to include the TDIU 5103 notice in the Award letter, add a tracked item for return of the 21-8940, and

suspense the pending EP for an additional 30 days.  If there are multiple deferred issues, to include TDIU, the claim should be forwarded to a Pre VSR for action needed.    All deferred ratings should receive priority handling.   No suspense date beyond 15 days should be assigned to a deferred rating.

July 2014 Compensation Service Bulletin (CSB) – The 8940 and 4192 are being updated to obtain necessary information from Veteran claimants still serving in the National Guard or Reserves who are unable to perform their duties due to a service-connected condition(s). While the forms are being updated, VSRs, RVSRs and DROs should continue paying close attention to any information indicating that a Veteran is unable to perform his/her guard or reserve duties due to a service-connected condition. Read Bulletin for further details…

From: VAVBASDC/RO/VSC Sent: Monday, September 08, 2014 4:10 PMSubject: FW: Effective dates for I.U.

Please see attached Effective dates for IU which can be used to assist in assigning the effective date for grants of I.U.   

Effective dates for claims for IU

#1. Veteran 60% SC for heart condition since 1994. Stops working 12-15-97, files 21-8940 4-2-98.Effective date would be 12-16-97. Because be filed the claim for IU within 1 year of leaving the job.

#2. Veteran 60% SC for heart condition since 1994. Stops working 4-1-96. Files claim 4-2-98.Effective date would be 4-2-98 since waited more than one year after leaving job to file the claim.If VAMC or military facility showed last worked 4-1-96, could grant IU from 4-2-96

#3. Rating dated 4-2-98 granted 60% for heart from 3-19-95 and invited a claim for IU. The 21-8940 was sent out 4-3-98 and the veteran returned it 4-15-98 showing that be had last worked 3-19-95.Effective date would be 3-20-95 since veteran returned 21-8940 within one year of the request.

#4. Rating dated 1-2-96 granted 60% for heart from 11-1-95 and invited a claim for IU. 21-8940 sent out 2-1-96. Veteran submitted 21-8940 on 4-2-97 showing last worked 11-1-95.Effective date would be 4-2-97 since veteran waited more than one year to submit the 21-8940.If VAMC or military facility records showed last worked 11-1-95 could grant IU from 11-2-95.

Consider a claim for IU as a claim for increase and apply 38 CFR 3.400(o)2 or 38 CFR 3.157 (if applicable) to figure out the effective date.

Also see III.iv.5.C.5

Notes from October 2014 IU Training (Anthony Galloway & Carlos Rosario) –

PowerPoint says that 4.16 says “unable to secure or follow a substantially gainful occupation solely due to service connected disabilities.” – contradicted by August 2016 Consistency Study

Infer IU is examiner says prevents/precludes or seriously impairs ability to work. Otherwise, the functional impact question is geared toward 3.324 and 3.321(b), not 4.16.

For mental issues, consider the whole record, plus the examiner’s answer on occupational and social functioning. Can go back & ask, if needed.

No new exam needed if infer, exam is within one year, and exam and TRs are sufficient/complete. No need for Gen Med, just specific issues, if not already on file. If must deny & evidence is old/incomplete/inconsistent, get exam & opinion.

SSA records are not required if you can grant. BUT, must request if evidence shows in receipt of SS. (Golz v. Shinseki (1/4/10) & Murincsak v. Derwinski (4/24/92))

Voc Rehab – M28R, IV.8.2 (2.13 specifically)

A veteran that is just unemployed does not automatically meet “reasonably raised” & just meeting 4.16

doesn’t “reasonably raise” the issue of IU.

Faust v. West (2000) - http://www.census.gov/hhes/www/poverty/data/threshld/index.html

Effective Dates – if filed within 1 year of last RD – base effective date on that decision (70% for 1 issue granted eff 1/21/06 by RD 12/15/06, 8940 rec’d 6/9/07 (whether inferred or not) shows not worked since 1/5/04 d/t 70% disability; grant IU 1/21/06); if filed OVER 1 year from last RD – it’s the DOC.

Bradley v. Peake – can’t go retroactive, but can reconsider IU to see if S is warranted; preserve S if increase to 100% (per Buie v. Shinseki (3/23/10))

October 2014 Rating Quality Call Notes –

IU needs to be rating & should not be administratively denied.

A veteran can write “all” in the block for specific disabilities.

July 2015 Compensation Service Bulletin (CSB) – updated 8940 & 4192, IV.ii.2.F

Per VA Pulse, https://www.vapulse.net/message/26718, if 5-year work history on 8940 is missing, the form is incomplete, return to veteran for completion & give 30 days; if have info on last year of employment, send 4192 employer & veteran [no need to ask for more]

Notes from December 2015 IU Training (John Trunick) –

Per Carlos Rosario, if infer IU, don’t need to get 4192 since you’re not inferring unless the veteran is unemployed

For Bradley v. Peake, continue IU & S on codesheet even if later combined is increased to 100%.

Have to request SSA records, but can grant before they arrive if have sufficient evidence.

Gen Med not automatic, but can request.

If have 8940 over a year-old, probably should get a new one.

No need for 4192 if evidence is sufficient to grant.

If retired, need to know if it was due to disability & which disability.

Intertwined Appeals: (1) NOD on evaluation of disab, claim for IU w/disab on Appeal is listed in Box 7; if IU denied, IU is now on Appeal; (2) NOD on IU, claim for increase on issue not on Appeal; if increase denied, evaluation is now on Appeal.

Per Rice v. Shinseki, IU is linked to underlying condition(s), so prior grant of SC or increase (w/i 1 year), can be used for effective date (not always date rec’d 8940).

March 2016 Quality Call Notes – Reminders on IU & Bradley v. Peake & Buie v. Shinseki (discusses effective dates & gives verbiage for if changing IU to be based solely on one disability), IV.ii.2.F.4.g

August 2016 Consistency Study contradicts October 2014 training & says “NSC disabilities or injuries occurring after military service have no bearing on a determination of whether SC disability renders a Veteran unemployable.”

My Notes: Only SC disabilities listed in box 7 are claims. Anything listed in box 9 is not a claim.

IU flowchart (from 2013) is saved at H:\VSC\Rating Reference

3.341 Total disability ratings for compensation purposes

3.343 Continuance of total disability ratings – can’t just be better because resting

III.iv.8

4.16 Total disability ratings for compensation based on unemployability of the individual – 1 @ 60% or 70% w/1 @ 40%, one disability is one or both upper/lower extremities, common etiology or a single accident, single body system, OR multiple injuries incurred in action or as a POW; Marginal employment shall not be considered substantially gainful employment

4.16(b) - III.iv.6.B.4.d shows how to submit claims to Compensation Service for extra-schedular consideration

IV.ii.2.F.4.d – can grant IU temporarily

IV.ii.2.F.4.e – 4.16 can also be applied to disabilities from same type of exposure event (i.e. herbicide, undiagnosed illnesses), musculoskeletal falls under single body system, GSWs fall under combat

IV.ii.2.F.4.f – for HB under Bradley, the single disability for the IU grant has to be at least 60% (also under IV.ii.2.H.10.b & IV.ii.2.H.10.c)

Floyd v. Brown (4/17/96) & Bagwell v. Brown (7/3/96) –consider IU if claimed or meets requirements & may be unable to secure or follow substantially gainful employment; also GC Opinion 6-96 (8/16/96)

March 2016 Quality Call Notes –

In Bradley v. Peake, the Court held that section 1114(s) does not limit the requirement for a “service-connected disability rated as total” to only a schedular rating of 100%, but may be satisfied by a Total Disability Individual Unemployability (TDIU) rating based on a single disability.

It must be determined if TDIU entitlement was based upon a single disability for the purpose of considering entitlement to SMC at the (s) rate.  The single disability has to be rated between 60% and 90% in order to count as a single “total” (100%) disability.

Rating Note: Bradley does not apply, as IU was not based on a single disability at 60% or more.

4.18 Unemployability4.19 Age in service-connected claims – cannot consider age for compensation or unemployability (only for pension)

Consider Ch. 35 with grants!!!

If don’t return VA Form 21-4140, Employment Questionnaire:

use Special Determination Requested & date rating is completed

Evidence: A letter was recently sent to you on {date} requesting that you complete and return VA Form 21-4140, Employment Questionnaire, but no response was receivedOR VA Form 21-4140, Employment Questionnaire, mailed to you on {date}, but not returned

IV.ii.2.F.5.f – we can call for missing info/clarification if 4140 is signedIV.ii.2.F.5.i – we cannot substitute a phone call for a signed 4140VA Form 21-0820, Report of General Information, dated {}

check address!!

In VBMS-R, Edit “Individual Unemployability Granted” Decision, then select Supplementary Decision “Proposed Change,” then OK, then choose “IU – Propose to Terminate (VA Form 21-4140)”*Use generated text

VBMS-R automatically proposes to discontinue Ch35

check to see if SMC is affected

If still not returned, In VBMS-R, Edit “Individual Unemployability Granted,” then select Supplementary Decision “Reduction/Discontinuance,” then choose “IU Discontinued – Failure to Return VA Form 21-4140”*Use generated text IV.ii.2.F.5.i - final reduction is date last paid (DLP) or the date indicated in the notice, whichever is later

*********************

3.501 (f) Employment questionnaire, failure to return. Reduce award to the amount payable for the schedular evaluation shown in the current rating as of the day following the date of last payment.

*********************If do return VA Form 21-4140 after IU proposed to be discontinued (use Authorized Review Requested & DOC):

In VBMS-R, select “Individual Unemployability Granted,” then supplementary decision “Confirmed and Continued Decision,” option will be “IU C&C” or “C&C (21-4140)”*Use generated text

Evidence: VA Form 21-4140, Employment Questionnaire, received {}

IV.ii.2.F.5.f, if 21-4140 is on file, but VSR incorrectly sends case RFD, defer it back to them & tell them:

for deferral: The 4140 was returned on {date} (with box 3 checked NO; uploaded {date}) & no rating is needed as there was no prior proposal to discontinue IU, per IV.ii.2.F.5.f.

for Claim Note: Not a rating issue per IV.ii.2.F.5.f. The 4140 was returned on on {date} (with box 3 checked NO; uploaded {date}) & no rating is needed as there was no prior proposal to discontinue IU. Deferral done.

Sever IU (need Long Form Narrative, per III.iv.6.C.7.a):

Evidence: Rating Decision with proposal to sever the total disability evaluation based on individual unemployability dated {}Notification letter to you regarding proposal to sever individual unemployability dated {}, with no response receivedVA Form 21-0820, Report of General Information, dated {}

Continued entitlement to individual unemployability. Continued entitlement to Dependents' Educational Assistance under 38 U.S.C. chapter 35.

Entitlement to individual unemployability is discontinued effective {}. Entitlement to Dependents' Educational Assistance under 38 U.S.C. chapter 35 is also discontinued effective {}.

Reasons for Decision: We have severed the total disability evaluation based on individual unemployability, effective {}, the first of the month following the 60-day period after notification of this decision (per QRT/GiaBao Nguyen 5/15/17 - final reduction is date last paid (DLP)), because …you did not return the VA Form 21-4140, telling us your current employment status {OR the evidence shows receipt of earned income from {} to {}}. VA regulations provide that a total disability rating for compensation purposes based on individual unemployability can be reduced if the evidence shows you are engaging in substantially gainful occupation, with maintenance of the occupation for a period of 12 consecutive months. {We received notification of earned income from {}}. Rating Decision dated {} proposed to sever your entitlement to a total disability evaluation based on Individual Unemployability. A notification letter was sent to you on {} advising you of this proposal, with a request for any medical or other evidence, but no response was received. Additionally, the Report of General Information shows we also attempted to call you on {}, but {there was no answer and we left a voicemail asking for the form and a phone call back}. This Rating Decision will not affect your entitlement to treatment for service-connected disabilities. Your overall combined evaluation will be {} percent.

Since we have severed the total disability evaluation based on individual unemployability, you are no longer entitled to the 100 percent rate, and therefore we have also severed entitlement to Dependents' Educational Assistance under 38 U.S.C. chapter 35.

backfill the “To Date” in the Master Record for IU & Ch. 35

Pension/Permanent and Total –

3.2 Periods of war – WWI: 4/16/17-11/11/18, Russia- 4/1/20 WWII: 12/7/41-12/31/46 [Bataan fell 4/9/42, Death March (to Camp O’Donnell) until 4/24/42, Corregidor fell

5/5/42; Battle of the Bulge was in Bastogne, Belgium from 12/15/44-1/28/45 (also called Ardennes Offensive), Battle of Iwo Jima 2/19/45-3/26/45, atomic bombing of Hiroshima 8/6/45, atomic bombing of Nagasaki 8/9/45]

Korean War: 6/27/50-1/31/55 [Chosin Reservoir Campaign 11/50-12/50] Vietnam War: 2/28/61-5/7/75 if in Vietnam, 8/5/64-5/7/75 if not in Vietnam [USS Pueblo held by North Korea

from 1/23/68-12/23/68 in Wonsan & Pyong Yang prisons] [Tet Offensive 1/31/68 to 2/68 & “mini-Tet” in May & August]

Gulf War: 8/2/90 to present

3.3 Pension – need 90 days or more, with 1 day during a period of war, is “permanently and totally disabled from nonservice-connected disability not due to the veteran’s own willful misconduct,” and meets income and net worth requirements; pension okay for old Philippine Scouts (enlisted prior to 10/45), but not for Philippine Commonwealth Army, USAFFE, new Philippine Scouts, or Recognized Guerilla Members- also see 3.40 & 3.41 3.400(b)(1) I.1.C.3.b & III.iv.3.A.5.a – get Gen Med DBQ if don’t have sufficient medical evidence

III.iv.6.B – inferred issues, do not infer to deny, retroactive pension V.ii.1.B III.iv.6.D for codes

III.iv.6.E.3.b - all disabilities need an evaluation / % if pension is involved

Note to File: Technically III.iv.6.E.3.b says only need evaluations for NSC disabilities if “rating a claim” for pension only, or for compensation and pension, but historically we also added evaluations to subsequent ratings, so evaluations are added to all/new NSC disabilities.

III.v.2.A.3.b & c V.i.1.2.d – the wartime service requirement must be met during the minimum active duty

V.i.2 – lots of info, incl that we should get Gen Med DBQ if don’t have sufficient medical evidence

V.ii.1.A PL 107-103 says P&T for pension if 65 yrs old, or in nursing home, or SS disabled (SSDI and SSI) & meet

service, income & net worth requirements, eff 9/17/01 [SSDI is Social Security Disability Insurance (also called Title II) paid to blind/disabled workers, their children, widow(er)s and adults disabled since childhood, and is based on earnings record of the insured worker; SSI is Supplemental Security Income (also called Title XVI, V.i.2.2.g says a “Y” under XVI indicates SSA data is available & you should view the “SSI basic Info” tab & the “SSA Basic Info” tab to review the “disability onset date,” if getting SSI, that meets the disability requirement for VA pension) and is paid to those 65+, blind/disabled adults and blind/disabled children with limited income/resources]

Rating Note: There is no “Disability Onset Date,” so the veteran is not in receipt of Social Security Disability, and SSA records are not needed or being requested.

PENSION RATE TABLES 3.342 Permanent and total disability ratings for pension purposes – can grant pension for residuals of

alcoholism/substance abuse

3.321 General rating considerations, III.iv.5.B.2.h

3.321(b)(1) - ES1, III.iv.6.B.4.d shows how to submit claims to Compensation Service for extra-schedular consideration

4.17 Total disability ratings for pension based on unemployability and age of the individual

3.12a Minimum active-duty service requirement – 24 months or the full period for which called/ordered to active duty if entered at an enlisted grade after 9/7/80; or, if otherwise entered after 10/16/81 with an enlisted or officer grade; III.ii.6; see notes/references under SE1 and SE2

From 1/13/11 Rating Team POD:If a LOD shows willful misconduct, the veteran is not eligible for NSC pension for the injury found to be not LOD. 

Pension grant / grantp&t (Pension decisions need Long Form Narrative, per III.iv.6.C.7.a):

VBMS-R System-Generated Text: Entitlement to non-service-connected pension will be granted to Veterans who are basically eligible and who are unable to secure and follow a substantially gainful occupation by reason of disability, which is likely to be permanent.

The evidence shows that you are disabled due to {}. Therefore, entitlement to non-service-connected pension benefits is established effective {}.

Possible additional paragraph for Long Form Narrative:We have granted entitlement to a nonservice connected permanent and total evaluation as the evidence shows that you are unable to secure and follow a substantially gainful occupation due to disability. The evidence shows you are {} years old and you last worked in {} as a {}. The {treatment records} show you are permanently disabled due to {}. You are entitled to pension effective {}, the day VA received your claim for pension.

EXAMG & PT-65 & PT-EX & PT-MED

add, if needed:Although you do not meet the schedular requirements of a single disability ratable at 60 percent or more, or two or more disabilities combining to 70 percent with at least one ratable at 40 percent, considering the level of disability and other factors, such as your age, education and occupational background, an extraschedular permanent and total disability rating is authorized subject to approval by the Adjudication Officer.OrAlthough you do not meet the schedular requirements of a single disability ratable at 60 percent or more, or two or more disabilities combining to 70 percent with at least one ratable at 40 percent, you have multiple disabilities from {a common etiology, a single body system, multiple injuries incurred in action, multiple disabilities incurred as a prisoner of war, or disabilities of one or both of the upper or lower extremities} {that combine to 60 percent or that combine to 40 percent with additional disabilities bringing the combined evaluation to 70 percent}, so entitlement to pension benefits is granted.

Pension denial / denyp&t (Pension decisions need Long Form Narrative, per III.iv.6.C.7.a):

*usually only deny if failed to report & have no treatment records, or if young & have few disabilities (as of March 2012, per VSCM)We have considered but not established an evaluation of permanent and total disability for entitlement to nonservice-connected disability pension. We will assign a rating of permanent and total disability to veterans who are basically eligible and who are unable to secure and follow a substantially gainful occupation by reason of disability which is likely to be permanent. Permanent and total disability for pension purposes is held to exist when a veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as the result of such disability(ies).

Permanent and total disability for pension purposes is held to exist when there is a single disability ratable at 60 percent or more, or where there are two or more disabilities with a combined evaluation of 70 percent or more, with at least one of the disabilities rated at least 40 percent, and the veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as the result of such disability(ies).

You have disabilities which combine to a total evaluation of {} percent and do not meet the above requirements. The combined evaluation is not the result of simply adding the individual disability evaluations. It is computed based on a table designed to measure the overall efficiency of the average person as affected first by the most disabling condition, then by

other, less disabling conditions, in the order of severity.

Where the evidence fails to establish the basic disability percentage requirements, consideration will be given to extraschedular entitlement to nonservice-connected pension based on such factors as the degree and nature of the disability, the veteran's age, educational and occupational background or other factors pertinent to the individual case.

The evidence of record shows that you are {} years of age, have a level of education reported as {} years of {}, and you last worked in {} as a {}. The {evidence / DBQ / treatment records} fail(s) to demonstrate that you are unable to secure or follow a substantially gainful occupation as the result of disability, so we cannot establish entitlement to nonservice-connected disability pension.

also see PT-D

Special Monthly Pension (SMP) -

V.ii.3.1 – A&A - as of 11/20/15 - there is no need for a 100% disability; the need for A&A does not have to be permanent; no rating is needed for the issue of A&A when the veteran is a patient in a nursing home (cannot be an assisted living facility); My Notes: In some situations, it seems that you can tell the VSR to do an administrative grant of pension, then just do a rating for SMP A&A (it’s not explicit in the manual & V.ii.3.1.c says to code disabilities & show evaluations, but RVSRs are doing it in certain situations).

V.ii.3.2 – HB - Master Record has to show a permanent disability at 100% (4.16 applies, but unemployability under 4.17 does not apply; upheld by Chandler v. Shiseki); always need a rating

denysmp:USE VBMS-R System-Generated Text___________________

The veteran must have one disability evaluated at 100 percent disabling. Although the {} shows that you need aid and attendance due to {}, since you do not have one disability evaluated at 100 percent disabling, we cannot establish entitlement to special monthly pension based on aid and attendance.also see PMC-AAD & PMC-SMPD

Special Provision Determinations -

3.324 Multiple noncompensable service-connected disabilities – grant if two ore more permanent SC disabilities “interfere with normal employability”

III.iv.5.B.2.g III.iv.6.B – inferred issues, infer even if infer to deny; III.iv.6.B.2.b – must consider in all applicable ratings,

including confirmed ratings (with multiple 0%s), even if deny

Competency –

3.353 Determinations of incompetency and competency – consider whenever have mental at 100% or if there is a question about managing affairs; effective date of incompetency is the date of the rating making the person incompetent, effective date of competency is date shown by evidence; due process is not necessary if the beneficiary has been declared incompetent by a court of competent jurisdiction or if a guardian has been appointed for the beneficiary based upon a court finding of incompetency

3.400(x) & (y) III.iv.8.A – evidence must clearly and convincingly show that the person is incapable of managing the VA

benefit without limitation

III.v.9.B

Per VA Pulse, https://www.vapulse.net/message/41033, must be a mental disability (not physical), and “It was noted that just because the Veteran chooses allow someone else to manage or assist in management of their funds, it does not mean that they are incompetent to do so.  On a more serious note, to play upon what David mentioned regarding drug and alcohol abuse, it was also noted that just because a Veteran is not managing their benefits wisely, does not mean that they are incompetent to do so.”

Incompetency proposal / proposeincomp (Proposals & Final incompetency decisions need Long Form Narrative, per III.iv.6.C.7.a):

We are proposing to make a determination of incompetency for VA purposes. A mentally incompetent person is defined as one who, because of injury or disease, lacks the mental capacity to control or manage his or her own affairs, including disbursements of funds without limitation. Since the {} shows incompetency and an inability to manage personal affairs to include disbursement of funds, we are proposing to make a determination of incompetency for VA purposes.OR USE VBMS-R System-Generated Text; also see PMC-INCCC & PMC-INCDEF

Incompetent (effective date is date of rating!) (Proposals & Final incompetency decisions need Long Form Narrative, per III.iv.6.C.7.a):

We have determined you are incompetent for purposes of managing VA payments. A mentally incompetent person is defined as one who, because of injury or disease, lacks the mental capacity to control or manage his or her own affairs, including disbursements of funds without limitation. Where there is a doubt as to whether the beneficiary is capable of administering his or her funds, such doubt will be resolved in favor of competency. Since the {} shows incompetency, and an inability to manage personal affairs to include disbursement of funds, we have determined you are incompetent for purposes of managing VA payments. lots of VBMS-R Glossaries

Rating Note: Since there is a doubt as to whether the veteran is incapable of administering his funds and there is no definitive finding of incompetency due to a mental disability, the doubt is resolved in favor of competency, per 3.353(d).

Ancillary Decisions –

3.707 Dependents’ educational assistance – DEA, Ch. 35

III.iv.6.B – inferred issues, do not infer to deny

IX.ii.2.1

denych35 / Ch. 35 / DEA:We have considered but denied eligibility to Dependents' Educational Assistance. We will establish eligibility when a veteran was discharged under other than dishonorable conditions and has a permanent and total service-connected disability; or has a permanent and total disability in existence at the time of death; or died as a result of a service-connected disability. Since the evidence does not show {(L) you have a permanent and total service-connected disability {as you only had a temporary total evaluation based on your convalescence following surgery, OR as your total evaluation was not permanent}; (D) or the veteran had a service-connected permanent and total disability at the time of death; or died as a result of a service-connected disability}, we cannot establish eligibility to Dependents' Educational Assistance.

3.808 Automobiles or other conveyances; certification – (i) 1 or both feet, (ii) 1 or both hands, (iii) bilateral impairment of vision (see reg for details), (iv) severe burn, (v) ALS; adaptive equip only- ankylosis of 1 or both knees or hips (SC or 1151); $11,000 eff 12/16/03; $18K in 2013, $20,114.34 eff 10/1/14; as of 3/24/15, auto forms (21-4502 & 10-1394) are not claim for increase, so only address auto, but can use 21-526 for auto too

III.iv.6.B – inferred issues, do not infer to deny

IX.i.2 – includes severe burn injury as of 9/16/14; includes ALS as of 2/25/15; can get second allowance under certain circumstances (i.e. natural disaster w/no insurance); can get adaptive equipment multiple times

VAOPGCPREC 3-2004 (3/9/04) - A veteran's entitlement under section 1151(a) to compensation for a disability “as if” service connected does not satisfy 38 U.S.C. 3901(1)(A)'s requirement, for eligibility for automobile benefits under chapter 39 of title 38, United States Code, of entitlement to compensation under chapter 11 for a disability that “is the result of an injury incurred or disease contracted in or aggravated by active military, naval, or air service.”

September 2013 Compensation Service Bulletin (CSB) – A new regulation will codify the provision of section 803 of Public Law 111-275 and adds “severe burn injury” to the disabilities listed under 3.308(b). “Severe burn injury” is “deep partial thickness or full thickness burns resulting in scar formation that cause contracturesand limit motion of one or more extremities or the trunk and preclude operation of an automobile.” Effective 10/1/11 - applies to claims receive on or after 10/1/11, and any claims pending on 10/1/11.

March 2015 Compensation Service Bulletin (CSB) – ALS qualifies for auto allowance, IX.i.2

July 2015 Compensation Service Bulletin (CSB) – can get second allowance due to natural or other disasters

grantauto:We have established entitlement to automobile and adaptive equipment because you have service-connected {anatomical loss/permanent loss of use} of {one foot/both feet/one hand/both hands}/{ permanent impairment of vision of both eyes with central visual acuity of 20/200 or less in the better eye with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye}/{severe burn injury with deep partial thickness or full thickness burns resulting in scar formation that cause contractures and limit motion of one or more extremities or the trunk and preclude effective operation of an automobile – eff 10/1/11}/ALS. This entitles you to a certificate of eligibilityfor financial assistance in the purchase of one automobile or other conveyance, and necessary adaptive equipment.

denyauto:The evidence does not show that you have any of the above service-connected conditions.

3.809 Specially adapted housing under 38 U.S.C. 801(a) – (SAH) (i) both LE, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, (ii) bilateral blindness w/LPO, plus 1 LE, (iii) 1 LE, plus residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude

locomotion without the aid of braces, crutches, canes, or a wheelchair, (iv) 1 LE, plus 1 UE which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, (v) burns, (vi) ALS; actual adjustmenets to house, hallways, doorways; cannot get this & SHAG at same time, if this is granted, cannot grant SHAG also; but can get SHAG prior to this, then get difference between the 2 when this is granted; this is the greater benefit of the two; different for GWOT (9/11/01, eff 10/1/11-9/30/16)

III.iv.6.B – inferred issues, do not infer to deny

IX.i.3 December 2012 Compensation Service Bulletin (CSB) – Section 202 of Public Law 112-154 provides that in

addition to those Veterans currently eligible for SAH under 38 U.S.C. § 2101(a) (see 38 C.F.R. § 3.809), Veterans who served on or after September 11, 2001, and incurred a permanent, but not necessarily total, disability that is “due to the loss or loss of use of one or more lower extremities which so affects the functions of balance or propulsion as to preclude ambulating without the aid of braces, crutches, canes, or a wheelchair” are eligible for the SAH benefit. The amendment is temporary, and provides that the SAH benefit may be awarded for claims pending on or after October 1, 2012, as long as the application is approved on or before September 30, 2013. Unless Congress extends or makes this benefit permanent, we will not amend the regulation, 38 C.F.R. § 3.809.

Decision makers should be aware that this new provision is only available to Global War on Terror (GWOT) Veterans and, in addition, differs from prior SAH benefits in the following ways:

There must be loss or loss of use (LOU) of a minimum of one leg, rather than both.

The loss or LOU must be permanent but need not be totally disabling.

The loss or LOU must prevent ambulation (walking) without the use of braces, crutches, canes or a wheelchair. Former SAH provisions provided that the disability must preclude locomotion, which may be interpreted as precluding movement rather than specifically precluding walking/ambulation. As a result, if a competent medical opinion shows that due to the loss or LOU of at least one lower extremity, the GWOT Veteran cannot walk without the use of braces, crutches, canes or a wheelchair, which are used for the purpose of balance or propulsion, award the SAH benefit to the Veteran.

This new SAH benefit does not change existing SAH procedures. Since Rating Board Automation (RBA) 2000 does not contain text regarding the law that provides this new benefit, decision makers who award this benefit should insert the following text in addition to the generated text in the Reasons for Decision block:

Section 202 of Public Law 112-154 provides that in addition to those Veterans currently eligible for Specially Adaptive Housing (My Notes: It’s actually called Specially Adapted Housing.) under 38 U.S.C. § 2101(a), Veterans who served on or after September 11, 2001, and incurred a permanent disability that is “due to the loss or loss of use of one or more lower extremities which so affects the functions of balance or propulsion as to preclude ambulating without the aid of braces, crutches, canes, or a wheelchair” are eligible for the SAH benefit. The amendment, which is temporary, provides that the SAH benefit may be awarded for claims pending on or after October 1, 2012, as long as the application is approved on or before September 30, 2013.

NOTE: VBMS-R users should insert the standard glossary text entitled “SAH_GWOT” in addition to the generated text in the Reasons for Decision block.

SAH_GWOT December 2013 Compensation Service Bulletin (CSB) Addendum –SAH provisions of PL 113-37 and 112-

154 to 9/30/14; adds ALS as qualifying condition; need to use WTEMS from addendum & add this text to Ratings:

o Temporary provisions of 38 U.S.C. §2101(a) provide that Veterans who served on or after September 11, 2001, and incurred a permanent disability that is “due to the loss or loss of use of one or more lower extremities which so affects the functions of balance or propulsion as to preclude ambulation without the aid of braces, crutches, canes, or a wheelchair” may be awarded SAH. The temporary provisions apply to claims pending on or after October 1, 2012 and approved by the Secretary on or before September 30, 2014.

o ALS is a qualifying permanent and total disability for the purpose of specially adapted housing.

Per SAH_GWOT, Public Law 113-175 extended this provision for claims pending for the same period as long as the application is approved on or before September 30, 2015.

IX.i.3.1.f says extend to 9/30/18 by PL 114-58

...

specially adapted housing (SAH):We have established entitlement to specially adapted housing assistance because you have service-connected {loss/permanent loss of use of both lower extremities}, and need to use {braces, crutches, canes, or a wheelchair} for locomotion / blindness in both eyes, having only light perception, plus the {anatomical loss/permanent loss of use} of one lower extremity / {loss/permanent loss of use} of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion so that you need to use {braces, crutches, canes, or a wheelchair} for locomotion / loss/permanent loss of use of one lower extremity together with the loss of use of one upper extremity which so affect the functions of balance or propulsion so that you need to use {braces, crutches, canes, or a wheelchair} for locomotion / {loss/permanent loss of use} of both upper extremities such as to preclude use of the arms at or above the elbow / full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk. also see SHA_GWOT

3.809a Special home adaptation grants under 38 U.S.C. 801(b) – (SHA/SHAG) (i) bilateral blindness w/ 20/200 or less, (ii) both hands, (iii) burn, (iv) inhalation; can do this first, & when entitled to SAH later, get the difference between the 2; this is the lesser benefit of the two

III.iv.6.B – inferred issues, do not infer to deny

IX.i.3 December 2012 Compensation Service Bulletin (CSB) – Section 203 of Public Law 112-154 changes are

codified at and amend 38 CFR § 3.809A, and 38 USC § 2101(b)(2) (note that (b) is entitled “Adaptations to Residence of Veteran.” The public law amends the definition of blindness and deletes the term "permanent and total" from the description of blindness. As noted in the September 2012 VSCM call, Section 203 changes the requirement to central acuity of 20/200 or less in the better eye with the use of a standard correcting lens. An eye with a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having a central visual acuity of 20/200 or less.

The following text should be inserted into RBA, if there is an award of the SHA grant based upon the enhanced definition of blindness, until it can be amended:

Section 203 of P.L. 112-154 amends section 2101(b)(2) to provide special home adaptations to Veterans who have central acuity of 20/200 or less in the better eye with the use of a standard correcting lens. An eye with a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having a central visual acuity of 20/200 or less.

NOTE: VBMS-R users should insert the standard glossary text entitled “SHA_GWOT” in addition to the generated text in the Reasons for Decision block.

April 2013 Compensation Service Bulletin (CSB) – Do not return an otherwise sufficiently completed DBQ for a specific examiner statement using the “subtends” language (the statutory amendment provides the following new visual field equivalent of central visual acuity of 20/200: “the widest diameter of the visual field subtends an angle no greater than 20 degrees.”). Contraction of the visual field to 20 degrees or less is synonymous with the statutory standard. A grant of SHA based on blindness requires no better than the specified visual acuity or the equivalent field loss in either eye. Therefore the examiner should have checked “yes” to item 4.e or 10.e. on the DBQ indicating legal or statutory blindness based on visual acuity or visual field loss.

October 2013 Compensation Service Bulletin (CSB) – an inhalational injury is characterized as due to breathing steam or toxic inhalants such as fumes, gases, and mists present in a fire environment (examples of toxic inhalants are acrolein, chlorine, phosgene, and nitrogen dioxide). A respiratory disability rated permanently and totally disabling must result from an inhalational injury consistent with the definition provided in the Federal Register to warrant entitlement to a SHA grant under § 3.809a. The mere existence of a respiratory disability is not synonymous with an inhalational injury. In the absence of such inhalational injury, the SHA grant will not be authorized.

also see SHA_GWOTspecial home adaptation grant (SHA/SHAG):We have established entitlement to special home adaptation grant because you have service-connected {blindness in both eyes with 20/200 visual acuity or less / {loss/permanent loss of use} of both hands / deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the

trunk / full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities/at least one extremity and the trunk / residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma and chronic pulmonary disease}. also see SHA_GWOT

specially adapted housing (SAH):USE VBMS-R System-Generated OR:We have considered but denied entitlement to specially adapted housing assistance. We will issue a certificate of eligibility for assistance in acquiring specially adapted housing when a veteran is permanently disabled from one of the following conditions which is the result of injury or disease incurred in or aggravated during active military service: the loss, or loss of use, of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; the loss or loss of use of one lower extremity together with the loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbow; or full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk. {Additionally, there is a temporarily expanded eligibility (through September 30, 2013) for veterans who served and became permanently disabled on or after September 11, 2001 due to the loss or loss of use of one lower extremity, severely affecting the functions of balance or propulsion.} Since a qualifying disability is not shown, we cannot establish entitlement to specially adapted housing assistance. also see SHA_GWOT

Special home adaptation grant (SHA/SHAG):USE VBMS-R System-Generated OR:We have considered but denied entitlement to special home adaptation grant. We will issue a certificate of eligibility for assistance in acquiring necessary special home adaptations when a veteran has a service-connected condition which is due to blindness in both eyes with 20/200 visual acuity or less; or loss or permanent loss of use of both hands; or deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma and chronic pulmonary disease). Since a qualifying disability is not shown, we cannot establish entitlement to special home adaptation grant. also see SHA_GWOT

If deny specially adapted housing & special home adaptation because conds are NSC, add the following:NOTE: Please contact the VA Medical Center concerning possible eligibility for home improvement and structural alteration (HISA) benefits.

3.810 Clothing allowance – Authorization issue only, no rating done - annual clothing allowance payment (ACAP) requests should be forwarded to the appropriate VAMC or Outpatient Clinic of jurisdiction, and veteran should be notified accordingly. IX.i.7.1.b

SPECIAL MONTHLY COMPENSATION (SMC) –

o The SMC Reference Tool is available here (or go to START – Run and enter: \\vbasdcnss1\Instructor Folder\DRO & RVSR References Tool and find “SMC Reference Tool.xls”)

o SMC Calculator [and it’s User Guide] – IV.ii.2.H.1.h - calculator required for ALL SMC & must upload SMC calculator sheet; as of 9/17, SMC Calculator in VBMS-R -

https://www.vapulse.net/message/171092 (as of 9/20/17) says we need to screen print the SMC Input Results screen and upload to the claims folder (also says “as long as both calculators are available, either one may be used”); http://vbaw.vba.va.gov/VBMS/docs/VBMS_Tips_and_Tricks_13_1.pdf - solution for the embedded SMC Calculator finalization error is: “Edit” each system generated SMC paragraph & code line (do paragraph first, then codes)

Subject: SMC Calculator Worksheet VBMS Document Category-Type: Worksheet: Rating Calculator WorksheetsSource: VBMS (shouldn’t source be “VBMS-R” now that it is an option?)

o Training documents are under “Higher Level Special Monthly Compensation” at http://hvnc.gdit.com/lc/

SMC_Info [spreadsheet] (from 2015) is saved at H:\VSC\Rating Reference

3.350 Special monthly compensation ratings – (SMC)

3.401(a) 4.63 4.64 III.iv.6.B – inferred issues, do not infer to deny

IV.ii.2.H V.iii.2.A – A&A for spouse (DIC)

H:\VSC\Training\NTC Class Material\Intro & Higher Level SMC 1-8-15

(a) K – anatomical loss/loss of use of:DCs

one or more creative organs (only one K allowed for creative organs)

III.iv.4.I.3.b – changed 8/17/16, When the evidence shows LOU of a creative organ due to an SC condition, entitlement to SMC (k) will be awarded even though the Veteran can achieve erection and penetration with the use of medication

IV.ii.2.H.4.b LOU includes partial erectile dysfunction & retrograde ejaculation, also includes loss

of use of one testicle if there is atrophy of a testicle resulting from mumps followed by orchitis), III.iv.4.I.3.h & III.iv.4.I.3.i – in all cases of radical prostatectomy, award SMC K for loss of use of a creative organ & consider SC for ED based on facts-found

May 2016 Quality Call Notes & May 2016 Compensation Service Bulletin (CSB) – does not matter if can penetrate & ejaculate without the use of medication (5C), give SMC K if have Yes in 5A (this is a change) My Notes: On some DBQs, it’s 4A.

* My Notes: Prior to this change, policy was that SMC was not warranted if medication was effective. So, if not granted, it is not a CUE. Unclear if you can grant for claims prior to 5/16.

7520, 7521, 7522, 7523, 7524

7617, 7618, 7619, 7620

one hand (per Jeff Myers 11/09 training, if there is no thumb loss, you can do LOU, if appropriate, but not anatomical loss)

5125, 5126, 5127, 5128, 5129, 5130, (5131)

one foot 5167, 5166, 5165, 5164, 5163, 5162, 5161, 5160

both buttocks (MG XVII, bilateral)(per Jeff Myers 11/09 training, can do L+K, if appropriate)

5317

blindness of 1 eye w/LPO (includes enucleation/anatomical loss of an eye, NLP and LPO)

6063, 6064

bilateral deafness with absence of air and bone conduction (both at XI or absence of air & bone conduction = 100%)

6100

complete organic aphonia (includes organs of speech, but not aphasia from stroke)IV.ii.2.H.4.i

6518, 6159, 7202

1 or both breasts (Women only)

IV.ii.2.H.4.k distinct from creative organ & can have one K for each (creative organ & breast(s)

eff 11/1/00 for loss of one or both breasts, including loss by mastectomy

eff 12/6/02 for loss of 25% or more from a single breast or both breasts, including loss by mastectomy, partial mastectomy or radiation treatment of the breast(s) (per Jeff Myers 11/09 training, do not need to show loss of tissue with radiation, as radiation affects/destroys normal function)

7626

$ cannot exceed rate at L if combine with “a” thru “j” & “s”$ cannot exceed rate at O if combine with “l” thru “n” or “p”

(b) L – anatomical loss/loss of use of:DCs Code Paragrap

hboth feet 5107, 5110 03 L1one hand & one foot 5104, 5105, 5108,

511103 L1

both eyes at 5/200 or less(includes concentric contraction of the filed of vision to 5 degrees or fewer) (excludes worse than 10/200 but better than 5/200)

6061, 6062, 6063, 6064, 6065, 6080

03 LB1

permanently bedridden (no reduction when at government expense, so this is a higher benefit) - need 1 disability at 100%

03 L1

A&A

IV.ii.2.H.8.b - need 1 disability at 100% which is the sole or partial cause of the need for A&A (but can use combined for MS, Parkinson’s, DM, etc), 4.16 does NOT apply, but 4.16 does apply for A&A for TBI to get to SMC T [if A&A granted based on October 2014 Compensation Service Bulletin (CSB) (in effect 10/14 to 1/5/16), do not change]

IV.ii.2.H.8.c – get exam if disability not at 100% but there is indication of worsening

A&A cannot be for something already getting “L” for, i.e. loss of feet, 1 hand & 1 foot, or both eyes [can’t use same disab for 100% A&A & 100% P OR 100% A&A & 100% LOU, to get to R1, need 3 at 100%]

IV.ii.2.H.8.d – says the need for A&A does not have to be permanent (My Notes: It seems the 100% disability

03 L1

still has to be permanent, but that’s not explicit anywhere in the manual or regs.)

2L’s=O3

(c) M – anatomical loss/loss of use of:*disability must be PERMANENT DCs Paragraphboth hands 5106, 5109 M1both knees w/o action w/prosthesis (My Notes: Prosthesis could be brace that doesn’t allow the joint to bend.)

5107, 5110 M2

one elbow w/o action w/prosthesis & one knee w/o action w/prosthesis

5104, 5105, 5108, 5111 M2

ANDblindness in both eyes w/LPO 6062 MB1blindness in both eyes (i.e. 5/200 or less) needing A&A 6061, 6062, 6063, 6064,

6065, 6080MB1

(d) N – anatomical loss/loss of use of:*disability must be PERMANENT DCs Paragraphboth elbows w/o action w/prosthesis 5106, 5109 N1anatomical loss of both hips so cannot use prosthesis 5107, 5110 N2one shoulder so cannot use prosthesis & one hip so cannot use prosthesis

5104, 5105, 5108, 5111 N2

anatomical loss of both eyes or blindness w/NLP 6061, 6062 NB1

(e) O – *disability must be PERMANENT DCs Paragraphanatomical loss/loss of use of both shoulders so cannot use prosthesis 5106, 5109 O1two or more of L-N O3bilateral deafness at 60% (only one ear has to be SC) & bilateral blindness at 20/200 (formerly 5/200) or less, eff 12/26/07

6100 & 6061, 6062, 6063, 6064, 6065, 6066 (70% or greater)

OB1

total deafness in one ear or bilateral deafness at 40% (only one ear has to be SC) & bilateral blindness w/LPO or less

6100 & 6061, 6062

OB2

paraplegia w/loss of anal & bladder sphincter control (will be at max O due to loss of use of both legs & helplessness)

5110, 7332 & 7542

O2

cannot give A&A for LOU of bilateral lower extremities as already at “L” for the latter, need separate pathology for the A&A, also cannot give bedridden & A&A for same LOU

(f) P – anatomical loss/loss of use of:*disability must be PERMANENT, can do P twice if involves triple loss, and can keep the K

DCs Paragraph

one foot & one knee w/o action w/prosthesis = L½ 5107, 5110 L2one foot & one hip so cannot use prosthesis = M 5107, 5110 M3one foot & one elbow w/o action w/prosthesis = L½ 5104, 5105, 5108,

5111L2

one foot & one shoulder so cannot use prosthesis = M 5104, 5105, 5108, 5111

M3

one knee w/o action w/prosthesis & one hip so cannot use prosthesis = M½

5107, 5110 M4

one knee w/o action w/ prosthesis & one hand = L½ 5104, 5105, 5108, 5111

L2

one knee w/o action w/prosthesis & one shoulder so cannot use prosthesis = M½

5104, 5105, 5108, 5111

M4

one hip so cannot use prosthesis & one hand = M 5104, 5105, 5108, 5111

M3

one hip so cannot use prosthesis & one elbow w/o action w/prosthesis = M½

5104, 5105, 5108, 5111

M4

one hand & one elbow w/o action w/prosthesis = M½ 5106, 5109 M5

one hand & one shoulder so cannot use prosthesis = N 5106, 5109 N3one elbow w/o action w/prosthesis & one shoulder so cannot use prosthesis = N½

5106, 5109 N4

ANDone eye at 5/200 & blindness w/LPO in other = L½ 6064 LB2one eye at 5/200 & anatomical loss or blindness w/NLP in other = M 6063, 6064 MB2blindness w/LPO & anatomical loss or blindness w/NLP = M½ 6062 MB3both eyes at 5/200, OR one at 5/200 & one w/LPO, OR one at 5/200 & one w/NLP, & total deafness in one ear = next higher, but no higher than O

6064, 6065 & 6100

PB1

bilateral blindness w/LPO OR one w/LPO & one w/NLP, & bilateral deafness at 10 or 20% (only one ear has to be SC) = next higher, but no higher than O

6062 & 6100 PB2

bilateral blindness under L, M, N, OR one at 5/200 & one w/LPO, OR one at 5/200 & one w/NLP, OR one w/LPO & one w/NLP, & bilateral deafness at 30% (only one ear has to be SC) = next higher, but no higher than O

6061, 6062, 6063, 6064, 6065, 6080 & 6100

PB3

bilateral blindness under L, M, N OR one at 5/200 & one w/LPO, OR one at 5/200 & one w/NLP, OR one w/LPO & one w/NLP, PLUS one hand, OR PLUS one foot (w/combined to 50%), OR PLUS one foot at <50% = next higher, but no higher than O

6061, 6062, 6063, 6064, 6065, 6080, & 5125, 5126, 5127, 5128, 5129, 5130, (5131) OR 5166, 5167

PB4 (hand) PB5 (foot & at 50%) or P3 (foot at <50%)

ANDadditional 50% = half step, but no higher than O (can only use 50% or 100%, not both) – *additional 50% disability must be PERMANENT, disability has to be separate & distinct from L+ disabilities, but can be the same as the K disability; 3.350(f)(3), IV.ii.2.H.6

P1

additional 100% = next higher, but no higher than O(4.16 applies; cannot use with temporary 100% under paragraph 30) (can only use 50% or 100%, not both) – *additional 100% disability must be PERMANENT, disability has to be separate & distinct from L+ disabilities, but can be the same as the K disability; 3.350(f)(4), IV.ii.2.H.6

P2

3 extremities = next higher, but no more than what is stated in P P3

November 2014 Rating Quality Call Notes – Failure to grant SMC P1 is still a common error. The criteria per 38 CFR 3.350(f)(3) requires:

o Additional independent 50% disabilitieso Disabilities must be separate and distinct from disabilities compensated SMC L – N ½o SMC K disabilities may be consideredo Is only granted once (per date) and never with P2

There have been concerns in the past regarding whether or not the SMC calculator is at fault for the P1 errors. However, the calculator functions properly as long as the data is input correctly.

So, decision makers need to spend a little extra time reviewing the codesheet when SMC L or higher has been awarded. If there are additional disabilities combining to 50% or higher, and it has not already been applied, the data should be correctly input into the SMC calculator, and the codesheet should be reviewed to ensure the data was correctly input.

from Carlos Rosario 12/1/14 -

In reference to SMC L and above, 38 CFR 3.350(f)(3) and (f)(4) allow us to can grant a half step or a full step for additional independent disabilities 50 percent or more, and for an additional independent disability evaluated at 100 percent. However, the disabilities must be permanent.

For example:

1. The veteran has LOU of both feet and there is a separate single 100% for prostate cancer.  The prostate cancer has a future exam.In this scenario you will assign SMC L for the LOU both feet but you cannot give a full step using the

100% for the prostate cancer because the evaluation for prostate cancer is not permanent.

2. The veteran has LOU of both feet and there is a separate single 60% for COPD. There is no future examination for COPD.In this scenario you will assign SMC L1/2 for the LOU both feet and a ½ step increase because of the permanent evaluation for COPD which is more than 50%. SMC (L+P1) = L1/2

3. The veteran has LOU of both feet and there is a separate single 100% for CAD. There is no future examination for CAD. In this scenario you will assign SMC M for the LOU of both feet and the full step increase because the permanent 100% CAD evaluation. SMC (L+P2) = M

Rating Note: Cannot apply P since 3.350(f)(3) says “the disability or disabilities independently ratable at 50 percent or more must be separate and distinct and involve different anatomical segments or bodily systems from the conditions establishing entitlement under 38 U.S.C. 1114 (l) through (n)” / 3.350(f)(4) says “the single permanent disability independently ratable at 100 percent must be separate and distinct and involve different anatomical segments or bodily systems from the conditions establishing entitlement under 38 U.S.C. 1114 (l) through (n),” and {} is not separate and distinct, involving different anatomical segments or bodily systems from {} / and none of the veteran’s disabilities are separate and distinct since they are all DM-related.

SMC Calculator questions translations:

i.e. - Is P warranted at a full step for additional, permanent, separate & distinct 100%?

i.e. - Is P warranted at a half step for additional, permanent, separate & distinct 50%?

(g) Q should be closed out if granting $ (Q1 or Q2)

(h) R for A&A with N ½ + K, O or P (R1) & A&A w/higher level of care w/ N ½ + K, O or P (R2)

R1 - can use same disability twice

R2 – need evidence (as of 1/5/16, no longer needs to be from treating or supervising licensed health care professional) that veteran needs “ongoing daily skilled care & in the absence of such care, would require care

in a facility”; can be provided by family members if supervised by MD; if have no statement, need exam, IV.ii.2.H.9.d

(i) S for 100% + 60% (S1) [per 3.350(i)(1) the additional 60% have to be separate & distinct, involving different anatomical segments/body systems], or 100% + HB (S2)

III.iv.6.B.3.d – inferred issues, do not infer to deny

III.iv.6.B.6.e – defines anatomical segment per 3.350(f)(3) & (4), it’s different from anatomical region in 4.55(b)

Howell v. Nicholson (3/23/06) - leaving one’s house for medical purposes does not preclude entitlement to SMC housebound benefits

Bradley v. Peake (11/26/08) & - SMC S based on IU if IU is based on a single disability and the veteran is housebound due to that disability, or has additional SC disabilities that combine to 60% or more. 4.16 does not apply for the IU based on a single disability (it truly has to be a single disability). IV.ii.2.F.4.f & IV.ii.2.H.10

January 2011 Compensation Service Bulletin (CSB) - Special Monthly Compensation (SMC) under 38 U.S.C. § 1114(s) (Statutory Housebound) and a Total Rating Based Upon Individual Unemployability (TDIU)The United States Court of Appeals for Veterans Claims (Court) held in Bradley v. Peake, 22 Vet. App. 280 (2008), that for purposes of SMC at the (s) rate, the statute does not limit a service-connected disability rated as total to only a schedular 100-percent rating. The regulation permits a TDIU rating based on a single disability to satisfy the statutory requirements of a total rating. For example, a Veteran who is in receipt of a TDIU rating based on a single disability, but is also service connected for other disabilities totaling 60 percent or more, is entitled to SMC housebound at the (s) rate – or “statutory housebound” – under the Bradley decision. If, subsequently, the Veteran files a claim for an increased evaluation and is increased to a schedular 100 percent evaluation, there is a question whether the Veteran continues to meet the entitlement criteria under Bradley for entitlement to SMC at the (s) rate.

The Court was clear that VA is obligated to maximize the benefits granted. In Bradley, the Court explained that in a case where an increase to a 100-percent schedular rating would subsume the TDIU rating and the Veteran would no longer be entitled to SMC at the (s) rate, VA decision makers are to assess whether the Veteran still meets the criteria for TDIU based on a single disability before substituting a combined total schedular rating for the TDIU. As a result, in cases where a single service-connected condition supports a TDIU rating and the Veteran has other service-connected conditions entitling him or her to statutory housebound, the TDIU evaluation should be retained if the Veteran would otherwise lose the SMC rate.

Guerra v. Shinseki (4/29/11) 38 CFR 4.16(a) cannot be applied for the grant of IU and then grant housebound. The Federal Circuit stated that the regulation’s reference to a “single service-connected disability rated as 100 percent” resolves any ambiguity in the statute and makes it clear that SMC S (3.350(i) is only payable if the veteran has a single disability that is rated 100 percent.

January 2013 Compensation Service Bulletin (CSB) – if a Veteran has a 100 percent combined schedular evaluation as the result of a single disease entity, such as multiple sclerosis, Parkinson’s disease, or diabetes mellitus, which is manifested by multiple disabilities, and the evidence shows that the Veteran requires A&A due to the disabilities related to the disease, SMC at the (l) rate may be granted. Multiple disabilities resulting from a single disease process is significantly different from any of the combinations identified under section 4.16(a). For example, a Veteran is service connected (SC) for Parkinson’s disease and has multiple disabilities related to the disease that result in a combined 100-percent schedular evaluation. If the evidence shows that the disabilities related to the disease are so severe that the Veteran requires A&A, entitlement to SMC at the (l) should be granted.

July 2013 Compensation Service Bulletin (CSB) – continuing from above, if entitlement to SMC (l) due to A&A has already been established as the result of multiple disabilities due to single disease entity, the subsequent grant of service connection for loss of use (LOU) of the upper or lower extremities would establish a second (l) rate, which would warrant a grant of SMC at the (o) rate on the basis of two separate (l) entitlements, if no condition is being considered twice.

Example where VBMS-R says to do temporary SMC S 6/20/16-6/30/17, but the SMC Calculator says to stop the SMC S on 7/1/17 (use 6/30/17 for Decision & Reasons for Decision lines)

My Notes: VBMS-R forces reviews of SMC S when there is one disability at 100% (or 70%+IU), but there are no separate disabilities that combine to 60% & there is no option for that specific “reason” for not granting SMC S, so I choose:

Rating Note: VBMS-R indicates the SMC S may be warranted, but the veteran does not have separate disabilities that combine to 60% & there is no option for that specific “reason” for not granting SMC S, so I chose the closest reason.

3.352 Criteria for determining need for aid and attendance and "permanently bedridden"

SummaryK: One hand/one foot/both buttocks/one eye LPO or anatomical loss/creative organ/bilateral deafness/complete

organic aphonia/one or both breasts

L: Both feetHand and footA&A (need one disability at 100%, reduce hospital rate unless bedridden)Both eyes 5/200

L½: Foot and other kneeElbow and foot

M: Both hands or kneesHand and hipElbow and kneeShoulder and footBoth eyes LPOBoth eyes 5/200 plus A&A due to blindness

M½: Hand and other elbowElbow and hipKnee and other hip

N: Both elbows or hips (highest level for lower extremities)Hand and other shoulderShoulder and hipBoth eyes NLP/anatomical loss

N½: Elbow and other shoulder

O: Both shouldersParaplegia (i.e. both feet) with loss of bowel and bladder (no hospital reduction)

Both hands and both feetTwo of “L” through “N”Bilateral deafness at 60% or more and bilateral vision 5/200 or lessTotal deafness in one ear or bilateral deafness at 40% and bilateral blindness (LPO or less)

P: Blindness and loss of hand or foot (keep elevations for 50% and 100%)Plus ½ step for 50% (can be combined)Plus 1 step for 100% (single disability, but can use 4.16)Can only use 50% or 100% once per effective date!

R1: At max under “O” or “P” and needs A&A (always reduced during hospitalization, max of “O”)

R2: At max under “O” or “P” and needs HLC (always reduced during hospitalization, max of “O”)

TRIPLE EXTREMITY- add ½ step plus KM+K: Both feet (L) and one hand (1/2 for 50%, 1/2 for 3rd extremity, K)M½+K: Both hands (M) and one foot (1/2 for 3rd extremity, K)N+K: Both hands (M), one foot (1/2 for 3rd extremity, K) and % to get to 50% (1/2 for 50%)

VBMS-R SMC Paragraph Codes

K1 = anatomical loss/loss of use of a creative organanatomical loss/loss of use of both buttocksanatomical loss of one eye/loss of use of one eye having only light perceptionanatomical loss/loss of use of one footanatomical loss/loss of use of one handanatomical loss of one or both breasts (including loss by mastectomy)complete organic aphonia with constant inability to communicate by speechdeafness of both ears, having absence of air & bone conduction (both at XI, 100%)

*there is an optional sentence which says “Not payable concurrently with SMC under subsection (l))”

*disability must be PERMANENTL1 = anatomical loss/loss of use of both feet (various combinations)

anatomical loss/loss of use of one hand and one foot (various combinations)being permanently bedriddenbeing so helpless as to be in need of regular aid and attendance

L2 = anatomical loss/loss of use of one foot/hand with the anatomical loss/loss of use of one arm/leg at a level or with complications preventing natural elbow/knee action with prosthesis = L½ (from P)

LB1 = blindness in both eyes at 5/200 or less

LB2 = blindness of one eye at 5/200 or less and blindness of the other eye having only light perception = L½ (from P)

*disability must be PERMANENTM1 = anatomical loss/loss of use of both hands (various combinations)

M2 = anatomical loss/loss of use of one leg at a level or with complications preventing natural knee action with prosthesis in place and anatomical loss/loss of use of one arm/the other leg at a level or with complications preventing natural elbow/knee action with prosthesis in place

M3 = anatomical loss/loss of use of one foot/hand with the anatomical loss/loss of use of one arm/leg so near the hip/shoulder as to prevent the use of a prosthetic appliance (from P)

M4 = anatomical loss/loss of use of one arm/leg at a level preventing natural elbow/knee action with prosthesis in place with the anatomical loss of one leg/one arm/the other leg so near the hip/shoulder as to prevent the use of a prosthetic appliance = M½ (from P)

M5 = anatomical loss/loss of use of one hand with the anatomical loss/loss of use of one arm at a level or with

complications preventing natural elbow action with prosthesis in place = M½ (from P)

MB1 = blindness in both eyes having only light perception/rendering the veteran so helpless as to be in need of regular aid and attendance

MB2 = blindness of one eye with 5/200 or less and anatomical loss of the other eye/blindness of the other eye having no light perception (from P)

MB3 = blindness in one eye having only light perception and anatomical loss of the other eye/blindness of the other eye having no light perception = M½ (from P)

*disability must be PERMANENTN1 = anatomical loss/loss of use of both arms at a level or with complications preventing natural elbow action with

prosthesis in place

N2 = anatomical loss/loss of use of one leg so near the hip as to prevent the use of a prosthetic appliance and the anatomical loss of one arm/the other leg so near the hip/shoulder as to prevent the use of a prosthetic appliance

N3 = anatomical loss/loss of use of one hand with the anatomical loss of one arm so near the shoulder as to prevent the use of a prosthetic appliance (from P)

N4 = anatomical loss/loss of use of one arm at a level or with complications preventing natural elbow action with prosthesis in place with the anatomical loss of the other arm so near the shoulder as to prevent the use of a prosthetic appliance = N½ (from P)

NB1 = anatomical loss/blindness without light perception in both eyes (three combinations)

*disability must be PERMANENTO1 = anatomical loss of both arms so near the shoulders as to prevent the use of prosthetic appliances

O2 = paraplegia with loss of use of both legs and loss of anal and bladder sphincter control (will be at max O due to loss of use of both legs and helplessness)

O3 = two or more of L-N

OB1 = deafness at 60 percent or more (only 1 ear has to be SC) and bilateral blindness at 20/200 (formerly 5/200) or less (eff 12/26/07)

OB2 = unilateral total deafness or bilateral deafness at 40 percent or more (only 1 ear has to be SC) and (bilateral) blindness having only light perception or less

*additional 50% or 100% disability must be PERMANENTP1 = additional 50% = next higher, but no higher than O (can only use P1 or P2, not both)

P2 = additional 100% = next higher, but no higher than O (4.16 applies; cannot use with temporary 100% under paragraph 30) (can only use P1 or P2, not both)

P3 = 3 extremities = next higher, but no more than what is stated in P

PB1 = bilateral blindness at 5/200 or less/having only light perception/without light perception (three combinations), PLUS unilateral total deafness rated at 10 or 20 percent = next higher, but no higher than O

PB2 = bilateral blindness having only light perception/without light perception (two combinations), PLUS bilateral deafness rated at 10 or 20 percent (only 1 ear has to be SC) = next higher, but no higher than O

PB3 = bilateral blindness under L, M, N/at 5/200/having only light perception/without light perception (various combinations), PLUS bilateral deafness at no less than 30 percent (only 1 ear has to be SC) = next higher, but no higher than O

PB4 = bilateral blindness under L, M, N/at 5/200/having only light perception/without light perception (various

combinations), PLUS anatomical loss/loss of use of one hand = next higher, but no higher than O

PB5 = bilateral blindness under L, M, N/at 5/200/having only light perception/without light perception (various combinations), PLUS anatomical loss/loss of use of one foot (w/combined to 50%) = next higher, but no higher than O

PB6 = bilateral blindness under L, M, N/at 5/200/having only light perception/without light perception (various combinations), PLUS anatomical loss/loss of use of one foot at less than 50% = next higher, but no higher than O

(should be closed out if granting $)Q1 = TB completely arrested, not closed-out

Q2 = TB completely arrested, closed-out

R1 = at N ½ +K, or O, or the maximum P and being in need of regular aid and attendance

R2 = at N ½ +K, or O, or the maximum P and being in need of regular aid and attendance and needing a higher level of care

S1 = 100% + 60% (statutory) – neither the 100%, nor the 60%, need to be permanent

S2 = 100% + housebound (in fact) – *the 100% disability must be PERMANENT

Special Monthly Compensation Codes

SMC Abbreviation

SMC Code

Description

K 01 One disability under (k)- 38 CFR 3.350(a)2K 02 Two disabilities under (k)3K 14 Three disabilities under (k)L 03 (1)- 38 CFR 3.350(b) or 3.552(g) & (h)L+K 04 (1) plus one (k)L+2K 05 (1) plus two (k)'sL+3K 06 (1) plus three (k)'sL1/2 18 Intermediate evaluation between (1) and (m)- 38 CFR 3.350(f)(1),(2)&(3)L1/2+K 24 Intermediate evaluation between (1) and (m) plus one (k)L1/2+2K 29 Intermediate evaluation between (1) and (m) plus two (k)'sL1/2+3K 33 Intermediate evaluation between (1) and (m) plus three (k)'sM 07 (m) 38 CFR 3.350(c) or 3.552(g)&(i)M+K 08 (m) plus one (k)M+2K 09 (m) plus two (k)'sM+3K 10 (m) plus three (k)'sM1/2 20 Intermediate evaluation between (m) and (n)- 38 CFR 3.350(f)(1), (2),(3)& (4) or 3.552(i)M1/2+K 26 Intermediate evaluation between (m) and (n) plus one (k)M1/2+ 2K 31 Intermediate evaluation between (m) and (n) plus two (k)'sM1/2+3K 35 Intermediate evaluation between (m) and (n) plus three (k)'sN 11 (n) -38 CFR 3.350(d) or 3.552(g) & (i)N+K 12 (n) plus one (k)N+2K 13 (n) plus two (k)'sN+3K 15 (n) plus three or more (k)'sN1/2 22 Intermediate evaluation between (n) and (o) -38 CFR 3.350(f)(1), (2),(3)& (4)

N1/2+K 28 Intermediate evaluation between (n) and (o) plus one (k)O 37 Equal to (o); No rating of need for regular A/A under (1), (m) or (r) -38 CFR 3.350(e)P=M 19 Equal to(p)(m) -38CFR3.350(f)(1),(2),(3)&(4)P=M+K 25 Equal to (p)(m) plus one (k)P=M+2K 30 Equal to (p)(m) plus two (k)'sP=M+3K 34 Equal to (p)(m) plus three (k)'sP=N 21 Equal to(p)(n) 38 CFR 3.350(f)(1),(2),(3)&(4)P=N+K 27 Equal to (p)(n) plus one (k)P=N+2K 32 Equal to (p)(n) plus twoQ 36 Statutory grant for arrested TB (formerly 38 U.S.C. 314(q), 38 CFR 3.350(g))R1=N1/2(A/A)+K 43 Entitlement to A/A is based on the disabilities establishing N1/2 plus K. Entitled to N 1/2 plus K

rate while hospitalized 38 CFR 3.350(h), 3.552(b)(2).R2=N1/2(A/A with HLC)+K

44 Entitlement to A/A and need for higher level of care is based on the disabilities establishing N1/2 plus K. Entitled to N1/2 plus K rate while hospitalized -38 CFR 3.350(h), 3.552(b)(2)

R1= O(L(A/A)+L) 51 Entitled under (o) based on need for A/A under (1) plus entitlement under (1) for other conditions. Entitled to(m) while hospitalized -38 CFR3.550(h), 3.552(f) & (g).

R1 = O(L(A/A)+L1/2)

52 Entitled under (o) based on need for A/A under (1) plus entitlement at the intermediate rate between (1) and (m) for other conditions. Entitled to the intermediate evaluation between (m) and (n) while hospitalized -38 CFR 3.350(h), 3.552(f)&(g).

R1= O(L(A/A)+M) 53 Entitled under (o) based on need for A/A under (1) plus entitlement under (m) for other conditions. Entitled under (n) while hospitalized -38 CFR 3.350(h), 3.552(f)&(g).

R1= O(L(A/A) + M1/2)

54 Entitled under (o) based on need for A/A under (1) plus entitlement under (p)(1) at the intermediate rating between (m) and (n) for other conditions. Entitled to the intermediate evaluation between (n) and (o) while hospitalized -38 CFR 3.3.50(h), 3.552(f)&(g).

R1=O(N+L(A/A)) 55 Entitled under (o) or (p) based on need for A/A with R1= O(N1/2+L(A/A)) entitlement to (n), or the intermediate evaluation between (n) R1=O+L(A/A) and (o), or (o). Entitled to (o) while hospitalized -38 CFR 3.350(e), 3.552(b)(2).

R2= O(L(A/A with HLC)+L)

56 Entitled under (o) based on need for A/A under (1) plus entitlement under (1) for other conditions, and in addition is in need of a higher level of care. Entitled to (m) while hospitalized -38 CFR 3.350(h), 3.552(f)&(g)

R2=O(L(A/A with HLC)+L1/2)

57 Entitled under (o) based on need for A/A under (1) plus entitlement at the intermediate rate between (1) and (m) for other conditions, and in addition is in need of a higher level of care. Entitled to the intermediate evaluation between (m) and (n) while hospitalized -38 CFR 3.350(h), 3.552(f) & (g)

R2=O(L(A/A with HLC)+M)

58 Entitled under (o) based on need for A/A under (1) plus entitlement under (m) for other conditions, and in addition is in need of a higher level of care. Entitled to (n) while hospitalized -38 CFR 3.350(h), 3.552(f)&(g)

R2=O(L(A/A with HLC)+M1/2)

59 Entitled under (o) based on need for A/A under (1) plus entitlement under (p)(1) at the intermediate rate between (m) and (n) for other conditions, and in addition is in need of a higher level of care. Entitled to the intermediate evaluation between (n) and (o) while hospitalized -38 CFR 3.350(h), 3.552(f)&(g)

R2=O(L(A/A with HLC)+N)

60 Entitled under (o) or (p) based on need for A/A with R2=O(L(A/A with HLC)+N1/2) entitlement to (n), or the intermediate evaluation between (n) R2=0+L(A/A with HLC) and (o), or (o) and in addition is in need of a higher level of care. Entitled to (o) while hospitalized -38 CFR 3.350(e), 3.552(b)(2)

S 48 Housebound under (s) -Total plus 60% or housebound -38 CFR 3.350(i)S+K 49 Housebound under (s) plus one disability under (k)S+2K 50 Housebound under (s) plus two disabilities under (k)

Specific Injury Codes

Code Loss of Use Description Anatomical Loss Description Code00 No loss of use No amputation 00

Code Single Loss of Use Single Amputation Code

11 Eye (blind one eye) Eye (enucleation or avulsion) 11

12 Hand Hand 1213 Foot Foot 1316 Deafness total    17 Aphonia    

Code Double Losses of Use Double Amputations Code21 Eyes (blindness both eyes) Eyes (enucleation or avulsion) 21

22

Eyes (use only for blindness, both eyes in combination with total deafness or loss of use of one eye and enucleation of other eye in combination with total deafness)

Eyes (use only for enucleation, both eyes in combination with total deafness)

22

23 Hands Hands 2324 Feet Feet 2425 Hand and foot Hand and foot 2526 Eye and hand Eye and hand 2627 Eye and foot Eye and foot 2729 Deafness and aphonia    

Code Triple Losses of Use Triple Amputations Code31 Hand and feet Hand and feet 3132 Hands and foot Hands and foot 3233 Eye and hands Eye and hands 3334 Eye and feet Eye and feet 3435 Eyes and hand Eyes and hand 3536 Eyes and foot Eyes and foot 3637 Eye, hand, and foot Eye, hand, and foot 37

Code Other Multiple Losses of Use Including Aphonia81 Eye(s) and aphonia82 Hand(s) and aphonia

Code Quadruple Losses of Use Quadruple Amputations Code41 Hands and feet Hands and feet 4142 Eye, hands, and foot Eye, hands, and foot 4243 Eye, hand, and feet Eye, hand, and feet 4344 Eyes and hands Eyes and hands 4445 Eyes and feet Eyes and feet 4546 Eyes, hand, and foot Eyes, hand, and foot 46

Code Other Multiple Losses of Use Other Amputations Code51 Eye, hands, and feet Eye, hands, and feet 5152 Eyes, hand, and feet Eyes, hand, and feet 5253 Eyes, hands, and foot Eyes, hands, and foot 5361 Eyes, hands, and feet Eyes, hands, and feet 61

83 Foot(feet) and aphonia84 Eye(s), hand(s), and aphonia85 Eye(s), foot(feet), and aphonia86 Hand(s), foot(feet), and aphonia87 Eye(s), hand(s), foot(feet), and aphonia

Code Other Multiple Losses of Use Including Deafness and Aphonia91 Eye(s), deafness, and aphonia92 Hand(s), deafness, and aphonia93 Foot(feet), deafness, and aphonia94 Eye(s), hand(s), deafness, and aphonia95 Eye(s), foot(feet), deafness, and aphonia96 Hand(s), foot(feet), deafness, and aphonia97 Eye(s), hand(s), foot(feet), deafness and aphonia

Other Loss Codes

Code Description0 No losses in this group1 Loss or loss of use of creative organ2 Loss or loss of use of both buttocks3 Combination of codes 1 and 24 Regular aid and attendance or permanently bedridden5 Combination of codes 1 and 46 Combination of codes 2 and 47 Combination of codes 1, 2, and 48 Loss of one or both breasts9 Combination of any code 1 through 7 and code 8

Other Loss Codes “8” and “9” added in April 2002

M21-1, Part I, Appendix A has Paragraphs and CodesM21-1, Part I, Appendix B has Rate Tables (as of 2018, links don’t work), also here: http://vbaw.vba.va.gov/bl/21/publicat/Manuals/Rates/rates_home.htm (as of 2018, only through 12/1/14)

2017 COLA Rates is saved at H:\VSC\Rating Reference

Common code combinations:LOU creative organ: 01/01/00/00/1 L (A&A): 03/48/00/00/4 L (A&A)+K: 04/49/00/00/5 S: 48/48/00/00/0 S+K for creative organ: 49/49/00/00/1

Quick Reference Handout for Aid and Attendance (A&A) (by Jeff Myers)

Code Other Multiple Losses of Use Including Deafness71 Eye(s) and deafness72 Hand(s) and deafness73 Foot (feet), and deafness74 Eye(s), hand(s), and deafness75 Eye(s), foot(feet), and deafness76 Hand(s), foot(feet), and deafness77 Eye(s), hand(s), foot(feet), and deafness

Regular A&A/Permanently Bedridden:

Grant SMC (L) under 3.350(b) if a veteran is permanently bedridden or so helpless as to be in need of regular A&A. Par. L1.

- The criteria for regular A&A/bedridden are found in 3.352(a).- If possible, determinations should be made on the basis of bedridden rather than for need of A&A to avoid

reduction during hospitalization.- A single disability rated as 100 percent disabling under a schedular evaluation is generally a prerequisite. If

the evaluation is less than 100 percent, and the disability is so severe as to demonstrate a need for A&A, refer to C&P Service for an advisory opinion. M21-1 MR IV.ii.2.H.44. III.vi.1.A

- Be specific in the Rating as to which disabilities cause the need for A&A. Disabilities which are not used to justify A&A may entitle the veteran to higher levels of SMC.

Hospitalization Adjustments:

- The SMC allowance for A&A must be discontinued during hospitalization at government expense unless the need for A&A is due to: (1) paraplegia with paralysis of both lower extremities and loss of anal and bladder sphincter control; or (2) Hansen’s disease. M21-1 MR IV.ii.2.H.38.

- Follow directions given by Hospital Rate footnotes on M21-1, Part I, M21-4 Appendix B, SMC Codes and Rates.

A&A with Additional SMC (K) Awards:

1) SMC (K) awards may be granted in addition to A&A so long as the disabilities entitling the veteran to SMC (K) were not used to justify A&A.

2) If a disability that warrants SMC (K) is used to justify A&A, enter an SMC Paragraph K1, not payable concurrently with SMC under subsection (L). The veteran will be entitled to the SMC (K) award when hospitalized.

A&A with Additional Independent Permanent Disabilities:

1) Grant a full-step increase under 3.350(f)(4) if the veteran has an additional single permanent disability independently ratable at 100 percent. Code p = total SMC entitlement, Par. P2.

2) Grant a half-step increase under 3.350(f)(3) if the veteran has an additional permanent disability or combination of permanent disabilities independently ratable at 50 percent or more. Code p = total SMC entitlement, Par. P1.

3) You may only grant one of these two options, and only one time.

A&A with Loss or Loss of Use of Two or More Extremities :

1) If entitlement to A&A is required due to the loss or loss of use of two extremities, grant SMC based on the extremities. This is a higher benefit because it is not reduced when hospitalized.

2) If A&A can be justified disregarding the disabling effects of the loss or loss of use of the two extremities, grant a separate award of SMC for A&A. The veteran would be entitled to SMC (O) under 3.350(e)(1)(ii) based on conditions entitling to two or more rates (L) through (N). The veteran would also be entitled to SMC (R1) or (R2) based on SMC (O) with the need for A&A.

A&A with Bilateral Blindness:

1) If entitled to SMC (L) or (L1/2) based on bilateral blindness resulting in the need for A&A, grant SMC (M) based on aid and attendance under 3.350(c)(1)(v). Par. MB1.

2) If entitled to SMC (M) or higher based on bilateral blindness resulting in the need for A&A, grant SMC based on bilateral blindness. This is a higher benefit than A&A because it is not reduced when hospitalized.

3) If SMC (L) or higher is warranted for bilateral blindness, and A&A can be justified disregarding the disabling effects of the visual impairment, grant a separate award of SMC for A&A. The veteran would be entitled to SMC (O) under 3.350(e)(1)(ii) based on conditions entitling to two or more rates (L) through (N). The veteran would also be entitled to SMC (R1) or (R2) based on SMC (O) with the need for A&A.

SMC (R):

SMC (R) is warranted under 3.350(h) if: (1)Entitlement is established to SMC (O), the maximum rate under (P), or SMC (N1/2+K); and (2) A&A is required .

- This benefit is payable even if A&A was used to establish SMC (O) or the maximum rate under (P), or if the

need for A&A is based on the same disabilities establishing entitlement to SMC (N1/2+K).- Entitled to SMC (R1) for regular A&A.- Entitled to SMC (R2) for a higher level of care as defined in 3.352(b). - The SMC allowance for A&A must be discontinued during hospitalization, regardless of the disability involved,

if entitlement is established under SMC (R1) or (R2). M21-1 MR IV.ii.2.H.38.

SMC Involving Bilateral Blindness (by Jeff Myers)

Public Law 110-157 now provides SMC (o) under 3.350(e)(1)(iii) if the veteran has bilateral visual acuity of 20/200 or less with bilateral deafness rated at 60 percent or more and the hearing impairment in either one or both ears is service connected. Code 37, Par. OB1. See Fast Letter 08-12.

Better eye: Visual acuity 5/200 or worse

Other eye: Visual acuity 5/200 or worse – SMC (l), 3.350(b)(2), Code 03, Par. LB1Light perception only – SMC (l1/2), 3.350(f)(2)(i), Code 18, Par. LB2No light perception or anatomical loss – SMC (m), 3.350(f)(2)(ii), Code 19, Par. MB2

Bilateral blindness above with hearing impairment:1) Grant SMC (o) under 3.350(e)(1)(iii) if the veteran has bilateral deafness rated at 60 percent or more and the

hearing impairment in either one or both ears is service connected. Code 37, Par. OB1.2) Grant a full-step increase under 3.350(f)(2)(vi) if the veteran has bilateral deafness rated at 30 percent or more

disabling and the hearing impairment in either one or both ears is service connected. Code p = total SMC entitlement, Par. PB-3.

3) Grant a half-step increase under 3.350(f)(2)(iv) if the veteran has service connected total deafness in one ear. Code p = total SMC entitlement, Par. PB1.

Bilateral blindness in combination with loss or loss of use of one or more extremities:1) Grant a full-step increase under 3.350(f)(2)(vii)(A) if the veteran also has service connected loss or loss of use

of one hand. Keep the (k). Code p = total SMC entitlement, Par. PB-4. 2) Grant a full-step increase under 3.350(f)(2)(vii)(B) if the veteran also has service connected loss or loss of use

of one foot which by itself or in connection with another compensable disability would be ratable at 50 percent or more. Keep the (k). Code p = total SMC entitlement, Par. PB-5.

3) Grant a half-step increase under 3.350(f)(2)(vii)(C) if the veteran also has service connected loss or loss of use of one foot which is ratable at less than 50 percent and which is the only compensable disability other than bilateral blindness. Keep the (k). Code p = total SMC entitlement, Par. PB-6.

4) If the veteran has loss or loss of use of two extremities, the veteran will be entitled to SMC (o) under 3.350(e)(1)(ii) based on conditions entitling to two or more rates (l) through (n) with no condition being considered twice. Code 37, Par. O3. If aid and attendance (A&A) is needed, even if it is due to the visual impairment or extremities, entitlement to SMC at the R1 or R2 level is also warranted. For regular A&A: Code 55, Par. O3 and R1. For a higher level of care: Code 60, Par. O3 and R2.

Bilateral blindness with additional disabilities:1) Grant a full-step increase under 3.350(f)(4) if the veteran has an additional single permanent disability

independently ratable at 100 percent. Code p = total SMC entitlement, Par. P2.2) Grant a half-step increase under 3.350(f)(3) if the veteran has an additional single permanent disability or

combinations of permanent disabilities independently ratable at 50 percent or more. Code p = total SMC entitlement, Par. P1.

3) You may only grant one of these two options, and only one time.

Bilateral blindness with aid & attendance (A&A):1) If entitled to SMC (L) or (L1/2) above, consider entitlement to SMC (m) under 3.350(c)(1)(v) if blindness in both

eyes leaves the veteran so helpless as to be in need of regular A&A. Code 07, Par. MB1. If SMC (m) or higher is warranted based on visual impairment, this is a higher benefit because it is not reduced when hospitalized.

2) If SMC (l) or higher is warranted for visual impairment, and A&A can be justified disregarding the disabling effects of the visual impairment, grant a separate award of SMC for A&A. The veteran would be entitled to SMC (o) based on conditions entitling to two or more rates (l) through (n). The veteran would also be entitled to

SMC (r)(1) or (r)(2) based on SMC (o) with the need for A&A.

Bilateral blindness with ancillary benefits:1) Auto allowance is warranted for permanent impairment of vision with corrected visual acuity of 20/200 or

less in the better eye, or if the widest diameter of visual field is no greater than 20 degrees in the better eye.2) Special home adaptation grant is warranted for permanent and total disability due to blindness in both eyes

with visual acuity of 5/200 or less.

Better eye: Light perception only

Other eye:Light perception only – SMC (m), 3.350(c)(1)(iv), Code 07, Par. MB1No light perception or anatomical loss– SMC (m1/2), 3.350(f)(2)(iii), Code 20, Par. MB3

Better eye: No light perception or anatomical loss

Other eye:No light perception or anatomical loss – SMC (n), 3.350(d)(4), Code 11, Par. NB1

Bilateral blindness above with hearing impairment:1) Grant SMC (o) under 3.350(e)(1)(iv) if the veteran has service connected total deafness in one ear or bilateral

deafness rated at 40 percent or more and the hearing impairment in either one or both ears is service connected. Code 37, Par, OB2.

2) Grant a full-step increase under 3.350(f)(2)(vi) if the veteran has bilateral deafness rated at 30 percent disabling and the hearing impairment in either one or both ears is service connected. Code p = total SMC entitlement, Par. PB3.

3) Grant a half-step increase under 3.350(f)(2)(v) if the veteran has bilateral deafness rated at 10 or 20 percent disabling and the hearing impairment in either one or both ears is service connected. Code p = total SMC entitlement, Par. PB2.

Bilateral blindness in combination with loss or loss of use of one or more extremities:1) Grant a full-step increase under 3.350(f)(2)(vii)(A) if the veteran also has service connected loss or loss of use

of one hand. Keep the (k). Code p = total SMC entitlement, Par. PB4. 2) Grant a full-step increase under 3.350(f)(2)(vii)(B) if the veteran also has service connected loss or loss of use

of one foot which by itself or in connection with another compensable disability would be ratable at 50 percent or more. Keep the (k). Code p = total SMC entitlement, Par. PB5.

3) Grant a half-step increase under 3.350(f)(2)(vii)(C) if the veteran also has service connected loss or loss of use of one foot which is ratable at less than 50 percent and which is the only compensable disability other than bilateral blindness. Keep the (k). Code p = total SMC entitlement, Par. PB6.

4) If the veteran has loss or loss of use of two extremities, the veteran will be entitled to SMC (o) under 3.350(e)(1)(ii) based on conditions entitling to two or more rates (l) through (n) with no condition being considered twice. Code 37, Par. O3. If aid and attendance (A&A) is needed, even if it is due to the visual impairment or extremities, entitlement to SMC at the R1 or R2 level is also warranted. For regular A&A: Code 55, Par. O3 and R1. For a higher level of care: Code 60, Par. O3 and R2.

Bilateral blindness with additional disabilities:1) Grant a full-step increase under 3.350(f)(4) if the veteran has an additional single permanent disability

independently ratable at 100 percent. Code p = total SMC entitlement, Par. P2.2) Grant a half-step increase under 3.350(f)(3) if the veteran has an additional single permanent disability or

combinations of permanent disabilities independently ratable at 50 percent or more. Code p = total SMC entitlement, Par. P1.

3) You may only grant one of these two options, and only one time.

Bilateral blindness with aid & attendance (A&A):3) If SMC (l) or higher is warranted for visual impairment, and A&A can be justified disregarding the disabling effects

of the visual impairment, grant a separate award of SMC for A&A. The veteran would be entitled to SMC (o) based on conditions entitling to two or more rates (l) through (n). The veteran would also be entitled to SMC (r)(1) or (r)(2) based on SMC (o) with the need for A&A.

Bilateral blindness with ancillary benefits:1) Auto allowance is warranted for permanent impairment of vision with corrected visual acuity of 20/200 or less in

the better eye, or if the widest diameter of visual field is no greater than 20 degrees in the better eye.2) Specially adapted housing is warranted for permanent and total disability due to bilateral blindness with light

perception only or less with anatomical loss or loss of use of one lower extremity.3) Special home adaptation grant is warranted for permanent and total disability due to blindness in both eyes with

visual acuity of 5/200 or less.

Blindness Diagnostic CodesEnucleation + Enucleation 6061 Anatomical loss of both eyes

LPO + LPO 6062 No more than light perception in both eyes.LPO + NLP 6062 No more than light perception in both eyes.LPO + Enucleation 6062 No more than light perception in both eyes.NLP + NLP 6062 No more than light perception in both eyes.NLP + Enucleation 6062 No more than light perception in both eyes.

5/200 + Enucleation 6063 Anatomical loss of one eye and 5/200 in the other eye

5/200 + LPO 6064 No more than light perception in one eye and 5/200 in the other eye5/200 + NLP 6064 No more than light perception in one eye and 5/200 in the other eye

5/200 + 5/200 6065 5/200 bilaterally

Quick Reference Handout for SMC Involving Loss or Loss of Use of Two or More Extremities(by Jeff Myers)

Two Upper Extremities  Hand - LOU or Anat. Loss Elbow - LOU or Anat. Loss Shoulder - Anat. Loss

Hand - LOU or Anat. Loss m m1/2 nElbow - LOU or Anat. Loss m1/2 n n1/2

Shoulder - Anat. Loss n n1/2 oOne Upper Extremity and One Lower Extremity

  Foot - LOU or Anat. Loss Knee - LOU or Anat. Loss Hip - Anat. LossHand - LOU or Anat. Loss l l1/2 mElbow - LOU or Anat. Loss l1/2 m m1/2

Shoulder - LOU m* * *Shoulder - Anat. Loss m m1/2 n

Two Lower Extremities  Foot - LOU or Anat. Loss Knee - LOU or Anat. Loss Hip - Anat. Loss

Foot - LOU or Anat. Loss l l1/2 mKnee - LOU or Anat. Loss l1/2 m m1/2

Hip - Anat. Loss m m1/2 n

* 3.350(f)(1)(iv) allows SMC (m) for loss or loss of use of one foot with loss of use of one arm at the shoulder. In all other cases, loss of use of the shoulder or hip is treated as loss of use at the elbow or knee.

Paraplegia:Grant SMC (o) under 3.350(e)(2) if the veteran has paralysis of both lower extremities together with loss of anal and bladder sphincter control through the combination of loss of use of both legs and helplessness. Since this includes the need for aid and attendance (A&A) entitlement to SMC at the R1 or R2 level is also warranted. For regular A&A: Code 55, Par. O2 and R1. For a higher level of care: Code 60, Par. O2 and R2.

Additional permanent disabilities:1) Grant a full-step increase under 3.350(f)(4) if the veteran has an additional single permanent disability independently ratable at 100 percent. Code p= total SMC entitlement, Par. P2.

2) Grant a half-step increase under 3.350(f)(3) if the veteran has an additional single permanent disability or combinations of permanent disabilities independently ratable at 50 percent or more. Code p = total SMC entitlement, Par. P1.

Note: A full-step and half-step increase for additional permanent disabilities cannot be granted simultaneously.

Three extremities:Use the combination of two extremities which results in the highest SMC above. Grant a half-step increase under 3.350(f)(5) for the third extremity and keep the (k). Code p = total SMC entitlement, Par. P3.

Four extremities:The veteran will be entitled to SMC (o) under 3.350(e)(1)(ii) based on conditions entitling to two or more rates (l) through (n) with no condition being considered twice. Code 37, Par. O3. If aid and attendance (A&A) is needed, even if it is due to the extremities, entitlement to SMC at the R1 or R2 level is also warranted. For regular A&A: Code 55, Par. O3 and R1. For a higher level of care: Code 60, Par. O3 and R2.

Ancillary Benefits:Infer the issues of Automobile and Adaptive Equipment Allowance, Specially Adapted Housing, and Special Housing Adaptation Grant if entitlement is shown.

Loss or loss of use of two extremities with aid and attendance (A&A):1) If entitlement to A&A is required due to the loss or loss of use of two extremities, grant SMC based on the extremities. This is a higher benefit because it is not reduced when hospitalized.

2) If A&A can be justified disregarding the disabling effects of the loss or loss of use of the two extremities, grant a separate award of SMC for A&A. The veteran would be entitled to SMC (o) based on conditions entitling to two or more rates (l) through (n). The veteran would also be entitled to SMC (r)(1) or (r)(2) based on SMC (o) with the need for A&A.

(More detailed than Quick Reference guide above, also by Jeff Myers)

Two Upper Extremities

Hand - Loss of Use or Anatomical Loss

Elbow - Loss of Use or Anatomical Loss

Shoulder - Anatomical loss

Hand - Loss of Use or Anatomical Loss

SMC (m), 3.350(c)(1)(i),Code 07, Par. M1

SMC (m1/2), 3.350(f)(1)(x), Code 20, Par. M5

SMC (n), 3.350(f)(1)(xi),Code 21, Par. N3

Elbow - Loss of Use or Anatomical Loss

SMC (m1/2), 3.350(f)(1)(x), Code 20, Par. M5

SMC (n), 3.350(d)(1),Code 11, Par. N1

SMC (n1/2), 3.350(f)(1)(xii), Code 22, Par. N4

Shoulder - Anatomical Loss

SMC (n), 3.350(f)(1)(xi),Code 21, Par. N3

SMC (n1/2), 3.350(f)(1)(xii), Code 22, Par. N4

SMC (o), 3.350(e)(1)(i), Code 37, Par. O1

One Upper Extremity and One Lower Extremity 

Foot - Loss of Use or Anatomical Loss

Knee - Loss of Use or Anatomical Loss Hip - Anatomical Loss 

 

Hand - Loss of Use or Anatomical Loss

SMC (l), 3.350(b), Code 03, Par. L1

SMC (l1/2), 3.350(f)(1)(vi), Code 18, Par. L2

SMC (m), 3.350(f)(1)(viii), Code 19, Par. M3

Elbow - Loss of Use or Anatomical Loss

SMC (l1/2), 3.350(f)(1)(iii), Code 18, Par. L2

SMC (m), 3.350(c)(1)(iii), Code 07, Par. M2

SMC (m1/2), 3.350(f)(1)(ix), Code 20, Par. M4

Shoulder - Loss of Use SMC (m)*, 3.350(f)(1)(iv), Code 19, Par. M3 * *

Shoulder - Anatomical loss

SMC (m), 3.350(f)(1)(iv), Code 19, Par. M3

SMC (m1/2), 3.350(f)(1)(vii), Code 20, Par. M4

SMC (n), 3.350(d)(3),Code 11, Par. N2

Two Lower Extremities

Foot - Loss of Use or Anatomical Loss

Knee - Loss of Use or Anatomical Loss Hip - Anatomical Loss

Foot - Loss of Use or Anatomical Loss

SMC (l), 3.350(b),Code 03, Par. L1

SMC (l1/2), 3.350(f)(1)(i), Code 18, Par. L2

SMC (m), 3.350(f)(1)(ii), Code 19, Par. M3

Knee - Loss of Use or Anatomical Loss

SMC (l1/2), 3.350(f)(1)(i), Code 18, Par. L2

SMC (m), 3.350(c)(1)(ii), Code 07, Par. M2

SMC (m1/2), 3.350(f)(1)(v), Code 20, Par. M4

Hip - Anatomical Loss SMC (m), 3.350(f)(1)(ii), Code 19, Par. M3

SMC (m1/2), 3.350(f)(1)(v), Code 20, Par. M4

SMC (n), 3.350(d)(2),Code 11, Par. N2

* 3.350(f)(1)(iv) allows SMC (m) for loss or loss of use of one foot with loss of use of one arm at the shoulder. In all other cases, loss of use of the shoulder or hip is treated as loss of use at the elbow or knee.

Examples from Jeff’s Training:

Part I, SMC:

1. A&A due to SC renal failure on dialysis at 100% = SMC L, 03/48/00/00/4, Par. L1

2. A&A due to SC MS at 100% with LOU of both feet = SMC L, 03/03/24/00/0, Par. L1

3. A&A due to SC CAD, plus SC ED with LOU of a creative organ = SMC L+K, 04/49/00/00/5, Par. L1 & Par. K

4. A&A due to DM (40%), retinopathy (70%), nephropathy (60%) and R BKA, all of which combines to 100% = SMC L, 03/49/00/13/4, Par. L & Par. K (add the sentence in the “SMC Paragraph” that says “Not payable concurrently with SMC under subsection (l)”)

5. Anatomical loss of both feet (100%), prostate cancer with prostatectomy (100% with future exam) & OSA (50%) = SMC L1/2 + K, 24/24/00/24/1

6. A&A due to CAD (100%), plus has asthma (100%) & PTSD (50%) = SMC M, 19/48/00/00/4

7. LOU of left hand & left foot (100%), plus A&A due to heart disease with CHF (100%) = SMC R1 (L for LOU, plus L for A&A = O = R1), 51/07/25/00/4

8. Anatomical loss of both feet (100%), A&A due to dementia (100%) with need for administration of injection and physical therapy, DM with ED (40%), lumbar strain (40%) = SMC R2 (L for anatomical loss of both feet, plus M+A&A for dementia = O, plus K for ED, ½ step for additional 50%), 57/26/00/24/5

9. Anatomical loss of both feet (100%), anatomical loss of right hand (60%) = SMC M+K (L for anatomical loss of both feet, ½ step & K for 3rd extremity, ½ step for additional 50%), 25/25/00/31/0

10. Anatomical loss of both hands (100%), anatomical loss of left foot (40%), hypertension (20%) = SMC N+K (M for hands, ½ step & K for 3rd extremity, ½ step for additional 50%), 27/27/00/32/0

Part II, Loss or Loss of Use of Two or More Extremities:

1. DM (20%) with secondary transmetatarsal amputation of the right foot and above the knee amputation of the left leg = SMC L1/2, 18/18/00/24/0, Par. L2

2. Anatomical loss of the right hip without prosthesis, and paralysis of the external popliteal nerve with left foot drop = SMC M (from P), 07/07/12/12/0, Par. M1

3. Residuals of cold injuries with anatomical loss of the thumb, index, middle and little fingers of the right hand, and peripheral neuropathy of the left upper extremity with inability to grasp and manipulate objects = SMC M, 07/07/12/12/0, Par. M1

4. Extremely unfavorable ankylosis of the right wrist and anatomical loss above the left elbow = SMC M ½, 20/20/12/12/0, Par. M5

5. Left shoulder amputation and right below the knee amputation with no prosthesis/natural knee action = M1/2, 20/20/00/25/0, Par. M4

6. DM (20%) with residual stroke with LOU of right upper and lower extremities (100%) = SMC M (loss of use of the whole extremity is equivalent to the knee/elbow level), 07/07/25/00/0, Par. M2

7. Same as above, plus PTSD (50%), temp 100% for hospitalization with amputation of left toes without metatarsal loss = SMC M1/2, 20/20/25/00/0

8. Same as above, plus left below the knee amputation with prosthesis allowing natural knee action = SMC N+K (from P), 27/27/25/13/0

9. 3 amputations: right arm above the elbow & left hand above the wrist (100% for anatomical loss of both hands), plus right leg above the knee (60%) = SMC N1/2+K, 28/28/00/32/0

10. Same as above, now needs A&A due to amputations = R1 (N1/2 + K + R1 A&A), 43/28/00/32/4; can’t use R1 code because A&A is due to amputations

11. Same as 9, now needs A&A due to CAD (100%) = R1 (N1/2 + R1 A&A), 55/37/00/32/4, now at R1 code because at O due to N1/2 for amputations and separate L for A&A for CAD

Examples from January 2015 Training:

L BKA + R AKA - these two = L 1/2 (actual example says L, 3.350(f)(1)(i)R hand LOU = K60% = 1/2 steptriple loss = 1/2 step= M 1/2 + K

L leg above the knee + R leg above the knee = M

CAD 100% (need A&A) = LParkinson’s with BLE LOU = L= O = R1

both hands = Mboth feet = L= O (likely needs A&A = R1)

BLE LOU = L50% = L 1/2 (P)

FAMILY MEMBER RATINGS -

3.351 Special monthly dependency and indemnity compensation, death compensation, pension and spouse’s compensation ratings 3.401(a) 3.402(c) 3.404 III.iv.3.A IV.iii.2.2

Grant Templates:

spousal A&A:We have granted entitlement to additional benefits based on the need for aid and attendance for your spouse, {}, because the examination form shows that the criteria regarding aid and attendance have been met, as {he/she} is in need of the aid and attendance of another person in performing routine activities due to {}. We have assigned an effective date of {}, the day VA received your claim.

For surviving spouse A&A, per III.iv.8.A.2.c: Competency must be considered if needs A&A for mental condition. If competent, just mention in issue. If incompetent, do a proposal.

helpless child:can only be rated a maximum of 3 mos prior to 18th b-day; only rate if veteran is at least 30% disabledIII.iii.7We have established {}, who is over 18 years of age, as a helpless child from {}, the original date of claim and date that the veteran became entitled to additional benefits for dependents. The evidence shows that {} became permanently incapable of self-support prior to {his/her} 18th birthday by reason of physical or mental disability diagnosed as {}, and the evidence clearly indicates that the disability will not improve to the extent that {he/she} may become self-supporting in the future.OR USE VBMS-R System-Generated Text

Competency must be considered if veteran is deceased. If competent, just mention in issue. If incompetent, do a proposal.

If veteran is not 30% disabled, put a note in the Special Notation box as follows:Please address the claim for helpless child, as the veteran is not 30% disabled.

Denial Templates:

spousal A&A:USE VBMS-R System-Generated TextORWe have considered but denied additional benefits because of the need for aid and attendance for {}. We will establish entitlement to additional benefits based on the need for aid and attendance when the claimant is blind in both eyes having visual acuity of 5/200 or less, or has contraction of the visual field to 5 degrees or less; or is a patient in a nursing home because of mental or physical incapacity; or when the evidence shows aid and attendance of another person is required to perform routine activities of daily living. Since the {} does not show that these requirements have been met, we cannot establish entitlement

Surviving Spouse A&A/HB:We have considered but denied special monthly entitlement based on the need for aid and attendance or for being housebound. We will award aid and attendance benefits when the claimant is blind in both eyes having visual acuity of 5/200 or less, or has contraction of the visual field to 5 degrees or less; is a patient in a nursing home because of mental or physical incapacity; or when the evidence shows aid and attendance is required to perform routine activities of daily

living. The routine activities of daily living are basic self-care tasks which include such things as the ability to dress or undress one's self, to keep one's self ordinarily clean and presentable, ability to feed one's self, the ability to attend to the needs of nature, or the ability to protect one's self from the hazards or dangers incident to his or her daily environment. We will award housebound benefits when the claimant is substantially confined to his or her home or immediate premises by reason of a disability or disabilities which are reasonably certain will remain throughout the claimant's lifetime. Since there is no objective medical evidence that any of these requirements have been met, we cannot award special monthly entitlement based on the need for aid and attendance or for being housebound.

Surviving Spouse A&A:We have considered but denied special monthly entitlement based on the need for aid and attendance. We will award aid and attendance benefits when the claimant is blind in both eyes having visual acuity of 5/200 or less, or has contraction of the visual field to 5 degrees or less; is a patient in a nursing home because of mental or physical incapacity; or when the evidence shows aid and attendance is required to perform routine activities of daily living. The routine activities of daily living are basic self-care tasks which include such things as the ability to dress or undress one's self, to keep one's self ordinarily clean and presentable, ability to feed one's self, the ability to attend to the needs of nature, or the ability to protect one's self from the hazards or dangers incident to his or her daily environment. Since there is no objective medical evidence that any of these requirements have been met, we cannot award special monthly entitlement based on the need for aid and attendance.

Helpless child:effective date is 18th birthday, or DOC if not filed within a year of 18th birthdayIII.ii.7

VBMS-R System-Generated Text:For purposes of establishing entitlement to VA benefits, a child over 18 years of age must be shown to be permanently incapable of self-support by reason of mental or physical defect by the age of 18.

Capable Of Self Support:The extent and nature of the claimed disability is not sufficient to establish that {} is permanently incapable of self-support.

No Incapacity Before 18:The extent and nature of the claimed disability is not sufficient to establish that {} became permanently incapable of self-support prior to age 18 on {}.

Child Gainfully Employed:Incapacity for self-support will not be considered to exist when the child by his or her own efforts is provided with sufficient income for his or her reasonable support. The fact that a claimant is earning his or her own support is prima facie evidence that he or she is not incapable of self-support. The evidence establishes that {} is gainfully employed and entitlement is therefore denied.

My paragraphs:Permanent incapacity for self-support is not established for {}. For purposes of establishing entitlement to VA benefits, a child over 18 years of age must be shown to be permanently incapable of self-support by reason of mental or physical defect by the age of 18.

Capable Of Self Support or No Incapacity Before 18:The extent and nature of the claimed disability is not sufficient to establish that {} is permanently incapable of self-support OR became permanently incapable of self-support prior to age 18 on {}, and entitlement is therefore denied. OR There is no clear evidence which shows that {} became permanently incapable of self-support prior to age 18 on {}, and entitlement is therefore denied.

Child Gainfully Employed: use above paragraph from VBMS-R

DENTAL –

3.381 Service connection of dental conditions for treatment purposes – a dental rating does not allow for $, but if a veteran files a 21-526 later, we can’t deny, but we won’t pay back to the dental rating date (per Sue Haak), same w/insurance & VocRehab ratings

4.150. Dental and Oral Conditions

4.150 Schedule of Ratings—Dental and Oral Conditions

changed 2/17/94 (changed 9900, 9905 & 91513, deleted 9510, added 9914,9915 & 9916)changed 9/10/17 (combined 9902, 9906, 9907 into one code, 9902; 50% & dietary restrictions added to 9905; 9911 & 9912 combined under 9911; 9916 modified; 9917 & 9918 added) – NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 9/10/17 (if filed before 9/10/17 or within a year of 9/10/17), AND can’t go one year prior to DOC (if filed more than a year after 9/10/17, but had evidence of increase on 9/10/17, still have to use DOC). However, can use medical evidence of increase to take back to 9/10/17, if filed w/i 1 year & medical evidence shows increase warranted on 9/10/17. – prior to 9/10/17*you can find the old schedule at Regulation Citator at http://vacoappbva2.dva.va.gov, search 4.150; or in CPKM

– NOT LIBERALIZING, My Notes: 3.114 does not apply, so can’t grant increase based on new criteria prior to 5/13/18 (if filed before 5/13/18 or within a year of 5/13/18, AND can’t go one year prior to DOC if filed more than a year after 5/13/18, but had evidence of increase on 5/13/18, still have to use DOC. However, can use medical evidence of increase to take back to 5/13/18, if filed w/i 1 year & medical evidence shows increase warranted on 5/13/18.

Per QRT/GiaBao Nguyen, 12/1/17 - When there is any change in the evaluation criteria for a disability applicable to a pending claim where an otherwise sufficient examination was already completed and the rating was not completed prior to the release of the new VASRD criteria, then an addendum to the examination is needed and if not possible, then a new examination should be requested as the examination of record would be insufficient to evaluate the condition as of the date of the law change. Supporting citations for this stance would include: M21-1 III.iv.3.D.3.a; M21-1 III.iv.3.D.3.b (Barr v. Nicholson); and 38 CFR 3.159(c)(4).

III.ii.2.B.1.d III.v.7.B & III.v.7.C Introduction to Dental and Oral Conditions Rating Schedule Changes, TMS 4284803

IX.ii.2.2 IX.ii.2.3, changes eff 9/10/17, not liberalizing; new DBQs release same day per September 2017 Compensation

Service Bulletin (CSB) Note 2 - separately evaluate associated impairments (loss of vocal articulation, loss of smell, loss of taste,

neurological impairment, respiratory dysfunction, other impairments (scars, etc)

need x-rays for nonunion, 9903, 9916 (no need of copy, just note that reviewed by examiner)

TMD / TMJ / TMJD – max inter-incisal 35-50mm; mechanically altered foods (blending, chopping, grinding, mashing to make easier to chew & swallow), then 4 levels (full liquid, puree, soft & semi-solid) – must be recorded/verified/endorsed by a physician (i.e. if indicated on exam report)

IX.ii.2.3.a – with grants, notify veteran to take notice to VHA eligibility office, maybe use this:

VSR: Please instruct the veteran to take the decision notice to the nearest VHA eligibility office to obtain more information regarding their eligibility for treatment of their dental/oral disability.

From: VAVBASDC/RO/VSC Sent: Monday, September 11, 2017 11:33 AMSubject: FW: Q-Tip: Revised Rating Schedule Criteria for Dental and Oral ConditionsGood Morning VSC,

Q-Tip:  Revised Rating Schedule Criteria for Dental and Oral Conditions

Target Audience:  RVSRs and DROsThe Rating Schedule criteria for Dental and Oral Conditions, 38 CFR 4.150, was revised effective September 10, 2017.

Notable changes include: Addition of new diagnosis of osteonecrosis. Mandible loss of, including ramus, unilaterally or bilaterally - 2 additional levels of disability were added to 2

existing levels; this change allows to evaluate the loss of bone where it cannot be replaced by prosthesis; it will provide the rating for more severe impairments in cases where the loss of the bone cannot be replaced by prosthesis.

Temporomandibular disorder (TMD) – evaluation criteria now based on limited motion/movement and dietary restrictions.

New diagnostic codes for Neoplasm, hard or soft tissue, malignant or benign.

The revised evaluation criteria can be viewed here (pdf version) and soon at e-CFR (if not so already).

The manual was updated on September 8, 2017 to consider these changes at M21-1 IX.ii.2.3, to include: Guidance on separate evaluations for potentially associated impairments that cannot be rated under the DCs

provided by 38 CFR 4.150. Information on imaging confirmation requirements imposed by regulatory changes to 38 CFR 4.150 involving

nonunion of the mandible or maxilla. Guidance based on content imposed by the regulatory changes to 38 CFR 4.150 involving evaluation of

temporomandibular joint dysfunction. Clarification that the new rating schedule changes are not liberalizing. Reference on the effect of regulatory changes on claims.

If a Veteran’s claim was pending or there was an Intent to File (ITF) notice received by VA at the time of regulation’s effective date (September 10, 2017), then the claim must be considered under both previous and new rating criteria.  For handling claims when there are regulatory changes, see M21-1 IV.ii.2.K.6.b.

Updated DBQs for “MUSC Temporomandibular Joint” and “DENT Dental and Oral Conditions” were scheduled to be pushed to VHA C&P sites on September 10, 2017, but may be delayed due to Hurricane Irma.

VBMS-R was also scheduled to be updated September 10, 2017 to allow consideration of evaluation for dental and oral ratings across multiple schedules.  See slides 2 – 5 from the training deck.

GC Opinion 5-97 (1/22/97)

August 2009 Compensation Service Bulletin (CSB) - Requesting Deluca Factors on Dental and Oral Examinations for Temporomandibular Joint (TMJ) DisordersC&P Service has received multiple questions regarding the application of the DeLuca factors in evaluating disability resulting from Temporomandibular Joint (TMJ) disorders. The Board of Veterans' Appeals (Board) has remanded claims for new examinations including consideration of DeLuca as relating to TMJ disorders. Although the DeLuca decision was predicated in large part on the provisions of 38 CFR 4.40 and 4.45, which are part of the rating schedule for musculoskeletal conditions, and TMJ disorders are coded and evaluated under the “Dental and Oral Conditions” part of the schedule, the temporomandibular joints are clearly musculoskeletal joints and the evaluation of the TMJ is based on loss of motion. Therefore, the provisions of the DeLuca decision must also be applied to the evaluation of diagnostic code 9905, temporomandibular articulation, limited motion of.

12/19/14 DBQ Call – TMJ exams can be done by general medical clinicans. July 2015 Compensation Service Bulletin (CSB) – new proposed rule

http://epss.vba.va.gov/mepss/http://cptraining.vba.va.gov/C&P_Training/RVSR/RVSR_Curriculum/SG/Dental-SG.dochttp://en.wikipedia.org/wiki/Maxilla - upper jawhttp://en.wikipedia.org/wiki/Mandible - lower jaw

9900 Maxilla or mandible, osteomyelitis or osteoradionecrosis of9905 Temporomandibular articulation, limited motion of – use for TMJ & other related disorders

ONLY SC FOR TREATMENT PURPOSES ALLOWEDWe CAN establish service connection for treatment purposes for the following dental issues, but only if a dental rating is

requested by the dental clinic: treatable carious teeth replaceable missing teeth dental or alveolar abscesses periodontal disease My Notes: chipped/broken teeth and other gum/pulp issues are also included

If a Veteran is claiming TREATMENT ONLY for the above dental issues, you don't rate the issue. We only need to have a copy of the claim form sent to the Dental Clinic. III.v.7.B & III.v.7.C

If a Veteran is claiming COMPENSATION/SERVICE CONNECTION for the above dental issues, you deny as “not a disability” because we cannot grant compensation/service connection for those issues, only for treatment. You also have a copy of the claim form sent to the Dental Clinic. The Dental Clinic decides if treatment is warranted. If they can't decide, they send it back to us and we decide if service connection for treatment purposes is warranted.

Note: Calculus, acute periodontal disease (i.e. gingivitis), third molars without disease or pathology, and impacted or malposed teeth are not ratable conditions per 3.381 and IX.ii.2.

We CAN establish service connection for tooth loss but only if the loss is a result of bone loss due to trauma or disease, such as osteomyelitis. This does not include tooth loss due to periodontal disease, as that can only be service-connected for treatment purposes, as discussed above.

If a veteran is claiming COMPENSATION/SERVICE CONNECTION for tooth loss, but it is not due to bone loss from trauma/disease, you deny because there is tooth loss, but it the tooth loss is not due to bone loss from trauma or disease. Again, you have a copy of the claim form sent to the Dental Clinic. The Dental Clinic decides if treatment is warranted, as the tooth loss likely falls under “replaceable missing teeth.” If they can't decide, they send it back to us and we decide if service connection for treatment purposes is warranted.

WE CAN ONLY ESTABLISH SERVICE CONNECTION FOR DENTAL TREATMENT PURPOSES IF ASKED TO DO A DENTAL RATING BY THE DENTAL CLINIC

Issue: Service connection for dental treatment purposes for {}.

Decision: Service connection for dental treatment purposes is granted for {} due to combat wounds or trauma/as secondary to another service-connected disability. (also has due to a SC pathological dental cond)

Reasons for Decision: VA outpatient dental treatment may be furnished for dental conditions which are due to combat wounds or other service trauma/caused by another service-connected disability. Service connection for dental treatment purposes is granted for {} because the records show {}. [NOTE: This must be tooth loss due to bone loss from trauma/disease.]

Although your dental condition or disability is service connected, eligibility for treatment for that disability is limited by statute. You may not be eligible for VA dental care. Please contact the Business Office at the VHA facility that is nearest to your home for a determination on whether you are eligible for treatment for your service-connected dental condition or disability.

Dent – toothOdont – teethGnatho – jaw/cheekGingiv – gumPeri – surroundingRTC – Root Canal TherapyOrth – straightOcclusi – closure/blockagePalat – roof of mouthCusp – pointedLingu – tongueOHI - Oral Hygiene InstructionStomato – mouthMaxilla – upper jawMasti – chew

Brux – grindEndo – withinTMJ – temporomandibular joint

BONES:Nasal bones are two small oblong bones that lie side-by-side between the front of the maxillae

Inferior nasal conchae are located in the outside wall of each nasal cavity. They are thin, curved bony plates that increase the surface area of the nasal mucosa and aid in moistening and warming inhaled air.

The Vomer forms part of the nasal septum, or cartilage that helps to maintain an open airway for both the left and right sides of the nasal cavity.

Lacrimal bones are located in the wall of the eye orbit nearest the nasal bones. They are the smallest facial bones and the lacrimal sac is located in a depression in the bone. Tears drain from the lacrimal sac into the nasal cavity.

Zygomatic bones are the cheekbones. These bones connect the maxilla with the frontal and temporal bones. The facial and temporal nerves pass through these bones.

Palatine bones refer to the palate, or roof of the mouth. These bones form the posterior, or rear portion of the hard palate and parts of the floor and walls of the nasal cavity, and the floor of the oral cavity.

Maxillae join to form the upper jaw. The maxilla holds the upper teeth, forms the roof of the oral cavity, and contributes to the structure of the nasal cavity. The two maxillary bones are fused in the middle forming the middle third of the face.

The mandible is a single bone comprising the lower jaw. It extends from one temporal bone to the other forming the chin. It is the largest and strongest facial bone. The mandible consists of two horseshoe-shaped bones joined to two perpendicular bones.

NERVES:Cranial Nerve VII (Facial) is the primary motor nerve supply to the muscles of facial expression, the auricle of the ear, and the back of the head (occiput). It has five branches: the temporal, zygomatic, buccal, mandibular and cervical branches that can be affected by stroke, Bell's Palsey, and some seizure victims.

Cranial Nerve V (Trigeminal) provides sensory nerves to the skin of the face. It is divided into three divisions:The Ophthalmic division innervates the upper eyelid and nose.The Maxillary division innervates the face below the eyes and above the upper lip.The Mandibular division innervates the face below the level of the lower lip.

TYPES OF TEETH:20 primary teeth32 permanent teeth – 1 is right top/maxillary third molar, 32 is right bottom/mandibular third molar

Each jaw holds four incisors. These teeth consist of a chisel-shaped crown and a single conical, or cone shaped, root located in the front part of both jaws and are used for cutting and biting food.Each jaw contains two canines. These are pointed conical teeth located between the incisors and the first bicuspids. These teeth are used for tearing and shredding.Each jaw holds four premolars. Any of eight bicuspid teeth located in pairs on the left and right side of the upper and lower jaws behind the canines and in front of the molars. These teeth are used for chewing food.

Each jaw holds six molars. A tooth having a crown with three, four, or five cusps, or pointed ends, on the grinding surface, a bifid root in the lower jaw, and three conical roots in the upper jaw. There are three on either side behind the premolars. These teeth are used for chewing and grinding food before swallowing.

The gums, or gingiva is firm connective tissue covered with a mucous membrane that surrounds the teeth. The gums hold the teeth in position, and the roots of the teeth are embedded in the maxilla and mandible jaws by cementum, a binding material.

Attached Gingiva - The tissue that is attached to the bone and mucosa lying underneath.Free Gingiva - The soft thin tissue that is movable, which forms the inside of lips and cheeks.

The visible part of the teeth that we see in our mouth is called the crown. It is comprised of enamel, dentine, and pulp.Enamel acts as a protective structure that covers the part of the tooth that is exposed.Dentine forms the mass of a tooth. It is located below the tooth enamel on the crown and below the cementum on the root.

Pulp is a tissue that contains nerves and blood vessels that supports the tooth.

The root is the part of the tooth that is not visible when you look inside your mouth. The root is embedded in the sockets that are in the jaw bone. Blood vessels travel through the jaws and into the pulp of the tooth to supply the teeth with blood. Dentin, a bonelike material, covers the pulp, and a hard protective enamel covers the dentin. Cementum is located on top of the dentine under the gums (in the root).

EVIDENCE -

III.ii.2.D.2.c & III.ii.3.D.2.e – managing evidence

http://vbaw.vba.va.gov/VBMS/Resources_Job_Instruction_Sheets.asp

VBMS EVIDENCE DOCUMENT CATEGORIES AND TYPES

Also see Searchable Doc ID Guide (as well as “eFolder Maintenance Plan,” which can be found under the “eRO” button at Compensation Service Transformation Initiative & Pilot (TIP) Sheets )

The highlighted documents are frequently used.

Applications – Informal ClaimsVA 21-526VA 21-526b

Applications – Original Claim –VA 21-526cVA 21-526EZ

Applications – Other Special Claims –VA 21-4502

Applications – Subsequent Compensation Claims –VA 21-8940

BDN Screen Print – BDN Print Screens

Checklist – Compensation Checklist

Correspondence – Correspondence – only for communication/letters received from a veteran (to include faxes that do not contain a form, as well as VA documents returned by the claimant & date-stamped by VA), per Doc Indexing GuideMAP-D Development Letter - to include any letter requesting information from the claimant (both MAP-D and non-MAP-D letters)Status Letter – distinct from Notification letter, per Doc Indexing GuideVCAA Notice Acknowledgement

Correspondence – Development Letters –VCAA/DTA Letter5103 Notice Acknowledgement5103/DTA letter

Correspondence – Miscellaneous –Email CorrespondenceFax Cover SheetMiscellaneous C&P CorrespondenceVA 119 Report of ContactVA 21-0820 Report of Contact – to include 27-0820sVA 21-4138 Statement in Support of ClaimVA 21-8359 Information Re Veteran in Uniformed Services Hospital or Dispensary

VA 70-7216a Request for and/or Notice of Transfer of Veterans Records/COVERS5103 Checklist for Development

Correspondence – Notification Letters – VA Examination letter

Correspondence – Returned Mail – Returned Mail – to include all forms/documents returned with VA letters

Correspondence – Supplemental Award –Third Party Correspondence – to include POA/VSO cover/transmittal sheets and communication/letters/faxes received from entities OTHER than the veteran (including DOD, DFAS, etc), per Doc Indexing Guide [the actual fax transmittal/cover sheet should be indexed as Fax Cover Sheet]

Determinations – Administrative DecisionVA Memo

Income –SHARE Print Screens – to include MAP-D Contention Screen

Medical Records –C&P Exam (QTC/VetsFed exam results) – list type of examCAPRI (any VATRs) – list Facility, conditions & date rangeVA Examination (VA exam results) – list type of exam

Medical Records – Private –Medical Treatment Record – Non-Government Facility – list Facility or Provider name

Medical Records – VAX & AMIE – Request Worksheets –VA 21-2507a Request for Physical Examination (the actual exam request in CAPRI or ExamTrack/CAATS)VA Exam Worksheet (our greensheet for selecting types of exams)

Non-Medical Evidence –Buddy/Lay StatementWeb/HTML Documents

Non-Medical Evidence – Live Evidence –VA 21-4192 Request for Employment Information in Connection with a Claim for Disability

Rating Decisions –Deferred Rating (e.g. VA Form 21-6789) – https://vbaw.vba.va.gov/bl/20/cio/20s5/forms/VBA-21-6789-ARE.pdfRating Decision – CodesheetRating Decision – NarrativeRating Decision (e.g. VA Form 21-6796)

Representation – National Service Officer –VA 21-22 Appointment of Veterans Serv. Org. as Claimant Rep – list POA abbreviation, “Revoked” if applicable

STRs – list date range for ALL below (indicate “Dental” or “OPMF” if they are included with STRs)STRSTR – DentalSTR – LabSTR – Medical

STR – Medical – PhotocopySTR – Reserve STR

Service Personnel Records –Certificate of Release or Discharge from Active Duty (e.g. DD214, NOAA 56-16, PHS 1867) – for DD214s that are NOT certified – list entrance & separation datesMilitary Personnel Record – list type of record (OMPF, etc)VA 21-3101 Request for Information – to include emails to RMC – list “RMC request” or “RMC response”; or if PIES request/response, list just “request” or “response”

Service Personnel Records – DD Form 214/215 –DD 214 Certified Original - Certificate of Release or Discharge from Active Duty – for certified DD214s – list entrance & separation dates

Entering the below notes is helpful for your own review/organization, and for anyone following you on the claim. They are also nice for future claims.

CLAIM - I like to put something like "I-HL, N-back, R-R foot.” I=increase, N=new, R=reopen. The increase and previously denied (reopen) contentions should be listed in VBMS & VBMS-R as they are listed in the corporate records, with the Veteran’s wording in parentheses, per VA Pulse. https://www.vapulse.net/message/152898. New contensions should be listed in VBMS & VBMS-R exactly as claimed by the veteran. There are a few exceptions to the procedure for new contentions (like misspellings, or…) .

DD214 - I like to put the dates of service & the branch (A, N, MC). If the MOS, combat medals or locations of service are relevant, I also include those.

STRs - I like to put something like "back p4,99; enlist p7; sep p102" - if I run out of room, I delete spaces & Ps, so it'll say "back4,99;enlist7;sep102....”

TRs - I like to put the Dr./Facility name, plus a note if there is treatment for a claimed disability "back.”

VAEs - I like to put the diagnoses so I know if all requested exams were done. I also will put (+) or (-) on opinions.

RDs - I like to put the previously denied issues if the veteran is claiming that issue now.

If something is a duplicate, please mark it the same as the original, so that I can tell it’s a duplicate. I’d still like to review it, so I’ll do “Manage Duplicates” when I rate the claim. The exception is DD214s. Please do “Manage Duplicates” on DD214s.

Here are some examples of correct Document Types that are often uploaded incorrectly. I spend a lot of time fixing incorrect Document Types. Please note that there are specific choices for:

exam requests – use Medical Records - VAX & AMIE - Request Worksheets : VA 21-2507a Request for Physical Examination (you just have to type “2507” & it will pull this up)

exam notification letters – use Correspondence – Notification Letters: VA Examination Letter (you just have to type “exam letter” & it will pull this up)

STR requests – use Service Personnel Records: VA 21-3101 Request for Information (you just have to type “3101” & it will pull this up); OR if it’s an email sent to RMC, use Correspondence - Miscellaneous : Email Correspondence (you just have to type “email” & it will pull this up)

exam results – use Medical Records – C&P Exam (or Medical Records – VA Examination)

Contention Classification Job Aid is saved at H:\VSC\Rating Reference

From: VAVBASDC/RO/VSC Sent: Thursday, July 21, 2016 4:31 PMSubject: Quality Tip: Tabbing Evidence in VBMS

Good Afternoon VSC,

Attention:  VSRs, RVSRs, and DROs.

To aide in the expeditious processing of our Veterans’ claims, please be sure to annotate records, as needed.  Tabbing of pertinent evidence will allow for a streamlined review by all that review a claim, behind you.  Please read the information below on requirements of all personnel when processing electronic records.

Change date of  June 27, 2016 with regard to new mail, eFolder notes, bookmarking, and annotation of documents:

III.ii.4.G.2.a. VBMS New Mail Indicator - When new evidence or correspondence is uploaded into a claimant’s eFolder, an icon representing a new envelope will appear in the NEW MAIL column of the work queue and eFolder.  This icon, hereafter referred to as the “new mail indicator,” must be cleared on all documents upon completion of initial development.  All subsequent new documents must be opened and reviewed for relevant information.  This action must be completed by any employee handling the eFolder.

III.ii.4.G.2.m.  Associating an eFolder Note - To document information or recent actions taken on a claim, you can add a note from any screen in VBMS that displays the ADD NOTE icon.Associating a note to a Veteran or claim determines whether or not the note will be temporary or permanent.  A note associated to a

Veteran is always permanent, and claim can be temporary or permanent.

Notes can be added and viewed through both VBMS and MAP-D to document information or recent actions taken on a claim.  Notes should reflect actions that are not captured by a tracked item or development letter. Examples:  Notes can be used to document

unsuccessful attempts to contact the Veteran the reason for postponement of a routine future exam an explanation for establishing an EP 930, or the rationale for changing the date of claim (DOC) of an EP.

III.ii.4.G.2.n.  Bookmarking an eFolder Document - To identify any relevant evidence and add additional information as need, a predefined bookmark may be added to any document on the DOCUMENTS screen.The available bookmark icons are

Medical Appeals Peer review Working notes Deferrals, and Dependency.

III.ii.4.G.2.o.  Annotating a Document in VBMS - Annotations are useful electronic notations that can be added to a document to supply additional information or notes to other VBMS users.  Annotations generally contain information related to a claimant and highlight the details that are related to a document within the eFolder.

eFolder Maintenance:

III.iii.1.D.1.a.  Routine Review of eFolder Documents

 

During routine review of the electronic claims folder (eFolder) all claims processors must conduct eFolder maintenance to ensure

end product (EP) controls are consistent with claims document, including use of a correct

o date of claim o EP series, and o claim label

information regarding the Veteran’s service dates and character of discharge in VA systems are consistent with the evidence in the eFolder, including

o the Veterans Benefits Management System (VBMS) o Benefits Identification and Records Locator Subsystem (BIRLS), and o Participant Profile

the claims folder contains proper documentation of claimant representation, including system updates of

o Share, and o VBMS

any documents identified as duplicate upon review are managed in accordance with M21-1, Part III, Subpart ii, 4.G.2.q

any documents reviewed are indexed properly in accordance with M21-1, Part III, Subpart ii, 4.G.2.r

any misfiled document(s) are removed and transferred to the proper claims folder(s) following the procedures outline in M21-1, Part III, Subpart ii, 4.G.2.c, and

all pertinent evidence is properly noted, bookmarked, and/or annotated following the respective guidance found in

o M21-1, Part III, Subpart ii, 4.G.2.s o M21-1, Part III, Subpart ii, 4.G.2.n , and o M21-1, Part III, Subpart ii, 4.G.2.o

Note:  To manage the documents associated with the Veteran’s eFolder in VBMS, click the DOCUMENT link on the VETERAN PROFILE screen.

References:  For more information on

viewing eFolder documents, see the VBMS User Guide EP series, see M21-4 Appendix B date of claim, see M21-4 Appendix B, Section I, Block c Veteran’s service dates and character, see M21-1, Part III, Subpart ii, 6.A and

B updating military service information, see M21-1, Part III, Subpart ii, 3.C.7, and power of attorney (POA) appointments, see M21-1, Part III, Subpart ii, 3. C.4.

III.ii.4.G.2.d – document deletion

III.iv.6.C – listing evidence in RD; all evidence that is relevant and necessary to the determination needs to be cited

o III.iv.6.C.4.c – list:

STRs/SPRs with date of receipt & period of service (month & year) - April 2017 Quality Call Notes say look for 3101 w/date-stamp for receipt date, if there is no date-stamp, use “Overall Completion Date”

VATRs with name of facility & dates covered (month, day & year)

PMEs / PTRs / PMRs with name of facility/physician, date of receipt & dates covered [VBMS-R shows “Private Treatment Records”] (month & year)

DBQs with facility/contractor & date conducted

other Govt (Fed, State) records with name of agency/facility & date of receipt

lay stmt with source & date of receipt

forms with full name of form & date of receipt

evidence requested, but not received following this example: Private Medical Records (PMRs) requested from {}, but not received [I added this as Evidence Type, with PTRs, in VBMS-R]

evidence considered in a prior VA decision with each piece of evidence separately, including the prior decision

confidential medical evidence with date & name of facility

non-relevant records not requested as detailed under I.1.C.4.f - Records from [name of facility or physician] not requested because they are not relevant

Service Personnel Records (SPRs), received {}, for the period of service from {month & year} through {month & year}Service Treatment Records (STRs), received {}, for the period of service from {month & year} through {month & year}VAMC (Veterans Affairs Medical Center) treatment records, VAMC {}, from {month, day & year} through {month, day & year} My Notes: We should probably treat MTF records (not from JLV) the same as VATRs.Military Treatment Facility (MTF) Records, received {}, dated {month, day & year} through {month, day & year}Private Treatment Records (PTRs), {}, received {}, dated {month & year} through {month & year}Disability Benefits Questionnaires (DBQs), {QTC/MSLA/VetFed/VAMC San Diego}, dated {}DoD Military Treatment Facility (MTF) Records from JLV / VistAWeb, {facility, if not multiple}, received {}Joint Services Records Research Center (JSRRC) response, received {} – if get negative response, no memo needed, per VA Pulse https://www.vapulse.net/message/78380 & IV.ii.1.D.4.a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, received on {}VA Form 27-0820, Report of General Information, dated {}Private Treatment Records (PTRs) requested from {}, but not receivedPrivate Treatment Records (PTRs) requested from {}, but not received, as they indicated your records were destroyed

March 2014 Compensation Service Bulletin (CSB) – The VBMS-R Import Evidence functionality pulls the list of evidence into the eFolder by the date of receipt. All evidence can be listed by the date received, and not by the date range covered by the received evidence. This will include RVSRs using the date of receipt of STRs in the evidence list. There is no need to change to the date range covered by the STRs.

Auto-populating DBQs – only from VAMC SD, West LA & 11 other VAMCs; only for 6 DBQs (back, neck, HL/tinnitus, endocrine, thyroid/parathyroid & DM DBQs), but document then says only for 3 DBQs…

3.159 Department of Veterans Affairs assistance in developing claims – changed 9/25/01

I.1.A.3.a & I.1.C.4 – relevant records (selecting & storing electronic VATRs - III.iii.1.C.4.h & III.v.6.G.1.c)

Rating Note: The {date} records from Dr. {} listed on the {} are not relevant since DBQs were conducted & SC for {} has been granted (per I.1.A.3 & Raugust v. Shinseki, since we do not have a specific reason to believe that the records identified by the Veteran would contain necessary information to substantiate the claim, we have no duty to obtain records {& do not need to request a 4142}). I.1.C.4

OR

Rating Note: The {date} records from Dr. {} listed on the {} are not relevant since DBQs were conducted & SC for all claimed disabilities has been granted, per I.1.A.3 & I.1.C.4.

III.iii.1.C.2.d – If a veteran has received treatment at a VAMC and/or outpatient clinic, and a summary of that treatment is relevant to a pending claim … then request/retrieve a summary of treatment through CAPRI dating one year prior to the date of claim (DOC) and/or any other dates indicated by the claimant as relevant to the claim. Emphasis added

Rating Note: All VAMC records were reviewed, but only the new, relevant records {from the prior year} were uploaded.

Rating Note: All VAMC records were reviewed, but there were no new, relevant records to upload.

Rating Note: There are no new, relevant records from the prior year at the VAMCs.

Notes from March 2018 Training Provided by Central Office by Andrew Grey (Site Visit Training) on Relevant Records:Records are relevant if affect SC, evaluation or effective date, I.1.C.4.d (i.e. don’t need records from 1984 for CFI in 2014 since doesn’t affect SC, eval or effective date; don’t need records from 9 years ago on original claim for presumptive DM with current records since doesn’t affect SC, eval or effective date)

Question: The manual (III.iii.1.C.2.d) instructs VSRs to obtain OPTRs dating back one year from the date of the claim (and any other specific treatment identified). Where this whole relevancy conversation becomes problematic from the standpoint of the RVSR, however, is under the rubric of historic/informal claims rules under 3.157, which still applies to OPTRs pre-dating 3/24/2015. This factor seems largely lost on many folks, and also seems to compel the RVSR (if potentially relevant) to go back, review and upload any/all pre-03/24/2015 records. This takes time, particularly when the OPTRs are voluminous. Can you expand on relevancy of records within the context of 3.157, since it can take up a lot of time uploading OPTRs the manual no longer requires the VSR to obtain?Answer: While the manual (III.iii.1.C.2.d) instructs the VSRs to obtain OPTRs dating one year prior to date of claim unless specific treatment is identified by the Veteran, the historical application under 38 CFR 3.157 and effective date implications are still relevant for VAMC records prior to 3/24/2015. RVSRs and DROs are responsible for the assignment of effective dates and review of all records within the custody of the VA. If records impacting the effective date are identified within CAPRI, those records must be included in the Veteran’s eFolder. The identification and association of these records and the application of the historical provisions of 3.157 is the responsibility of the RVSR to ensure that the Veteran receives all benefits to which they are entitled.

San Diego RVSR Training (Version 2).pptx, recorded training & email message with answers to questions are saved at H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18\2018 Site Visit

Training

I.1.A.3.c & I.1.B.1.j – inherently incredible claims or claims that clearly lack merit (have to send 5103 Notice, but no further development is needed)

III.iii.1.A III.iii.1.C.2.c – might need 7131 for archived records when treatment is alleged at a VAMC prior to late

2004 (also at III.iii.1.C.2.e); registration date is for VA healthcare, enrollment date is for each facility (implemented 1996); check enrollment date (REPORTS tab – (1) VIEW REGISTRATION DATA (menu on left-hand side) – scroll down report to APPLICATION INFORMATION field to see date veteran registered with VHA and (2) PATIENT PROFILE MAS (Full), then ENROLLMENTS to see the date they enrolled at that VAMC

III.iii.1.C.2.e – when to use 7131 (based on dates provided by veteran, registration date in CAPRI, enrollment date in CAPRI)

III.iii.1.C.2.i – concluding VAMC records do not exist; if enrolled on or before date of alleged treatment, it’s likely the records exist, use electronic VA Form 10-7131 in CAPRI (no longer use hard-copy, they will be rejected; also do not email or fax 10-7131 per III.iii.1.C.2.d), also stated in July 2017 Quality Call Notes; if enrolled after date of alleged treatment can conclude VA records do not exist

See http://vbaw.vba.va.gov/bl/21/DEMO/index.htm for VAF 10- 7131 Request Contact List

Rating Note: Enrollment/ Registration date ({date from CAPRI}) is subsequent to reported date of treatment ({date veteran reported treatment started}). III.iii.1.C.2.i says we can reasonably conclude that records do not exist. *VSR did not complete 0820.

OR

Rating Note: Veteran reported treatment at VAMC {} from {start date-end date}. CAPRI has records from

{start date-end date}. In response to our 7131 requests for records from {start date-end date}, we received paper records from {start date-end date}. CAPRI shows a registration date of {} and an enrollment date of {}. However, since we only got {start date-end date} records from the VAMC, we have to conclude that the other records do not exist. *VSR did not complete 0820.

OR

Rating Note: Per III.iii.1.C.2.c, VAMC {} records from {start date-end date} would be in CAPRI since VHA completed the transition to electronic recordkeeping at all VAMCs in late 2004. III.iii.1.C.2.e says we may assume the records do not exist if they are not available electronically.

Evidence: We have been unable to obtain records from [insert name of VAMC] for the period [insert date range of treatment]. We have determined that these records do not exist. We will now make a decision based on the evidence of record.

NEED TO SEND 7131:

for deferral: We need to send an electronic 7131 for the identified VAMC {} records from {}. CAPRI only has records from {} to {}. *See Claim Notes for more details

for Claim Note: Claim is not RFD. We need to send an electronic 7131 for the identified VAMC {} records from {}. CAPRI only has records from {} to {}. Deferral done.

III.iii.1.C.4.g – VATRs, if an Enterprise Search shows no VAMC treatment, add a permanent note in VBMS; My Notes: “No pertinent VA Healthcare records from the VAMC available.”

Rating Note: CAPRI kept crashing & I could not upload the most recent TRs.

…

FEDERAL RECORDSFire was July 1973, at NPRCArmy: November 1912 to January 1960Air Force: Hubbard to Z, September 1947 to January 1964

I.1.A – Ensure that all identified treatment records are obtained, or attempted. VA Pulse, https://www.vapulse.net/message/143604, says just copies are not sufficient & we have to attempt to get STRs from an official source (does not discuss if final notification letter needed when have copies & cannot get originals)

I.1.C.1 & I.1.C.5 – STRs, other service dept records, VATRs(removed 7/26/17 & addressed under III.iii.1.C.4.d), SSA records, Public Health Service records (military hospital / Military Treatment Facility / MTF not listed but they are federal records; III.iii.1.C.3.d says OPTRs from an MTF should be in JLV unless it’s a Coast Guard facility [only do 8359 if records are not in JLV; as of sometime before 8/17, NMC now requires a DD Form 2870 authorizing NMC to release the records to us (HIPPA issue)], but VA Pulse response, https://www.vapulse.net/message/151521, says JLV is last resort, so I asked for clarification, https://www.vapulse.net/message/154186); 30 days for initial request, then 15 days for f/u, per III.iii.1.C.2.b & III.iii.3.A.2; if it is reasonably certain that records do not exist or further efforts by VA to obtain the records would be futile (determined on a case-by-case basis), need to notify veteran with final notification letter; (III.iii.1.C.1.e – “ultimately unsuccessful” efforts; III.iii.2.I.4.a – unsuccessful attempts; and III.iii.2.I.4.b - f/u with NPRC if no negative response & if “do not exist or are irretrievable”; ALL need final notification letter (as of 10/27/17, no longer “10-day final-attempt letter” as 10 day response period is not needed/provided, per III.iii.1.C.1.e); no longer need 15 day letter per VA Pulse, https://www.vapulse.net/message/78341; FED_REC / FRU

per April 2012 IU Training – need final notification letter if cannot get Social Security Administration (SSA) records, but not if the veteran never filed for SSA / never had disability claim / SSA says no medical records were obtained for the Veteran’s claim, unless the Veteran specifically reports that SSA should have medical records

III.ii.2.D.3.c & IV.ii.2.A – Supplemental Service Treatment Records (STRs); January 2015 Compensation Service Bulletin (CSB) – reminder on how to handle supplemental STRs; February 2015 Authorization Quality Call Notes – another reminder on how to handle supplemental STRs SUPP;

IV.ii.2.A.3.c says supplemental STRs (non-duplicative) from claimant or representative during 1 year appeal period are a request for reconsideration.

Rating Notes: (1) We received supplemental STRs with new evidence, but none that indicate an increase, relate to a previously denied claim, or show a chronic disability, so no action is necessary, per IV.ii.2.A.3.b. (2) The STRs are not relevant to this claim for increase, so are not listed in the Evidence.

III.iii.1.C - III.iii.1.C.2.b (Federal civilian employment records, incl USPS)

III.iii.2.A – Developing for Service Records

III.iii.2.A.1.e – exams (entrance & discharge, if performed) medical hx dental exam reports/records clinical record cover sheets & summaries outpatient records physical profiles Med Boards Rx for eyeglasses/orthopedic footwear

III.iii.2.A.1.f (3/27/17, this is a change) – STRs are substantially complete if they contain at least one of the documents listed in III.iii.2.A.1.e (see above) for each period of qualifying service or if we have a DD Form 2963 (III.iii.2.B.2.c has exceptions, where may need (1) add dev – if (a) veteran indicates specific treatment AND (b) those records don’t exist in available STRs & they aren’t in JLV; or (2) final notification letter if 2963 says STRs are absent) –

My Notes: This seems to indicate, for example, that if we have just a medical history form on a 4-year period of service, the STRs for that 4-year period are substantially complete & we are supposed to rate the claim. I know this is a rare & extreme example, but this new policy could result in premature ratings with denials (not to mention the re-work once we actually get the rest of the STRs). Ryan Scalmanini talked to folks at CO & said “they forwarded our concern to policy. The regulation wasn’t meant to be a change on what constitutes complete but rather whatever was sent to us by the record holder is all they had at the time and further efforts to go back to that record holder would be futile. It does not mean to assume they are complete if one document is of record. We would still complete a 10 day letter and attempt to obtain records from other record holders if needed.”

VA Pulse, https://www.vapulse.net/message/146532, points out problems with the change to III.iii.2.A.1.f as well

updated 11/1/17 – added note that if the records are inconsistent & there is a clear lack of records for an extended period of service, we need a final notification letter (don’t do further development)

April 2017 Quality Call Notes –

Question: There have been many deferrals asking for the completion of a final attempt letter when the only STR available is the entrance exam (prior to entry into Active Duty service) obtained from DPRIS. This is a document typically found within the personnel file. Does this entrance exam document suffice as the one document rule for STRs?Answer: No. The document is one that constitutes part of the STRs, but as you have pointed out, it is also associated with personnel pages as well. In this instance, it was received as part of a request for personnel records, not STRs. A final-attempt letter should be sent.

III.iii.2.B.2 - “certification letter” / certification memo / DD Form 2963 / STR Certification

III.iii.2.D – PIES info

III.iii.2.E -

fire-related STRs, NO final notification letter needed per Station MRS (III.iii.1.C1.e says no final notification letter & to follow III.iii.2.E.1.c or f); NA Form 13075 for service, NA Form 10355 for

medical, https://www.vapulse.net/thread/27679; Per the Note under III.iii.2.E.1.c, include this in RD narrative & in the decision notice:

We were unable to obtain your service treatment records. You failed to return NA Form 13055. Further attempts to obtain the missing records cannot be undertaken without the completed form, and the decision is made on the evidence of record. For a copy of the form, please download from our website http://www.va.gov/vaforms or call us at 1-800-827-1000.

also see FIRE1 & PMC-NPRC I.1.B.1.f – need to send additional notice, per III.iii.2.E.1.b

III.iii.2.E.1.h – need formal finding (III.iii.2.I.4.c says use 0961) if can’t verify service

…

Examples of DD Forms 2963 showing STRs absent:

ONE OR MORE SECTIONS OF THE STR IS ABSENT AFTER CONDUCTING DUE DILIGENCE TO DETERMINE THE EXISTENCE/LOCATION OF THE SECTION(S). THE RECORDS PROCESSING CENTER HAS SPECIFIC INFORMATION REGARDING MISSING ELEMENTS OF THE STR.

AFTER SEARCHING WITH ALL DUE DILIGENCE IT IS DETERMINED THAT THE MEDICAL AND DENTAL RECORDS OF THIS SERVICE TREATMENT RECORD ARE ABSENT.

MISSING MEDICAL SECTION 1. ONE OR MORE SECTIONS OF THE STR IS ABSENT AFTER CONDUCTING DUE DILIGENCE TO DETERMINE THE EXISTENCE/LOCATION OF THE SECTION(S). THE RECORDS PROCESSING CENTER HAS SPECIFIC INFORMATION REGARDING MISSING ELEMENTS OF THE STR.

After searching with all due diligence, all sections of the Medical and Dental Service Treatment Record are absent.

Need clarification on what this means: MEDICAL SECTION 1 NEVER CREATED; THE ENTIRE STR, WITH THE EXCEPTION OF THE DIGITIZED ELEMENTS INCLUDED HEREIN, IS ACCOUNTED FOR IN THE AWP SECTION."

III.iii.3 – Social Security Administration (SSA) records, III.iii.3.A.2.e (if they say destroyed or not located, need final notification letter; if they say there are no records, no letter needed)

If a final notification letter was not sent prior to the case being sent RFD, you can notify the veteran in the RD. Possibly use this modified version of NO-STR:

Efforts to obtain your Social Security Administration (SSA) records were unsuccessful. If these records are located at a later date, this decision will be reconsidered.

or can add a note to the codesheet asking the VSR to send the letter, but Post might not want to send it & may defer it back to you…

VSR: Please send the final notification letter about the unavailable SSA records (per III.iii.3.A.2.e) with the notification letter for this decision.

Rating Note: III.iii.3.A.2.e says if SSA indicates there are no records, no letter is needed.

III.iii.4 IV.ii.2.A.3 – unassociated STRs / supplemental STRs

5/15/13 VSCM email : Requests to the SSANRC must be made using the following form to ensure that all required information is included. SSANRC-15, FAX Request for Medical Records/Information from the Social Security Administration National Record Center (SSANRC). Per III.iii.3.A.2.b & III.iii.3.A.2.c, the request should include, “the Veteran’s name, Social Security Number, VA file number, address, and date of birth as well as the requestor’s name, RO and address, direct phone number, and fax number.”  If the RO has a designated Super User or a main point of contact for SSA records request, it should also include that information.  For a sample copy of a request for SSA disability records at the NRC, see III.iii.3.A.8. Only WARMS has been updated.

At the April 2013 PTSD training, we were told that Vet Center are NOT considered Federal Records, but WEEKLY QRT Q-TIP FOR WEEK OF 06/17/2013 says they ARE considered Federal Records!!!

I.1.B.1.f – need to send additional notice about Vet Center records, per III.ii.1.C.4.j III.iii.1.C.4 – Vet Center records are VA medical records; If unable to get VAMC TRs, need 0820 (no final

notification letter) & RD must have this in Evidence:

We have been unable to obtain records from [insert name of VAMC] for the period [insert date range of treatment].  We have determined that these records do not exist.  We will now make a decision based on the evidence of record.

Notes from June 2015 CAPRI - DoD Records tab (& more) Training (Carlos Rosario) –

Certification / DD Form 2963 is required if separated in 2013 or later. It might say they don’t have STRs. If certification is on file, no final notification letter is required (however, I.1.C.1.d says we should treat certification as a statement that is is reasonably certain that additional STRs do not exist and further attempts to obtain additional records would be futile, so a final notification letter would be needed – checked with QRT/Carlos Rosario & he concurred that a final notification letter seems most appropriate but to ask on VA Pulse, so I entered Live Manual Feedback on VA Pulse 8/31/16, https://www.vapulse.net/message/103095, & they confirmed Carlos’ answer). Some service members don’t have separation exams.

Health Summaries tab - might have C&P exams

VistAWeb tab – has problem list that pulls from CHCS (might have different info than DoD); can sometimes find MSLA Hearing Loss & Tinnitus DBQ results here (Progress Notes, look for images under AWIV, possibly a Consult, Location may say “Comp and Pen,” may say “Choice”); III.iii.1.C.4.d says use AWIV for non-VA medical facility that provides services under a VA contract & under Veterans Choice Program

VistA Imaging AWIV – SD is 664, West LA is 691, All Programs – VBAPPS – CAPRIREMOTE – Vista_AWIV – AWIV_Weblogon OR just type in “AWIV Weblogon” from START menu; if CAPRI or VistAWeb says scanned document from other facility (including sleep studies, audiograms, MSLA exams), can save as PDF with OneNote

DOD CAPRI Tab Decommissioning –The Department of Defense (DoD) will terminate the Bidirectional Health Information Exchange (BHIE) Framework, which  feeds the DoD tab in CAPRI, on September 30, 2016.  Effective October 1, 2016, the DoD tab in CAPRI will no longer be a source for DoD medical records. VBA staff may use Joint Legacy Viewer (JLV)  as well as CAPRI’s VistAWeb tab to access an integrated view of health data from VA and DoD.

Rating Note: JLV / VistAWeb was reviewed, but no relevant records were found, nor was there any reference to possible relevant records

I.1.C.1.d & III.iii.2.B.2.c – If a “certification letter” / DD Form 2963 accompanies STRs from the service dept, no additional development is needed unless (a) veteran indicates specific treatment AND (b) the 2963 says those records don’t exist in ava STRs & they aren’t in JLV; also, a final notification letter is needed if 2963 says STRs are absent

III.i.1.4.g – RVSR duties include, “ensuring all recent and relevant treatment records found in the Compensation and Pension Records Interchange (CAPRI) and the Joint Legacy Viewer (JLV) have been associated with the claims folder and if necessary, associating the records”

III.iii.1.C.1.e – need to check JLV before sending final notification letter for STRs

Make sure select Certificate that says “Issuer: Veterans Affairs User CA B1”

To Build a Report in JLV:

o The “Documents” section is the best one to use for building a report.

o Click on & it will show all the records in a pop-up window.

o Click on name in the “Description” column to view “Document Details,” then click on in the top right corner of (or right-click on name in the Description column & it will give you the option to “Add Record to Report”).

o When all reports are added, click on in the top right corner of JLV, to the right of your name.

o It will pull up the Report Builder. Move items into date order (if needed). Click on .

o Click on in the pop-up window.

o It will generate a PDF file that you can save & upload to VBMS.

o If the generated file is only a list of Documents, but no actual details, you might have some records without any actual text. It may also give you just a white screen if you have some older records that are not actually in JLV, which appears to cause an error.

III.iii.2.B.3.k – table on how to index JLV records in VBMS if STRs, or clinical records.

This is for STRs:

Subject: Certified STRs from JLVCategory-Type: STRs: STR-OriginalSource: VBMS (My Notes: As of 4/17, VBMS now has “DOD Integration,” but not JLV.)

This is for post-service:

Subject: Post-service MTF records from JLVCategory-Type: Medical Records: Medical Treatment Record – Government FacilitySource: VBMS (My Notes: As of 4/17, VBMS now has “DOD Integration,” but not JLV.)

Notes from March 2018 Training Provided by Central Office by Andrew Grey (Site Visit Training) on Development of STRs:

PIES (discharges 1992-1998, depending on branch, see III.iii.2.A.3.d) – then RMC (discharges from end of PIES dates to 12/31/13 except Coast Guard; RMC sends to vendor when claim established) – then HAIMS (discharges from 1/1/14 except Coast Guard; HAIMS requests done through VBMS)

check JLV for STRs if all else fails

[need memo of unavailability (they mean final notification letter) if get negative response]

San Diego RVSR Training (Version 2).pptx, recorded training & email message with answers to questions are saved at H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18\2018 Site

Visit Training

_____________________________

PRIVATE RECORDS – PMEs / PTRs / PMRs - I.1.C.2, III.iii.1.C

I.1.C.2.a & I.1.C.2.c – 4142s

I.1.C.2.a - return unclear or insufficient private or VA medical records for clarification, per Savage v. Shinseki, 24 Vet.App. 259 (2011)

II.1.C.5.a & III.ii.1.C.3.g – private treatment records unavailability

III.iii.1.C.12.b – can send documents in foreign language to Pittsburgh RO for translation

III.iv.3.D.2.a – veteran provided DBQs / private DBQs must include actual signatures and cannot be digitally or electronically signed, also cannot be completed by means of telephone or videoconference examination, per III.iv.3.D.2.c. My Notes: Confirmed that can use date of DBQ for effective date if basing increase on those findings, 3.400(o)(2), per April 2017 VSCCR1 Quality Analysis and Trend Report; III.iv.3.D.2.f (also III.iv.3.D.2.c, telehealth & telemental health exams only for VHA & VBA-contracted examiners) – if authenticity or alteration is in question, RVSR/DRO may validate the results with the provider, request medical records or request a VA DBQ (if a veteran lives in CA & submits a DBQ from Puerto Rico, you should order a VA DBQ); Maritza Martinez in Ponce, PR; Ricardo J. Del Rio, PhD in Aguadilla, PR; (?Gina Uribe); per QRT/GiaBao, cannot use veteran provided DBQ / private DBQ for evaluation if information conflicts (like says flexion is 0-118, then checks the box for ankylosis and says loss of 22 degrees), however, what if we never tried to clarify insufficiency, per III.iv.3.D.2.e & just got a VA DBQ?

June 2018 Compensation Service Bulletin (CSB) - As a reminder of existing procedural guidance in M21-1, Part III, Subpart iv, 3.D.2.c, please be aware that examinations performed - or DBQs completed - via a telehealth (i.e. videoconferencing) protocol are only independently adequate for VA rating purposes when prepared by a Veterans Health Administration (VHA) examiner or VBA contract examination provider.  Telehealth examination reports/Disability Benefits Questionnaires (DBQs) prepared by private, non-VA providers must be accepted and considered in accordance with their respective evidentiary weight and probative value, but may not stand in place of a VA examination as permitted under 38 CFR 3.326.  Upon receipt of a private provider’s report of telehealth examination results, follow the procedures in M21-1, Part III, Subpart iv, 3.D.2.e, to order a VA examination as necessary and/or appropriate to adjudicate the claim.

PMR [PowerPoint] is saved at H:\VSC\Rating Reference

_____________________________

VCAA / DTA / 5103 (per I.1.A.1.c)

Caffrey v. Brown (3/31/94) - not assisting in development is not a CUE

Woods v. Gober (12/15/11) - VA’s duty to send notice of decisions to claimants

Pelegrini v. Principi (1/13/04) – (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant’s possession that pertains to the claim, or something to the effect that the claimant should “give us everything you’ve got pertaining to your claim(s).”

January 2004 Compensation and Pension Manager's Conference Call - VCAA notice is not required where there is no legal basis for entitlement (i.e. pension claim w/no wartime service)

VAOPGCPREC 1-2004 (2/24/04) - Pelegrini v. Principi stated that section 3.159(b)(1), explicitly, and section 5103(a), implicitly, require that VA request that the claimant provide any evidence in his or her possession that pertains to the claim. The CAVC's statement that sections 5103(a) and 3.159(b)(1) require VA to include such a request as part of the notice provided to a claimant under those provisions is obiter dictum and is not binding on VA. Further, section 5103(a) does not require VA to seek evidence from a claimant other than that identified by VA as necessary to substantiate the claim.

I.1.A.2.a – do not need to provide additional 5103 notices on subsequent claims if the same type of 5103 notice was provided on a current pending claim with the previous year (duty to assist / WTEMs); *however, even if sent incorrectly, need to wait 30 days since told veteran as much, per III.iii.1.B.2.d

I.1.B.1.c – claims for specific evaluations or effective dates - “Because the law permits a generic Section 5103 notice, it is not required that ROs include diagnostic criteria for a specific disability in the notice even if the claimant asserts entitlement to a specific evaluation level. See Wilson v. Mansfield, 506 F.3d 1055, 1062 (Fed. Cir. 2007).” Wilson v. Mansfield (10/15/07); Dingess/Hartman v. Nicholson (3/3/06).

July 2012 RVSR Treatment Records Development Training (Carlos Rosario) - even if we can grant the benefits claimed, we still have a duty to assist in getting all records identified; STRs – call documented on 21-0820, then letter [need both]; VATRs/SSA/other Fed – just letter (or just call) [not both]; per July 2012 Compensation Service Bulletin (CSB) – non federal record letters are now 15 days for each letter

April 2013 Compensation Service Bulletin (CSB) – the “theory that medical examinations are to be routinely and virtually automatically provided to all Veterans in disability cases involving nexus issues” was rejected in Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). The proper standard for obtaining examination with nexus opinion, contained in 38 CFR 3.159(c)(4)(i) requires that the evidence of record “indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability.” The Veteran’s claim, in and of itself, unenhanced by either medical nexus evidence or lay testimony does not establish such “indication.” However, the evidentiary threshold remains quite low. A Veteran’s assertion of continuity of symptoms from service to the present would generally satisfy the requirement, as would private medical opinion even if based upon incomplete data. McLendon v. Nicholson, 20 Vet.App. 79 (2006)

I.1.A III.ii.2.D III.ii.2.F.1.c III.v.6.A & III.v.6.G – CAPRI September 2015 Compensation Service Bulletin (CSB) – if 526EZ submitted through Stakeholder

Enterprise Portal (SEP), must have annotation that Standard 5103 Notice sent w/date. If not, need to send 5103 Notice.

III.i.4.B.2.i – need to wait 30 days from DOC or get 5103 notice waiver before rate claims submitted through Stakeholder Enterprise Portal (SEP)

3.326 EXAMINATIONS – $ will not be denied to POWs without a complete physical examination

From: VAVBASDC/RO/VSC Sent: Friday, December 22, 2017 10:45 AMSubject: Exam Complaints

VSC Employees,If you receive (or discover) a complaint about a VA or contract examination/physician, please route to the VSC front office mailbox.Thank-you,VSC Front Office

I.1.C.3 opinions on relationship to service (Medical Opinions); if there is evidence of treatment in service &

evidence of a current condition, & the veteran alleges a link between the two, we must get an exam & nexus opinion (also per 38 CFR 3.159(c)(4))

I.1.C.3.b - covers the 3 elements required for an exam and/or opinion

I.1.C.3.f - covers indication of association with service / Element 3

I.1.C.3.l (added 3/28/17) - make Claim Notes on exams warranted & not warranted (called “Exam Review,” use “exam review not yet performed,” “exam review partially complete,” “exam review incomplete,” “exam review complete”; use “no current condition” if no Element 1, “STRs negative” if no Element 2, “no nexus” if no Element 3, example:

Exam Review partially complete. Exams requested for PTSD and hearing loss. Exam review incomplete for back and knee pending receipt of PTRs from Dr. Jones, but STRs negative. Exam not needed for GERD—STRs negative.

III.iv.3 – DBQs, medical reports, or opinions submitted by a VA or private health care provider can be accepted in

lieu of an exam if otherwise adequate under relevant regulations. III.iv.3.D.2.e discusses what to do if DBQ is missing info or has contradictory evidence (call & document on 0820; if need review of STRs, testing or opinion, need to request those missing requirements from VA examiner)

III.iv.3.A.5.a - a General Medical examination is required when an Intent to File (ITF) a claim is received within a year of discharge and a substantially complete application is received within one year of the ITF.

III.iv.3.D.2.c – telemental exam, only by VHA or VBA-contracted examiner

III.iv.3.D.3 & III.iv.3.D.4- return exams for clarification if (1) the examiner mixes up right & left; or (2) objective findings are consistent with the subjective reports and a diagnosis appears to be warranted, but none was provided (like with radiculopathy); or (3) if no rationale was provided for an opinion; or (4) if the medical opinion is based on incorrect information (as tinnitus was shown in the STRs & the opinion is based on it NOT being in the STRs); or (5) if degrees of motion conflict (i.e. flexion to 40 with pain at 100, is the flexion actually 140?); or (6) if there are objective findings, but then no diagnosis is provided; all of those inconsistencies need to be resolved by the examiner; plus if any rating criteria are missing (i.e. ROM, % of body affected by skin cond, etc.)

o III.iv.3.D.3.e – details on entering insufficients & clarifications in CAPRI (do not enter as insufficient for VHA-contracted exams)

o III.iv.3.D.3.f – details on entering insufficients & clarifications in CAATS

o III.iv.3.D.4.i – x-rays

o III.iv.3.D.4.m & III.iv.4.F.5.a – sleep apnea must be diagnosed with a sleep study

Green v. Derwinski (1/18/91) – “Fulfillment of the statutory duty to assist here includes the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of the prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one.” –so examiners need to review the record prior to the exam & comment on the results of the review, also get new exam if other is more than 1 year old [1/11 info on stale exams slightly contradicts this]

Bielby v. Brown (12/20/94) – be impartial, unbiased and neutral when asking questions

Wray v. Brown (4/6/95) – discussion of expert medical opinions (examine, analyze & discuss each one)

Charles v. Principi (10/3/02) – DTA says VA may need to provide nexus opinion

Nieves-Rodriguez v. Peake (12/1/08) - a private medical opinion may not be discounted solely because the physician did not review the claims file. Likewise, a VA medical opinion may not be preferred over a private medial opinion solely because the VA examiner reviewed the claims file. It is what the examiner learns from the claims file in forming the expert opinion that matters, not just reading the file.

Jones v. Shinseki (3/25/10) – if examiner says cannot provide an opinion without resort/resorting to mere speculation, need to know why. The Court said “The examiner should also precisely identify what facts cannot be determined if unable to give an etiology opinion without resorting to speculation.” III.iv.3.D.2.r (Sharp v. Shulkin (2017) too)

Training documents are under “Changing the Game: VA Exams” at https://vba-tpi.vbatraining.org/lc

Notes from March 2013 “Changing the Game” VA examinations Training:

Medical evidence does not need to be in DBQ format unless under the ACE process.

Can add:

We have evaluated your disability based on treatment records. Please let us know if you believe your disability meets the next higher evaluation.

The Assessment (quiz) in TMS indicated (1) six months of treatment in service does not establish chronicity, still need a medical opinion; and (2) SC for stroke secondary to hypertension can be granted without etiology noted in TRs (do not need to get exam). **The latter (specifically arteriosclerotic manifestations, to include cerebral arteriosclerosis (8046) or thrombosis (8008) with hemiplegia [includes TIA, stroke, CVA, per Carlos Rosario]; nephrosclerosis of the kidneys with impairment of renal function (7507), and myocardial damage or coronary occlusion of the heart (7006) [does not include IHD/CAD, just MI, per Carlos Rosario]; is confirmed by III.iv.4.G.3.g & November 2013 Compensation Service Bulletin (CSB); *Note that November 2013 Compensation Service Bulletin (CSB) says effective date for

stroke/CVA & nephrosclerosis & myocardial damage/coronary occlusion (conds listed at III.iv.4.G.3.g) is date of claim or date entitlement arose, cannot apply 3.157 or 3.400 (it’s not a worsening of hypertension)

QRT Questions from Changing the Game: VA Examinations – can grant DM at 20% based on TRs if there are no potential complications; IU effective date question; can rate respiratory disabilities on meds, even without PFT; requirement for Gen Med exams; ACE exams & tender scars; cardio evals – need to know if there is cardiac enlargement & what METS are, but can give interim 10% based on meds then get exam; tinnitus complaints vs. diagnosis; requirement for Goldmann Bowl; chiropractic reports with ROM values aren’t sufficient to assign an eval based on LOM; even if can grant, still need to get TRs identified; if TRs show painful motion, can grant 10%, no need for exam

August 2013 Training Provided by Central Office by RQRS Challenge Instructors on Exams :Exams – B2 errorsWhen to get exam? When to get opinion? Are results sufficient?

Need 3 things to get an exam:1- Diagnosis or symptoms from veteran2- STRs or other records show an event in service3- Something to indicate a relationshipIf don’t have #3, deny for NONEX. (Examples: one treatment in service with complaints now, that’s it = no exam; one treatment in service with complaints now & a statement from veteran that related to service = get exam & opinion – he says claim for SC/comp is just a claim for disability & is not the same as a statement linking it to service)

If you have medical evidence that is adequate for rating purposes (just as good as an exam), don’t get an exam. You do not need to have evidence to grant the highest evaluation possible, just enough info to evaluate accurately. Don’t need Deluca or Mitchell with this type of info (only for VAEs). Only get an exam (including At Once exams) if NECESSARY. There is also no requirement related to the age of the evidence.

McLendon v. Nicholson, 20 Vet.App. 79 (2006) – Threshold is low, but exams are not automatic. We NEED to take lay evidence into consideration, including veteran’s & other’s statements.

Federal Court says VAEs are not routine/automatic, need to analyze case & see if have 3 requirements.

Insufficiencies – 4.2 – look at whole record; only send back if box/info/details could lead to a higher evaluation

December 2013 Compensation Service Bulletin (CSB) – confirms that “The last requirement for an “indication of association” can be satisfied by lay testimony. The Veteran’s indication that his/her condition has existed “since service” satisfies the requirement. However, without a medical or lay indication of association, no examination would be warranted in most cases.” Reiterates Examples above with distinction being that veteran says he hurt his back in service and it has hurt ever since.

VA Pulse, has document on Waters v. Shinseki - https://www.vapulse.net/docs/DOC-19848

December 2013 Compensation Service Bulletin (CSB) – VA may accept a DBQ as adequate for rating purposes if the DBQ is completed by a licensed health care professional who is not a medical doctor (i.e. Nurse Pracitioner or Physician’s Assistant), except for mental exams (see FL 06-03)

The Three Requirements That Must be Met Before an Examination is Warranted

Element GuidanceElement A Competent medical or lay evidence of current diagnosed disability or persistent or recurrent symptoms or disability.

In many instances the Veteran’s lay testimony in a claim is enough to establish that there is a current disability or persistent or recurrent symptoms of disability. Lay statements are generally competent to describe symptoms. In some instances, medical evidence is required to establish the presence of a diagnosed disability, such as identifying a form of cancer.

VA defines “competent medical evidence” and “competent lay evidence” in 38 C.F.R. § 3.159(a)(1) and (2).

Element BInjury, disease, or event in service.

To establish an event, injury, or disease in service, the Veteran merely has to have a single entry in the service treatment records; or, the Veteran’s lay statement will be sufficient if such statement is credible and otherwise consistent with the circumstances of the Veteran’s service. If the Veteran’s claim relates to combat, the Veteran’s lay statement(s) must be accepted as sufficient if consistent with the circumstances, conditions, or hardships of the Veteran’s service. In addition, this element is present if the Veteran has a disease or symptoms of a disease listed in 38 C.F.R. §§ 3.309, 3.313, 3.316, or 3.317 manifesting during an applicable presumptive period (provided that the claimant has the required service or triggering event to qualify for that presumption).

Element C Indication of association with the injury, disease, or event in service.

There must be an indication that the claimed disability or symptoms may be associated with the in-service injury, disease, or event or with another service-connected disability. For example, lay or medical evidence that a symptom has persisted “ever since service” would be an indication that a disability may be associated with service. Lay evidence of association can satisfy element C if the layperson is competent to indicate association. However, conclusory, generalized lay statements by the Veterans of an association may not be of sufficient weight to satisfy element C. Unlike element B, the evidence need not establish an association, but only indicate a possible association.

McLendon v. Nicholson - the element C “indicates an association” standard is a “low threshold standard”Waters v. Shinseki - element C only requires evidence indicating an association; this evidence does not need to be competent, nor does it need to be medical

12/19/14 DBQ Call – Examiners will only complete the ankylosis section if there IS ankylosis. If entire section is blank, even if did not check “No ankylosis,” then there is no ankylosis (the selection is there in case one side is ankylosed, but the other is not).

Notes from February 2015 “Understanding the Need for VA Exams” Training:

Need (1) current dx/recurrent sx, (2) in-service event & (3) indication that dx/sx may be associated (i.e. nexus/link) before exam is warranted.

Assess credibility (is it believeable?) & probative value (is it relevant & persuasive?) before assigning weight

Do no reject medical evidence unless (1) historical facts are uncertain/invalid/unsound OR (2) have other medical evidence

Wood v. Derwinski (7/12/91) – 3.157

Owens v. Brown (3/14/95) - Because the appellant's testimony concerning the extraction of his missing teeth conflicted with the SMRs, the BVA's rejection of the doctors' opinions, which were based on dental history related by the appellant was justified.

Wray v. Brown (4/6/95) – discussion of expert medical opinions (examine, analyze & discuss each one)

Curtis v. Brown (8/1/95) – must consider treating physician’s uncontradicted statements

Winsett v. West (9/21/98) – Tirpak v. Derwinski, 2 Vet.App. 609 (1992), that “may or may not” terminology is an insufficient basis for an award of service connection. Moreover, the Court has expressly declined to adopt a “treating physician rule” which would afford greater weight to the opinion of a veteran’s treating physician over the opinion of a VA or other physician (Guerrieri v. Brown, 4 Vet.App. 467, 471-73 (1993)).

Evans v. West (11/16/98) – veteran was not compliant with exams

If evidence is questionable or conflicting, further dev may be needed

Only order exams for CFIs if there is (1) evidence of increased disability OR (2) a statement from the veteran that the condition is worse . If don’t have either, John says to C&C [but Carlos Rosario says it’s not a claim, so VSR should send letter under EP 400.] – Per VA Pulse,

https://www.vapulse.net/message/7577, Rich Osborne says “The mere fact they said it worsened or request an increase is sufficient to trigger a VA examination” (argument is based on 3.326 saying if medical evidence is not adequate, need VAE; also argues that recent VAE cannot be used as that would be a DeNovo review)

Weekly Q-Tip (3/18/15) - Weekly Quality Tip: VA Examinations for Increase Claims

This week’s Quality Tip involves the issue of when to order a VA examination in claims where an increased evaluation was submitted for a service connected disability.

QUESTION:  When do we order a VA examination, where a claim for an increased evaluation for a service connected condition was submitted?

ANSWER:  We are required to order a VA examination for a claim for increased evaluation when the evidence of record is not sufficient to grant the benefit sought.

Discussion: A claim for an increased evaluation of a service-connected disability based on a statement from the claimant that the disability has worsened constitutes a substantially complete application. When the post-service medical records do not adequately reveal the current state of the Veteran’s disability, our statutory duty to assist requires a current medical examination. In claims for disability compensation, assist the claimant by providing a medical opinion or examination when the opinion or examination is necessary to make a decision on the claim.

In claims for an increase in evaluation of a service-connected disability, order a VA examination when:

1. The Veteran provides a statement that his/her condition is worse, or

2. There is evidence of increased disability but the medical evidence is insufficient for rating purposes.

Note:  If a Veteran had a VA examination for the claimed condition within the past year, consult with a RVSR before proceeding with another examination request.

The above note directs the RVSR to review the evidence to determine if the benefit sought (claim for increase) can be granted without an examination.  A confirmed and continued evaluation is not a grant for the benefit sought in a claim for increased evaluation as it is a denial for an increased evaluation.

Scenario: The Veteran is service connected for lumbar strain at 10% disabling. The Veteran filed a claim for increased evaluation for the lumbar spine. The previous VA examination for the lumbar spine was performed five months prior to the submission of the current claim for increased evaluation, and three months from the last rating decision.

Facts:  A review of VA treatment records is silent for any treatment for the lumbar spine, from the date of last examination and rating decision.  There was no private medical evidence indicated/submitted by the Veteran regarding treatment for the veteran’s lumbar spine since the last examination and last rating decision.  

In this scenario, it is clear the intent of the Veteran was to seek an increased evaluation for the service connected lumbar spine.  With submission of the current claim, the Veteran is stating the service connected lumbar spine condition has increased in severity since the last decision. Therefore, in the scenario provided, a VA examination is warranted to evaluate whether the lumbar spine condition has increased in severity since the last examination and decision, as there is no evidence of record to grant the increased evaluation for the lumbar spine in the absence of evidence in VA and private treatment records.

References: 38 CFR 3.159(c)(4)(i)38 CFR 3.160(f)M21-1MR I.1.C.7.a and bM21-1MR I.1.B.3.b (Note for Increase evaluations)Additional information:Compensation Service, “Changing the Game, VA Examinations,” last updated 10/03/2014 (TMS 3814935)TMS 1197953 (Requesting VA examinations) last updated 11/17/14

August 2015 Quality Call Notes - Per M21-1 Part III.iv.3.B.1.e, the Veterans Health Administration’s (VHAs) scheduling clinic or contract examiner will contact the Veteran or claimant regarding the date and time of a scheduled examination – including claims under the FDC program. Compensation Service is updating the manual to eliminate any conflicting guidance.

Q: Do we send examination notification letters for review exams? They're technically not "claims."A: The manual guidance regarding scheduling examinations is for all examinations. VHA has the responsibility for notifying the Veteran in all cases.

Q: If a Veteran files a claim on a Fully Developed Claim form, we don’t have to notify them regarding examination. What if the claim is filed on another prescribed form (not an FDC claim)? Are we required to notify the Veteran of the VA examination?A: The manual guidance regarding scheduling examinations is for all examinations. VHA has the responsibility for notifying the Veteran in all cases.

Q: What's the procedure for VAMCs that do not send a letter to a Veteran notifying them of their examination appointment? Certain VAMCs are cancelling examinations if they do not reach the Veteran by phone. No letters are being sent in these situations, as well. What's the quality process to ensure the VAMCs are being notified of the proper procedures for notifying Veterans of appointments? A: The link to the updated RSVP procedures is http://vaww.demo.va.gov/files/FactSheets/2015/FactSheetDMA-15-003.pdf .

Notes from December 2015 DBQ Medical Opinion Training (Konane Stradling) –

Even if an examiner says peripheral neuropathy is mild on a DM DBQ, still need a DBQ for peripheral neuropathy.

If non-PTSD diagnosis & can’t verify stressor (I think she means “event”), need Memo.

For Quick Start (My Notes: Quick Start discontinued 10/1/17, but this probably still applies to BDD), if a 3.309 disability is diagnosed on the DBQ & not claimed, need to solicit; but if it is a non-3.309 disability, do nothing. (My Notes: Probably safe to solicit if the exam was done in service, or there is treatment in the STRs, & the DBQ shows a clear diagnosis based on findings, not history. Ensure it’s a clear grant with the evidence on file at the time of your RD.)

As of 3/24/15, only need to upload the last year of VATRs.

For ERB, have to be on VBMS “Profile” screen to get it to pull the veteran’s information. If have VVA documents, choose the correct c-file type.

Notes from April 2016 Exams Refresher Training (focus on 3 Elements / Waters v. Shinseki) (GiaBao Nguyen) –

Element 1 (need for both direct & secondary) – evid of symptoms [but for any 3.309(a) condition, we need medical evidence of diagnosis (cannot use lay statement)]

Element 2 – veteran’s statement, spouse statement, MOS (buddy statement & MOS can be enough even if not in STRs); for secondary, just need SC disability

Element 3 – lay statement “since service” or in TRs with some sort of statement; for secondary, need medical evidence of a relationship, lay statement, medical treatise or regulation (i.e. 3.310 – heart disease secondary to amputations, TBI secondary conditions), cannot be inherently incredulous claim

HL & tinnitus, need #1 – can use lay evidence, #2 – duty MOS or combat, #3 - lay statement “since service” or in TRs with some sort of statement (this is a change) - #3 is no longer true as of early 2018

For presumptive, need #1- evid of diagnosis (since all 3.309), #2 – exposure, POW status, etc, #3 – regulation, 3.309

CFIs – last exam more than 1 year ago – get exam; last exam less than 1 year ago – need statement that worsened, see above I.1.C.3.i

Fear claim – still need SPRs/201 file, even if requesting exam

August 2016 Quality Call Notes - if the MO is already embedded within the ‘specific body-system DBQ,’ such as hearing loss, diabetes, male reproductive organs, etc., a separate ‘Medical Opinion DBQ’ is not needed. Regarding MOs in the ‘Hearing Loss and Tinnitus DBQ,’ please follow the guidance as required by M21-1, III.iv.3.A.7.h.

March 2017 Quality Call Notes - Do not ask legal questions when requesting Medical Opinions as directed by the Live Manual at M21-1

Part III.iv.3.A.7.i and M21-1 Part III.iv.3.A.7.b if using CAATS.

Do not return the exam for a Medical Opinion if there is no diagnosis.

Do not request a Medical Opinion for presumptive disabilities, including Agent Orange exposure under 38 CFR 3.309(e). Clearly state “VBA conceded AO exposure” if the examination is based on exposure to herbicides and the Veteran has a 3.309(e) diagnosis.

When you have an initial claim for a disability for Gulf War, please state “This is an INITIAL claim for Gulf War exposure-related disability” (My Notes: I added “exposure-related disability.”)

Notes from March 2017 “Changing the Game” VA examinations Training:

Whether the evidence is “current” should not be confused with the age of the evidence. The age of medical evidence does not, in and of itself, render it too old for rating purposes, as demonstrated in Palczewski v. Nicholson. VBA can use reports that are old as long as the reports show that the benefit can be granted.

Assessment Question: If the medical evidence of record is five years old, but is sufficient for rating purposes… Answer: A VA examination is not needed if the benefit being sought can be granted.

Notes from March 2018 Training Provided by Central Office by Andrew Grey (Site Visit Training) on VA Examinations:

Element 1 (current disability or persistent/recurrent symptoms) – lay is sufficient for most musculoskeletal sx; cancer & other diseases need TRs show diagnosis [just a claim does not establish Element 1]

Element 2 (event/injury/disease in service) – need treatment in service; OR Parachutist Badge; OR veteran reports shoulder injury when loading heavy cargo in Korea in 6/09, spouse corroborating statement (then says can also just use veteran’s statement) & SPRs show loadmaster & exercise in Korea 6/09 [be careful using acute & transitory]

Element 3 (indication of association) – easiest hurdle, can use veteran’s statement of persistent symptoms since service (or TRs, if have them) [just a claim does not establish Element 3]

Ensure opinion requests are through & relevant documents are tabbed & bookmarked

Question: For element 2, if the Veteran simply states that his/her claimed condition is due to combat trauma, the STRs are silent for factual treatment of the claimed condition, and the Veteran's DD214 lists participation in combat, would this satisfy element 2?

Answer: Element 2 would be satisfied if the Veteran identifies that the injury was a result of combat and the circumstances are consistent with the circumstances, conditions or hardships of combat.

San Diego RVSR Training (Version 2).pptx, recorded training & email message with answers to questions are saved at H:\VSC\FY2013 LANES\Training\NTC Training Recordings\FY18\2018 Site Visit

Training

3.328 Independent medical opinions –

III.iv.3 Reonal v. Brown (9/8/93) – opinion based on inaccurate data is not credible opinion, thus not material

evidence

Gardin v. Shinseki (7/16/00) - a private medical opinion may not be rejected solely on the basis of the physician having not reviewed SMRs. However, the omission of such review may be considered in determining the probative value of such evidence.

In January 2014, Comp Service confirmed (discussed at January 2014 Evaluation Builder Refresher Training) – that need we need a direct opinion if there are symptoms in service, but no diagnosis until after service. We also need an opinion if diagnosed in service and diagnosed with the same disability more than one year after RAD (even if claimed within one year). No opinion is needed if diagnosed in service AND diagnosed with same disability within one year of RAD. This excludes 3.309 chronic disabilities.

*Did not specifically discuss if diagnosed in service and diagnosed with a similar disability within one year of RAD, but November 2014 Rating Quality Call Notes say that when general medical examinations are ordered for recently discharged Veterans, please do not request opinions for all the conditions claimed.

September 2014, Rich Osborne (Comp Service Quality Review & Consistency Team) : \\vbasdcfpc2\shared\VSC\Training\NTC Class Material\Waters-Walker PPT ; different information than from January 2014.

Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) o December 2013 Compensation Service Bulletin (CSB)

o VA over-reacts as an agency (with VCAA, sent letters on everything, even if no letter needed; with McLendon v. Nicholson, 20 Vet.App. 79 (2006), requested exams on everything, but ignored 3.159(c)(4)(i)). Waters v. Shinseki says need causal connection, exams are not automatic. Need THREE prongs:

3.159(c)(4)(i) In a claim for disability compensation, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but:

(A) Contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; per Rich - can be statement from veteran/buddy/wife (“I’ve had right knee pain since service”), or medical evidence.

(B) Establishes that the veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in §3.309, §3.313, §3.316, and §3.317 manifesting during an applicable presumptive period provided the claimant has the required service or triggering event to qualify for that presumption; and per Rich – event, injury, disease. If the veteran or examiner says “duties,” but there is nothing in the STRs, still have to have something (i.e. Parachutist Badge or buddy/wife saying had symptoms in service [i.e. snoring/sleep apnea]). A lay report of an injury is not sufficient to establish an event/injury/disease. VA Pulse, https://www.vapulse.net/message/14042

My Notes on Kahana: “…the Court holds that the Board erred in making a medical determination concerning the severity of an anterior cruciate ligament (ACL) in violation of Colvin” (Colvin says “VA cannot reject opinions of physicians without citing medical testimony or treatises to the contrary).” The take-away, for me, is that the BVA said the veteran wasn’t competent to report an injury in service, when really he is competent, but the report may not be credible if there is no other evidence to support it. Hence our SNL denial rationale NOCRED. However, other RVSRs have taken the case as saying veterans are credible to report injuries in service that are not shown in the STRs. I don’t think that’s what the case says & in this case, the veteran did have treatment for his right knee in service, so BVA was wrong when it told the examiner there was no treatment & when it rejected a medical opinion without contrary medical evidence. That’s the crux. Additionally, III.iv.5.9.a says “A non-combat Veteran’s lay statements may be acceptable for establishing service incurrence or aggravation, but must be weighed against other evidence in the claims folder, including the absence of military records documenting or supporting the statements.”

(C) Indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. per Rich – any indication that it may be associated with service (lay testimony that existed “since service”). Can be in TRs. Mere claim form does not satisfy, but if complete forms with dates & locations of treatment in service, may meet this prong. McLendon v. Nicholson, 20 Vet.App. 79 (2006) got us and veteran into habit of not relating to service, but need SOMETHING.

o If can grant & evaluate accurately with medical evidence provided, no exam/opinion is needed.

o RVSRs can make judgment call. If we only have the first TWO prongs, can still get an exam. But you MUST get an exam if you have all THREE prongs.

o If the evidence shows an intercurrent injury, make sure you tab it.

Walker v. Shinseki (2013)

o April 2014 Compensation Service Bulletin (CSB)

o We can use medical evidence of “continuous symptoms” under 3.303(a) in lieu of a medical opinion.

“Continuous” means without stopping or recurring regularly. Medication counts as continuous medical evidence. Cannot be history of, but actual medical evidence.

o If there are isolated instances from/since service, they may not be sufficient to establish a nexus, but would be enough to meet the THIRD prong under 3.159(c)(4)(i), so get exam with opinion.

o If uncertain that medical evidence is sufficient to consititute “evidence of continuous symptoms,” get exam with opinion.

o Examples:

Close proximity (within one year from sep) - Claim 6 months after sep with med evid of symptoms & a diagnosis (right knee strain, dx also within one year from sep), + the same diagnosis is in the STRs = continuous symptoms, nexus under 3.303(a), no opinion needed, just explain it in your decision (see boxes below).

NOT close proximity (outside a year) - Claim 18 months after sep with med evid of a diagnosis (asthma), but with only recent treatment, + the same diagnosis is in the STRs, we need an opinion. *Note this is even with a diagnosis now & in STRs. – aligns with January 2014 guidance

NOT close proximity (outside a year) – Claim 2 years after sep with medical evid of a diagnosis (hemorrhoids) & continuous symptoms since service, + the same diagnosis is in the STRs = continuous symptoms, nexus under 3.303(a), no opinion needed, just explain it in your decision (see box below).

NOT close proximity (outside a year) - Claim 2 years after sep with reports of right knee pain since service, and medical evid of treatment for right knee pain since sep, plus recent diagnosis of right knee strain, + multiple treatments for right knee pain (no diagnosis) in the STRs including on sep exam = continuous symptoms, nexus under 3.303(a), no opinion needed, just explain it in your decision (see box below). *Note this is even with only pain in STRs & diagnosis 2 years out. – contradicts January 2014 guidance about pain

o If the scenario is different from those given, probably need an opinion.

o Asthma and hemorrhoids do not fall under 3.309(a).

Continuous sx after service:There is evidence of continuous symptoms with medical evidence from {} showing symptoms continuing without stopping or recurring regularly with minimal interruptions from/since service, showing a nexus to service. IV.ii.2.B.1.a.

Continuous sx in service & maybe after service too (for cases with only sx in service, dx after service, but clam & dx in close proximity):There is evidence of continuous symptoms with medical evidence showing symptoms continuing without stopping or recurring regularly with minimal interruptions, showing a nexus to service. IV.ii.2.B.1.a

Notes from June 2013 “Weighing Evidence” Training (Carlos Rosario):

Training documents are under “Weighing Evidence” at http://hvnc.gdit.com/lc/

III.iv.5, III.iv.6.C Do not weigh equivocal medical opinions. They are considered non-opinions and hold no weight. Do not use

reasonable dout on equivocal opinions. Reasonable doubt can only be used on evidence that can be weighed.

Must be credible and competent before assigned a weight.

Medical treatises should not be used by us, as they are often too general, but can be used by examiners (as long as they are interpreted correctly; PTSD & sleep apnea example where examiner was using the Abstract and not the actual conclusions)

Gonzales v. West (Fed Cir 2000) – we must review and weigh all relevant evidence, but do not have to discuss each and every piece of evidence

We must explain why any evidence in support of the claim is being rejected, even if the medical opinion does not.

If we do not discuss how the evidence was weighed to support the decision, it is not “substantially justified.”

Opinions based on the Veteran’s unsupported history may be discounted (Reonal case says not credible). Must explain in decision.

VA physician’s opinions may be assigned more weight if the VA examiner saw the claims file. Must explain in decision if one medical opinion was chosen over another.

Separation exam is the most probative (it’s contemporaneous, most reflective of condition, includes medical history). Statements made at the time of the event/injury (or shortly thereafter) are more accurate and probative than a statement made several years later. Statements to healthcare professionals for the purpose of seeking treatment are very probative. Business or Public records are factual, contemporaneous and prepared by an official, so are very probative.

June 2015 Rating Consistency Study & Training on Requesting VA examinations:

Action Facts of the Case Think It ThroughRequest DBQ only

STRs show event, injury, or disease of the claimed disability Veteran submits medical evidence showing current diagnosis and continuous symptoms since service discharge

If the evidence of record is sufficient to grant the benefit sought, no VA examination is necessary.

Request DBQ with medical opinion

STRs show event, injury, or disease of the claimed disability No continuous medical evidence from date of dischargeVeteran submits medical evidence showing current diagnosis and continuous symptoms since service dischargeDiagnosis is more than one year from separation from service

An exam with an opinion is necessary since there is no continuity of symptoms. This opinion is needed to determine if the current diagnosis is related to service and service connection should be granted under 38 CFR 3.303(a). It is also used to determine if service connection should be denied based on the findings of the medical exam and medical opinion. Although the Veteran has a current diagnosis, the diagnosis is more than one year from separation from service.

Request DBQ with Medical Opinion

A claim for service connection is submitted more than one year after dischargeThe Veteran's STRs show symptoms of a disease (diabetes mellitus) Lab findings show high blood sugar in service but no diagnosis of diabetes in serviceVeteran submits evidence of a current diagnosis of diabetesDiagnosis is more than one year from separation from service

An exam with an opinion is necessary if a Veteran has symptoms of a disease in service.

For example, if a Veteran's lab findings showing high blood sugar, an exam with an opinion is necessary to determine if the lab findings in service were an early manifestation of diabetes, thus establishing service connection.

Examples:Beth Jones was honorably discharged from the Army on February 1, 2012. She submitted a claim to VA on March 10, 2015, claiming service connection for right shoulder injury. The service treatment records show an event of right shoulder injury from pulling books down from a high shelf. There was no evidence of a shoulder disability at time of separation. She submitted no medical evidence in support of her claim and no statement that the disability has persisted since military service. - Deny the claim

Beverly Wilson was honorably discharged from the Navy on April 6, 2012. She submitted a claim to VA on May 9, 2015, claiming service connection for left knee injury. The service treatment records indicate the Veteran was seen on two occasions for injuries involving the left knee. There was no evidence of disability to either knee at time of service separation. She submitted no medical evidence in support of her claim, but she included a statement that she injured her left knee twice in service from falling and her knee has hurt ever since. - Request a DBQ and medical opinionJohn Langly was honorably discharged from the Marine Corps on January 15, 2015. He submitted a claim to VA on April 3, 2015, claiming service connection for low back pain. The service treatment records indicate the Veteran was seen for low back pain diagnosed as thoracolumbar strain on two separate occasions. The service separation examination noted diagnosis. The Veteran did not submit medical evidence in support of his claim nor statement of continuing symptomatology. - Request a DBQ onlyEric Hernandez, was honorably discharged from the Army on December 14, 2012. He submitted VA Form 21-526EZ, claiming left elbow tendonitis that was received by VA on April 9, 2015. He submitted private treatment reports from February 20, 2014, to February 28, 2015, showing current disability of left elbow tendonitis. An Elbow and Forearms Conditions DBQ completed by the private physician was sufficient for rating purposes. No statement from the Veteran was included with the claim. Review of the service treatment records indicates the Veteran was treated for left elbow pain in service. There was no evidence of a pre-service left elbow condition and the separation examination was negative of abnormalities to the musculoskeletal system. - Request a medical opinion onlyDaniel Cruz honorably served in the Army from November 11, 2009, to November 10, 2011. His Military Occupational Specialty (MOS) was Infantryman. The Veteran filed VA Form 21-526EZ, received at VA on May 4, 2015, claiming service connection for left knee injury. His statement indicated he was running from a burning building in Iraq when he fell on his left knee. Due to the hardships of serving in a combat zone, he was not seen for medical care until after discharge, but he has had continued left knee pain since. The Veteran submitted treatment reports from the Harvey Clinic dated February 20, 2012, through December 3, 2014, showing treatment for the left knee. He also submitted a Knee DBQ from his doctor sufficient for rating purposes, dated April 29, 2015, diagnosing chronic left knee strain. The Service Treatment Records (STRs) do not include evidence of event, treatment, or diagnosis relative to any knee injury. The Report of Medical History at time of service separation has an X marked by "trick" or locked knee, however, there are no physician comments. The separation examination is negative of abnormalities. - Request a medical opinion only. Although there is no documented evidence of event in the service medical records, the marking on medical history at time of separation makes the claim plausible based on the places, types, and circumstances of service. The DBQ and Harvey Clinic treatment reports support current disability. A medical opinion is needed to determine if there is a link between the Veteran's service (such as his MOS) and current disability.Janet Jenkins honorably served with the Army from October 11, 1969, to October 10, 1971. The Veteran submitted VA Form 21-526EZ on April 21, 2015, claiming shingles due to exposure to Agent Orange while serving in Vietnam. Included with the claim were treatment reports from Beltrami Clinic, dated November 22, 2014, through March 15, 2015, confirming shingles diagnosed November 22, 2014. The medical records were negative of suggestion or opinion that shingles would be related to Agent Orange exposure. Her DD 214 verified one year of service in Vietnam. The STRs do not include evidence of shingles during service or at time of separation. - Deny the claim. Shingles is denied on a direct basis because there is no evidence of disease contained in the STRs. Shingles is also denied as it is not a recognized disease associated with exposure to Agent Orange. The record does not support a causal connection or association to active military serviceGlenn Bosch, a GW Veteran who was honorably discharged from the Marine Corps on October 30, 2014, submitted a completed VA Form 21-526EZ through eBenefits on April 16, 2015. He claimed service connection for instability of left ankle due to chronic sprains. The STRs indicate the Veteran was seen on three separate occasions for left ankle sprain. There is no evidence of a pre-service left ankle condition. The Veteran stated he has not been able to afford care since his service discharge and does not live close to a VAMC. He reported his ankle rolls repeatedly and causes pain. - Request a DBQ only. An examination is needed to determine the current level of disability. A medical opinion is not needed since the claim was submitted within one year of separation from service and there is evidence of a service event. Current symptomatology is present based on his claim of ankle instability (rolling).

Trevor Niles is service connected for PTSD for which he has been prescribed medication since 2010. He submitted a claim on March 29, 2015, for metabolic syndrome stating it is the result of the medication taken for his PTSD. Review of the STRs failed to reveal evidence of treatment or diagnosis relative to metabolic syndrome. The Veteran submitted private treatment reports dated March through December 2014, showing diagnosis of metabolic syndrome. The Veteran was advised to appropriate diet and exercise. The Veteran's physician provided a cover letter with the following medical opinion: Mr. Niles has been a patient of mine since March 2014 for his disability of metabolic syndrome. He told me he has been on prescription medication for PTSD since approximately 2010. It is at least as likely as not that his metabolic syndrome is the result of the medication used to treat his PTSD. - Request a DBQ and medical opinion. The physician did not provide medical rationale for the opinion rendered. It was not supported by medical treaties or any source of justification. However, the statement does provide possibility of association with military service, thus requiring medical opinion. DBQ is needed to determine level of disability. (38 CFR 3.155)Billy Little Ghost, a GW Veteran, was honorably discharged from service four years ago. He filed a claim for flat feet, received by VA on May 9, 2015. He stated that his feet have bothered him since service and he is seen by Podiatry at his local VAMC. Review of VA records confirms the Veteran has been diagnosed with pes planus and has been provided custom built orthotics. Review of the STRs indicates the Veteran was seen with complaints of painful, tender arches of the feet but no accommodations were made. There was no evidence of a pre-service foot condition but the separation examination included continued complaints of painful feet, reported as likely due to combat boots. - Request a DBQ and medical opinion. The evidence shows an event in service and current disability. Since the Veteran has been discharged from service greater than a year ago and reports the feet have "bothered" him since service, a medical opinion is needed to link the current disability to the service event. A DBQ examination will provide current level of disability. It would be erroneous to deny the claim since there is a service event, current disability, and Veteran's report of symptomatology.

May 2016 Quality Call Notes – If there is nothing noted on the enlistment exam & the examiner gives a negative opinion based on the veteran’s report of a pre-service injury, but we have no clear evidence it pre-existed, “… return to examiner with clear instruction to disregard the Veteran’s statement concerning an earlier injury. Without clear and unmistakable evidence the condition existed prior to service, the presumption of soundness has not been overcome. See M21-1, IV.ii.2.B.4.b; M21-1, IV.ii.2.B.4.d; and, Wagner v Principi.” If have clear evidence it pre-existed, “…return the opinion to the examiner to inquire whether the condition was aggravated beyond natural progression by military service.” (this is a change from local policy)

4.2 Interpretation of examination reports – 4.1, 4.10, 4.40, 4.45, 4.70 - interpret exams “in the light of the whole recorded history,” “each disability must be considered from the point of view of the veteran working or seeking work,” return as inadequate if dx is not supported or if detail is missing; pain is not a disability

III.iv.3.A III.iv.5

4.6 Evaluation of evidence – weigh all evidence (C-C-W = Competency [qualifications], Credibility [worthiness of belief/plausibility], Weight [effect/persuasiveness of evidence inducing belief] - must do all 3 steps; if the evidence is not competent, then it has no probative value and do not need to determine if credible; but if competent, then credibility must be specifically addressed and findings made [determine if credible (believable/plausible) & then

determine probative value/weight (relevance/persuasiveness); if more credible, then more probative])

4.13 - Effect of change of diagnosis – only increase or decrease based on “actual change in the conditions,” “not merely a difference in thoroughness of the exam or in use of descriptive terms”; check if progression of that disease or independent entity (i.e. undiagnosed illness manifested by diarrhea changed to lactose intolerance)

III.iv.5.B.1.e

ftr:

VA Examination Report of No Show for examination scheduled for {}

VA Examination Report of unavailability for examination, received {}*see FTR for verbiage for Reasons for Decision

if cancelled by veteran:VA Examination Report of cancellation of examination scheduled for {}VA Examination Report of cancellation of examination rescheduled for {} (which was initially scheduled for {})III.iv.3.C.1.b changed 12/19/17 to say - Note:  If the rating activity determines that a necessary examination was canceled without a valid reason, it must submit a new examination request to the examining facility and specify why the previous cancellation was inappropriate.*might use VE1 instead of FTR for verbiage for Reasons for Decision, or the language on “if unavailable” under FTRIII.iv.3.C.1.d – procedure if cancelled because wants to submit DBQ from primary physician

VBMS Document Category-Type: Correspondence - Miscellaneous : Miscellaneous C&P Correspondence

DEFERRAL & EXAM REQUEST INFORMATION –

DeferralsRefresher_18April2016 [PowerPoint] & Deferral Resources and Reminders.pdf (with numerous links, including “Deferral for Exam-Related Action Job Aid”) are saved at H:\VSC\Rating Reference

To have a deferral mitigated / mitigate a deferral – email your Coach & they will email the QRT Coach

Job Aids

Order of Operations for Completing Deferred Rating Decisions – link no longer works & it’s not on the VBMS Job Aids page (https://vbaw.vba.va.gov/VBMS/Resources_Job_Aids.asp), so it’s now saved at H:\VSC\Rating ReferencePartial Rating with Deferral for Exam/Clarification Request

From: VAVBASDC/RO/VSC Sent: Monday, April 10, 2017 8:26 AMSubject: FW: Partial Ratings & deferring new and existing SC conditions in VBMS-R Q-Tip (RVSRs/DROs/Post-VSRs)

With the most recent update and change to VBMS-R, this Q-Tip is being sent to provide steps on how a rater will update VBMS-R to properly defer service connected conditions for examinations within VBMS-R.  Please see the attached guidance which outlines the correct procedures for deferring existing SC conditions, as well as for “at-once” (At Once) examinations following an original SC grant. 

For more information on when a partial rating is appropriate, please refer to M21-1 III.iv.6.A.1.b – When to make a partial rating: 

**Note:  Additional actions in accordance with the NWQ guidance are still required to be completed in VBMS for the actual deferral.

Note: RQRSs/AQRSs will also discuss this topic in upcoming team huddles.

(see below)

Deferring conditions which are already SC:

1. You will need to defer the evaluation under the “Diagnosis Information” chevron. Using the dropdown arrow, the deferred evaluation option is located under the “supplementary decision” box (see below). Be sure to save your changes.

2. If the required examination is based on an “at-once” (At Once) examination, this should be reflected on the “special issues and examination information” chevron.

3. The Summary chevron should also show deferred evaluation for the condition you are addressing. If not, repeat step #1.

4. If the information is correct, be sure to hit the “accept” button which will prompt a reason for the deferral that will also populated as suggested text for the narrative.

5. Review your draft codesheet to ensure the conditions which require examinations are properly reflected. Any deferred evaluations should appear at the bottom of the codesheet just above your signature line and below the NSC decisions. If the deferred issue is properly shown, finalize your rating.

From: VAVBASDC/RO/VSC Sent: Thursday, March 23, 2017 3:19 PMSubject: FW: Quality Tip (Q-Tip): VSRs/RVSRs/DROs: Partial Ratings with examination deferrals in the NWQ

VSC –

The QR Team would like to put out the below quality tip.

Target Audience:  All VSRs/RVSRs/DROsAs a reminder, when a partial rating is completed to expedite benefits and a deferral must be completed for an examination, the correct order of operations must be followed to ensure partial rating decisions are promulgated and not inappropriately returned to the National Work Queue (NWQ). 

If the rater is deferring to the VSR to input the examination request, a deferral must first be completed by the rater, the rating finalized, and then the VSR will request any examination(s) following Post action of promulgation/authorization of the rating decisions.  If the rater is inputting the examination request, the examination requests must first be submitted prior to the finalization of the rating decision.  Please review the steps below and ensure you are following the appropriate steps when requesting examinations in connection with partial ratings.

Deferring to VSR for Exam Requests:  (The deferral and rating decision must be finalized within the same business day)

1. The RVSR will complete any deferral(s) actions in VBMS and finalize the deferral.  This will change the status of the claim from an “RFD” status to “Open” status, and the deferral will show as “pending.”

2. The RVSR will pull in the claim to VBMS-R, complete the rating, defer any conditions necessary on the rating codesheet, and finalize the rating decision.  This will change the status of the claim from “Open” to “RDC.”

3. Post will take action to promulgate/authorize any benefits and continue the EP for development of the examination by Pre-D VSRs.

4. The claim will be reassigned in the NWQ to the next VSR.  Pre-VSRs will request any required examinations to “resolve” any pending deferrals in the system.

RVSR Exam Requests: (The deferral and rating decision must be finalized within the same business day)

1. The RVSR will complete any deferral(s) actions in VBMS and finalize the deferral. (This matches Steps 1-4 in the Order of Operations handout.)

2. The RVSR will request any examinations in the appropriate system (CAPRI/CAATS) and upload the requests to VBMS.  Tracked items must be created to keep the EP running.  This will change the status of the claim from an “RFD” status to “Open” status.

3. The RVSR will pull in the claim to VBMS-R, complete the rating, defer any conditions necessary on the rating codesheet, and finalize the rating decision.  This will change the status of the claim from “Open” to “RDC.”

4. Post will take action to promulgate/authorize any benefits and continue the EP.

Failure to properly follow these steps will result in missed ratings for promulgation/authorization and unnecessary delays of our decisions to our veterans.

Reference & Resource:  “Order of Operations for Completing Deferred Rating Decisions”

Triggers for Deferral Resolution

Primary and Detailed Deferral Reasons

Videos

Adding Supporting Documents to a Deferral

How to Create an Open-to-Open Deferral

Inititating a FULL deferral in VBMS – Click on claims drop-down menu & select appropriate claim

Click deferral tab OR icon

Bookmark ALL related documents with deferral bookmark

My Notes: It appears that if you add a deferral bookmark to a document, you are forced to select a specific contention, but if you do not add a deferral bookmark to a document, you are not forced to select a specific contention.

Click “Add Deferral” or deferral icon & select Primary Deferral Reason, then Secondary Deferral Reason:

Primary Deferral Reason Secondary Deferral Reason

Evidence Missed Development (250) (avoidable)New Records / Needs Review (250) (unavoidable)

IssueNew Issue (250) (unavoidable)Missed Issue (250) (avoidable)

Inferred Issue (250) (unavoidable)

Exam

Needs Exam (250) (avoidable)Opinion Needed (6000) (unavoidable)Insufficient Exam (250) (unavoidable)

Clarification Needed (250) (unavoidable)

Development Missed Development (250) (avoidable)New Record / Needs Review (250) (unavoidable)

Add bookmarked documents to the Supporting Documentation drop-down menu & can further explain deferral, as needed (all but Opinion Needed are limited to 250 characters, use Word – Review - Word Count (under Proofing))

Repeat steps if deferral applies to multiple contentions

Select “Finalize Draft” or add tracked item when ready (will change from DRAFT to PENDING)

Have 2 days to submit rebuttal to QRT Team & Coach, will get response in 2 days

Have 5 days to complete corrective actions

From: VAVBASDC/RO/VSC Sent: Tuesday, June 19, 2018 2:45 PMSubject: Q-Tip: Deferring in VBMS

All VSC Employees,

Q-Tip:   Deferring in VBMS

Target Audience:  All claims processors

This Quality Tip serves as a reminder for the proper steps required to defer claims in VBMS.  Additionally, the attached Avoidable vs. Unavoidable Reasons spreadsheet is provided for your reference to properly classify deferrals based on the actions that are needed. 

VBMS allows claims processors to return a claim to an earlier place of the claim cycle to correct either an avoidable or unavoidable erroneous action.  It is important to properly defer claims in VBMS to ensure optimal processing of claims.

Avoidable deferral = erroneous claims processing based on failure to follow established regulations, policies or procedures by a claims processor.

Example:  A claim is made RFD by a VSR but service has not been verified.  In this instance it is necessary to defer the claim for verification of service.  As this action should have been completed prior to sending the claim RFD the primary deferral reason is “development” and the detailed description is “missed development”. 

Unavoidable deferral = erroneous claims processing caused by an action outside of the control of the claims processor.

Example:  A claim is made RFD by a VSR, but while the claim is pending a decision a new claim for increase is received.  In this instance it may be necessary to defer the claim for any required VA examinations.  As the new claim was received after the claim was sent RFD, the primary deferral reason is “development” and the detailed description is “new records/needs review”.  This is classified as an unavoidable deferral.

Reminders:

1. All deferrals must contain a manual reference to support the deferred action2. Any relevant evidence or documents in VBMS must be properly bookmarked and associated to a deferral.3. A separate VA Form 21-6789 is not required unless additional information is needed to address all actions and

exceed the allowable character restrictions in VBMS.**Note:  The option to defer a claim in VBMS is currently only available to rating EPs.  All non-rating EPs require a blue plate to be uploaded outlining the required development needed and corroboration between teams to complete these actions.

Avoidable v unavoidable Reasons.xlsm & Order of Operations for Completing Deferred Rating Decisions are saved at H:\VSC\Rating Reference

GENERIC NOT RFD

for deferral: … *See Claim Note for details. [*OR had 6000 characters for Exam - Opinion Needed]

for Claim Note: Claim is not RFD. We need ... Deferral done.

PARTIAL GRANT:

for deferral: … *See Claim Note for details. [*OR had 6000 characters for Exam - Opinion Needed]

for Claim Note: Partial grant & deferral done. We need …

Rating Note: We need…

My Notes: If doing a partial grant, create & finalize deferral in VBMS (claim will change to OPEN status), THEN finalize rating (ensure claim is in RDC status).

NEED DBQ & DIRECT OPINION:

for deferral: We need a DBQ with direct opinion for {}. *See Claim Note for details.

for Claim Note: Claim is not RFD. We need a DBQ with direct opinion needed for {} based on {}. Deferral done.

NEED DIRECT OPINION:

for deferral: We need a direct opinion for {}. *See Claim Note for details.

for Claim Note: Claim is not RFD. We need a direct opinion for {} based on {}. Deferral done.

NEED DBQ & DIRECT OPINION ON 3.309 DISABILITY:

for deferral: We need a DBQ with direct opinion for {}. *See Claim Note for details.

for Claim Note: Claim is not RFD. We Need a Migraines DBQ with direct opinion. We have all 3 elements. Please note that although "recurring migraine headaches" was noted in the STRs & migraine headaches are included in 3.309(a) under other organic diseases of the nervous system, an opinion is needed based on Walker, which says "if a condition noted in service or in a presumptive period is not clearly identified as a chronic disease during such periods, a showing of continuity of symptomatology is necessary to establish service connection for the disease under § 3.303(b).”Deferral done.

NEED CLARIFICATION:

for deferral: Clarification / Review and reconciliation of conflicting evidence needed. *See Claim Note for details.

for Claim Note: Claim is not RFD. We need clarification / review and reconciliation of conflicting evidence as {}. Deferral done.

NEED DBQ WITH AGGRAVATION OPINION:

for deferral: We need a DBQ with aggravation opinion on {}. *See Claim Note for details.

for Claim Note: Claim is not RFD. Right ankle disability was not mentioned on enlistment exam, but was reported by veteran 1/71, distal fibula fracture with cast, so it clearly did pre-exist. Since it was treated with surgery (arthrotomy in service), we need a DBQ with aggravation opinion. I.1.C.3.h. Deferral done.

NEED AGGRAVATION OPINION:

for deferral: We need an aggravation opinion on bilateral pes planus (claimed as bilateral plantar fasciitis, but diagnosed as bilateral pes planus on the Foot DBQ). *See Claim Note for details.

for Claim Note: Claim is not RFD. Mild, asymptomatic pes planus was noted on the {date} enlistment exam, and the veteran reported {} on the {} separation exam. We need an aggravation opinion. I.1.C.3.h. Deferral done.

NEED COMPLETE STRS OR FINAL NOTIFICATION LETTER:

for deferral: The STRs are not on file/incomplete, so we need a final notification letter.

for Claim Note: Claim is not RFD. The STRs are not on file/incomplete, so we need a final notification letter per III.iii.1.C.1.e. Deferral done.

OR you can notify the veteran in the RD. Use NO-STR in Evidence. Ensure all necessary actions to obtain the records were properly taken.

OR you can add a note to the codesheet asking the VSR to send the letter, but Post might not want to send it & may defer it back to you…

VSR: Please send the final notification letter about the unavailable/incomplete STRs (per III.iii.1.C.1.e) with the notification letter for this decision.

If all grants, but no STRs, use this:

VSR: We need to attempt to get the veteran's Active Duty STRs or send a final notification letter, per III.iii.1.C.1.e.

NEED STRS/SPRS:

for deferral: No STRs or SPRs on file. Please request both.

for Claim Note: Claim is not RFD. We need STRs & SPRs. Deferral done.

NEED 4142 OR PTRS:

for deferral: We need to request a 4142 from the veteran for {} records, per I.1.C.2.a.

for Claim Note: Claim is not RFD. On the 526, the veteran reported treatment at {} from {}. These records are not on file. We need to ask the veteran for a 4142, so we can attempt to get these records, per I.1.C.2. Deferral done.

FILE NOT SCANNED:

for deferral: We need the STRs, 12/17/79 Administrative Decision & other Evidence listed on the 10/17/12 RD (sent to scanning 6/27/16). *See Claim Notes for more details.

for Claim Note: Claim is not RFD. The 10/17/12 RD lists STRs, a 12/17/79 Administrative Decision & additional Evidence. These records are relevant to this claim & are not on file. The 6/27/16 Claim Note says the files were sent to 376 for scanning. Deferral done.

National Work Queue – Phase 1 & 2 Playbook (revised 3/31/17 & 5/12/17)

RVSR Review for Examination – VSR adds “RVSR Examination” special issue & “Review Complex Exam” tracked item. RVSR marks “Review Complex Exam” tracked item as received & removes “RVSR Examination” special issue after requesting the claim & requesting exams

Use of Local Examiners/Medical Officers – says for VHA exam clarifications, requests for medical opinions & ACE (do not add tracked item or change status, keep in work queue; do add deferral to document erroneous action), says follow locally established procedures & notify supervisor, but we have no locally established procedures

Ordering Examinations Step by Step (by JaVon Chisley, with a bunch of My Notes) (also see III.iv.3.A.7.d & Requesting Exams Job Aid):

1. Create & finalize deferral in VBMS (claim will change to OPEN status). ALWAYS DO DEFERRAL BEFORE TRACKED ITEM, if requesting the exam yourself!!

2. Add tracked item for exam(s) (AMIERQST – specific DBQ) (claim will remain in OPEN status, but will change Deferral Status to Resolved; even if your deferral is still in draft, it will change Deferral Status to Resolved, as of 10/16, sometimes you cannot add a tracked item before finalizing a deferral) – or can let ERB create tracked item(s) for you, but DO NOT have ERB create tracked item(s) unless you’ve already finalized your deferral or it will change to OPEN & will no longer be assigned to you!!

3. Bookmark Evidence in VBMS, per III.iv.3.A.8.e

4. Copy the Veteran’s zip code into Exam Request Routing Assistant (ERRA) / ERRA Tool to confirm if VHA or Contractor has jurisdiction –III.iv.3.A.1.d - mandatory & must upload results in VBMS –

Subject: ERRA ResultsVBMS Document Category-Type: Medical Records - VAX & AMIE - Request Worksheets : VA Exam WorksheetSource: VBMS

August 2016 Routing Exam Requests Training (ERRA) – ERRA 2.0 Job Aid or here

CAATS

CAATS Quick Reference Guide

CAATS Frequently Asked Questions

ExamTrack Access - QTC Management – ExamTrack - VetFed ExamTrack

Contract Exam Inquiry Protocol

All employees who request compensation disability exams must follow the ERRA routing recommendation unless directed otherwise by III.iv.3.A.1.d (some info on the tool, says mandatory & need to upload), III.iv.3.A.2.b (a bit more info on the tool), and III.iv.3.A.1.j (has link to Contract Exam Exclusions list)

Use of ERRA is not required for exam clarifications, exam addendums, corrections of insufficient/inadequate exams, and ACE provided by a local VHA provider (i.e., in-house doctor) – use the Returning Exam Reports Decision Tree [“C&P Clinic POC List” - http://vaww.demo.va.gov/publicationslibrary.asp]

Need more than one clarification for an exam completed by a VBA contract vendor? Use the Additional Quality Assessment Job Aid

If no routing determination made by ERRA, use VHA/CAPRI

If zip code is outside contract vendor area, use VHA/CAPRI

If zip code is in contract vendor area, use CAATS for ”vendor” result(s) & CAPRI for “VA” result(s), but if ERRA recommends routing any required DBQ to a vendor and all DBQs are contract eligible, submit the exam request through CAATS (example: need DBQs for HL & retinopathy, ERRA says Audio-vendor & Eye-VA, use contract vendor; BUT if need DBQs for TBI & GW, ERRA says TBI-vendor, but GW is excluded per III.iv.3.A.1.j, so use VHA; so… even if says VA for some DBQs you need, if other DBQs you need say vendor & the VA ones aren’t excluded, use vendor), also see III.iv.3.A.2.c

If ERRA recommends sending all DBQs to VA, use CAPRI to submit the request to the appropriate VHA facility, also see III.iv.3.A.2.c

If ERRA states “route examination requests to the appropriate VA facility,” use CAPRI to submit the request to the appropriate VHA facility, also see III.iv.3.A.2.c

If a required DBQ is not contract eligible or other exceptions apply, use CAPRI to submit the request to the appropriate VHA facility, also see III.iv.3.A.2.c

From: VAVBASDC/RO/VSC Sent: Monday, October 24, 2016 8:03 AMSubject: FW: ERRA & CAATS

Good Morning,

ERRA and CAATS have been updated to reflect the geographic expansion of VBA’s exam contracts and the current availability of vendors.  CAATS vendors now include MSLA and LHI.  Please request exams through these specific vendors via CAATS if ERRA recommends to do so.

Please note: VHA may cancel exams submitted based on an ERRA routing recommendation.  If this occurs, please use ERRA to obtain the name of the vendor and the station number aligned with the Veteran’s location.  Please then submit the exam via CAATS, regardless of ERRA’s routing recommendation. 

Station ID Name State301 Boston  Massachusetts304 Providence  Rhode Island306 New York  New York307 Buffalo  New York308 Hartford  Connecticut309 Newark  New Jersey310 Philadelphia or Philadelphia PMC Pennsylvania311 Pittsburgh  Pennsylvania313 Baltimore  Maryland314 Roanoke  Virginia315 Huntington  West Virginia316 Atlanta  Georgia317 St. Petersburg  Florida

318 Winston-Salem  North Carolina319 Columbia  South Carolina320 Nashville  Tennessee321 New Orleans  Louisiana322 Montgomery  Alabama323 Jackson  Mississippi325 Cleveland  Ohio326 Indianapolis  Indiana327 Louisville  Kentucky328 Chicago  Illinois329 Detroit  Michigan330 Milwaukee  Wisconsin331 St. Louis  Missouri333 Des Moines  Iowa334 Lincoln  Nebraska335 St. Paul  Minnesota339 Denver  Colorado340 Albuquerque  New Mexico341 Salt Lake City  Utah343 Oakland  California344 Los Angeles  California345 Phoenix  Arizona346 Seattle  Washington347 Boise  Idaho348 Portland  Oregon349 Waco  Texas350 Little Rock Arkansas351 Muskogee  Oklahoma354 Reno Nevada355 San Juan  Puerto Rico358 Manila  Phillipines362 Houston Texas372 Washington  D.C.

373 Manchester New Hampshire

376 St. Louis RMC 377 San Diego  California397 Appeals Management Center 402 Togus or VA Maine Healthcare Maine405 White River Jct or Medical Center Vermont436 Fort Harrison or VA Montana Health Care Montana437 Fargo or Fargo VA Healthcare North Dakota438 Sioux Falls or Sioux Falls VA Health Care South Dakota442 Cheyenne or Cheyenne VA Medical Wyoming452 Wichita  Kansas459 Honolulu or VA Pacific Islands Health Care Hawaii460 Wilmington or Wilmington VA Medical Center Delaware463 Anchorage  Alaska501 New Mexico VA Health Care System New Mexico502 Alexandria VAMC Virginia503 Altoona - James E. Van Zandt VA Medical Center504 Amarillo VA Health Care System; My Notes: Lubbock506 VA Ann Arbor Healthcare System508 Atlanta VA Medical Center; My Notes: located in Decatur509 Charlie Norwood VA Medical Center

512 Baltimore Health Care VA Maryland Health Care System515 Battle Creek VA Medical Center516 Bay Pines VA Healthcare System; My Notes: C.W. Bill Young, Lee County517 Beckley VA Medical Center518 Edith Nourse Rogers Memorial Veterans Hospital; My Notes: Wheeling519 West Texas VA Health Care System520 VA Gulf Coast Veterans Health Care System; My Notes: Augusta521 Birmingham VA Medical Center523 VA Boston Healthcare System, Jamaica Plain Campus526 James J. Peters VA Medical Center (Bronx, NY)

528

VA Western New York Healthcare System at Buffalo; My Notes: Upstate New York, Batavia, Buffalo, ?Albany, ?Bath, ?Canandaigua, ?Syracuse, ?Dunkirk

529 VA Butler Healthcare531 Boise VA Medical Center; My Notes: Mountain Home534 Ralph H. Johnson VA Medical Center537 Jesse Brown VA Medical Center; My Notes: North Chicago538 Chillicothe VA Medical Center539 Cincinnati VA Medical Center540 Clarksburg - Louis A. Johnson VA Medical Center541 Louis Stokes VA Medical Center; My Notes: Cleveland / Wade Park542 Coatesville VA Medical Center544 Wm. Jennings Bryan Dorn VA Medical Center; My Notes: Columbia SC546 Miami VA Healthcare System548 West Palm Beach VAMC549 VA North Texas Health Care System: Dallas VA Medical Center550 VA Illiana Health Care System; My Notes: Danville, Peoria552 Dayton VA Medical Center553 John D. Dingell VA Medical Center554 VA Eastern Colorado Health Care System(ECHCS); My Notes: Denver556 Captain James A. Lovell Federal Health Care Center557 Carl Vinson VA Medical Center558 Durham VA Medical Center; My Notes: Raleigh561 VA New Jersey Health Care System562 Erie VA Medical Center564 Veterans Health Care System of the Ozarks565 Fayetteville VA Medical Center568 VA Black Hills Health Care System - Fort Meade Campus570 VA Central California Health Care System573 North Florida/South Georgia Veterans Health or Maclom Randall VAMC575 Grand Junction VA Medical Center578 Edward Hines Jr. VA Hospital580 Michael E. DeBakey VA Medical Center; My Notes: Houston581 Huntington VA Medical Center

583VA Medical Center (Indianapolis VA Medical Center); My Notes: Richard L. Roudebush

585 Oscar G. Johnson VA Medical Center586 G.V. (Sonny) Montgomery VA Medical Center589 Kansas City VA Medical Center; My Notes: Leavenworth590 Hampton VA Medical Center

593VA Southern Nevada Healthcare System (VASNHS); My Notes: IOANNIS A. LOUGARIS, Southern Nevada, Las Vegas

595 Lebanon VA Medical Center596 Lexington VAMC: Leestown Division

598Central Arkansas Veterans Healthcare; My Notes: Little Rock, Mountain Home, ?Fort Smith

600 VA Long Beach Healthcare System603 Robley Rex VA Medical Center605 VA Loma Linda Healthcare System; My Notes: Opened in 1977.607 William S. Middleton Memorial Veterans Hospital; My Notes: Madison608 Manchester VA Medical Center610 VA Northern Indiana Health Care System - Marion Campus612 VA Northern California Health Care System613 Martinsburg VA Medical Center614 Memphis VA Medical Center618 Minneapolis VA Health Care System619 Central Alabama Veterans Health Care System620 VA Hudson Valley Health Care System (Montrose)621 Mountain Home VA Medical Center623 Jack C. Montgomery VAMC626 Tennessee Valley Healthcare System - Nashville Campus629 Southeast Louisiana Veterans Health Care System630 VA NY Harbor Healthcare System631 Northampton VA Medical Center632 Northport VA Medical Center635 Oklahoma City VA Medical Center636 Omaha - VA Nebraska-Western Iowa Health Care System637 Asheville VA Medical Center; My Notes: Charles George640 Livermore, Melano Park or, Palo Alto VAMC642 Philadelphia VA Medical Center644 Phoenix VA Health Care System646 VA Pittsburgh Healthcare System, University Drive Division648 Portland VA Medical Center - Vancouver Campus649 Northern Arizona VA Health Care System650 Providence VA Medical Center652 Hunter Holmes McGuire VA Medical Center653 VA Roseburg Healthcare System654 VA Sierra Nevada Health Care System655 Aleda E. Lutz VA Medical Center656 St. Cloud VA Health Care System657 St. Louis VA Medical Center - John Cochran Division658 Salem VA Medical Center659 Salisbury - W.G. (Bill) Hefner VA Medical Center660 VA Salt Lake City Health Care System; My Notes: Wahlen662 San Francisco VA Medical Center

663VA Puget Sound Health Care System - Seattle Division; My Notes: American Lake

664 VA San Diego Healthcare System666 Sheridan VA Medical Center667 Overton Brooks VA Medical Center668 Spokane VA Medical Center; My Notes: Washington, Mann-Grandstaff

671

South Texas Veterans Health Care System; My Notes: Audie L. Murphy & San Antonio are together, but unclear f they are 671, unclear if Frank M. Tejeda is linked to any of these

672 VA Caribbean Healthcare System673 James A. Haley Veterans' Hospital

674Central Texas Veterans Health Care System; My Notes: Olin E. Teague / Temple

675 Orlando VA Medical Center676 Tomah VA Medical Center678 Southern Arizona VA Health Care System679 Tuscaloosa VA Medical Center

687 Jonathan M. Wainwright Memorial VA Medical Center688 Washington DC VA Medical Center689 VA Connecticut Healthcare System West Haven Campus691 VA Greater Los Angeles Healthcare System (GLA)693 Wilkes-Barre VA Medical Center695 Clement J. Zablocki Veterans Affairs Medical Center740 VA Texas Valley Coastal Bend Health Care System; My Notes: Harlingen756 El Paso VA Health Care System757 Chalmers P. Wylie Ambulatory Care Center951 HOV Services999 MES Solutions - Houston, TX OR VAMC Daytona Beach, FL

5. April 2016 Quality Call Notes – ROs working on Medical Officer of the Day (MOD); add “Medical Opinion may be completed by the MOD” or “Clarification may be completed by the MOD” to 2507, if applicable

6. If VHA (OPC) has jurisdiction of the exama. Have both the Profile Screen and Contention screen open in VBMSb. Run Exam Request Builder (ERB) [Exam Request Builder (ERB) Info – III.iv.3.A.2.e, February 2015

Authorization Quality Call Notes]c. Follow prompts to build requests then click “ok”d. Review request and make any changes necessarye. Open CAPRI and select appropriate facilityf. Click “Add a New Request”g. Verify Veterans address and complete all fields

Claim folder required? No = VBMS, Yes = Cfile to be shipped Electronic Claim Folder Available? Yes = VBMS

h. Select all DBQs you are requesting from “List of Exams”i. Copy your complete ERB request and paste it into the comments sectionj. Click “Send Exam Request”k. Upload 2507 and 6789 to VBMS

7. If a Contractor (VETSFED/QTC) has jurisdiction of the exam (see III.iv.3.A.1.j for contract exam exclusions, changed 4/29/16 & again 5/26/16)

a. Open CAATS Meera Braman says to contact her for any issues (including account deactivation,cc your Coach); Please

remember to use the second drop down in the contract exam drop down (CONTRACT EXAM REQUEST LIST) when you order your exams. DO NOT use the first drop down (CONTRACT EXAM VETERAN LIST) as this list searches the whole database first, slowing down the system.

Email them at CAATS.VBAMLA@VA.GOV if need them to change to finished, so can enter clarification (give them last name, first name & document #)

As of 11/22/16, all requests for a CAATS account reactivation must be either emailed to the NSD Help Desk or submitted telephonically at 1-855-673-4357 (select option 3, then option 2). 

b. Click “Contract Exam,” then “Contract Exam Request List”c. Change Station number to 377 (per 5/25/16 VSC email, “Select the appropriate station based on the

Veteran’s geographic location before creating an exam request. “ Per 6/30/16 VSC email “The ERRA routing recommendation will provide the end user with the correct station number…”; first paragraph of the ERRA information) then maybe click “Submit”June 2016 Compensation Service Bulletin (CSB) – When creating examination requests in CAATS, it is imperative that the employee create the request using the Station Code that aligns with the Veteran’s geographical jurisdiction.  If this section is not properly completed, the examination request could be cancelled by the vendor. Below you will find the Station Codes that align with geographical jurisdiction of contract examinations:

Atlanta (316) Seattle (346)Houston (362) Winston-Salem (318)

Providence (304) Columbia (319)Muskogee (351) Jackson (323)Roanoke (314) Philadelphia (310)

Los Angeles (344) San Diego (377)Salt Lake City (341) St. Petersburg (317)

Cheyenne (442) Oakland (343)Cleveland (325) Denver (339)Honolulu (459) Indianapolis (326)Lincoln (334) St. Louis (331)Waco (349) Pittsburgh (311)

IDES

d. Click “Add Document”e. Enter SSN, Claim Type and Request Type (what if only has claim #?)

If the Veteran has never been entered into CAATS, enter complete information (from Profile screen)

CDVA (044)VVA (070)AL (074)

AMVETS (077)DAV (083)

MOPH (089)VFW (097)

f. If information has changed since last exam, contact Exam Liaison (actually, email Meera Braman with the details of the info that needs to be changed; as of 6/6/16 can enter changes yourself)

g. Click “Create Exam Request”h. Complete Exam Request Details on the Header tab

Send claim file to contractor = VBMS Comments/Physician Instructions is where you would put sleep study findings or

response to rejected exams if needed Select the correct contract vendor (added 6/30/16, you can find this in the first paragraph of the

ERRA information)i. Click “Save” on each screenj. Claimed Conditions tab is for new/reopen or never adjudicated conditions (put NONE or

N/A if no new conditions) (changed so that have to “Add New Claimed Condition”)k. Diagnostic Codes tab (only for CFIs, skip if new or reopen)

Click Add New Diagnostic Code Add DC and copy the rating reason (name from codesheet) from VBMS into the Clarification

Information (i.e. DC 5257: Knee, other impairment, Clarification Information: Left knee patella femoral pain syndrome)

l. Medical Opinions Tab – you may use embedded opinion builder and complete appropriately with type of opinion and evidence.

August 2016 Quality Call Notes – The requirement to use the ERB tool for CAATS examination requests has been rescinded; however, all are encouraged to use the ERB tool. In CAATS, the ERB tool is only required to be used to generate the three opinion templates that are not already in CAATS (MST; Combat; and, SC death) – M21-1, III.iv.3.A.7.b.

m. Worksheets tab – Add all DBQs needed (Specialist – TBI, eyes, ears, dental, mental; or it may change answer to “Yes” automatically)

n. Action box – change to “Submit” and then click “Go”

o. If not already showing, select the station you used, click “Submit,” find veteran, “View” the request you just submitted and click “Generate Report” to save the 2507

p. Upload the Approved request as a 2507 and 6789 to VBMS (Source - VERIS?)q. If have to submit as insufficient, View – Worksheets – Edit specific worksheet – select

Inadequate or Insufficient – select Reasons – enter Physician Instructions – Save (can only Save once for each Worksheet; status will change to QA review & you are done, but may need to go out & back to View to “Generate Report” & save as PDF)

8. If partial grant, finalize rating (ensure claim is in RDC status) & enter case in ASPEN for credit fo only issues rated/decided (not deferred issues).

9. If full deferral, enter case in ASPEN for no credit.

10.Add “1000 – All DRO Actions” then “1103 - Management Referral” for 0.5 ASPEN credit for exam request

11.Send letter per III.iv.3.A.1.g:

Step Action1 Is the creation of a development letter to the Veteran already underway

in VBMS? If yes, proceed to Step 7. If no, proceed to the next step.

2 Select the LETTERS tab in VBMS.3 Click the ADD NEW LETTER button.4 Select Subsequent Development Letter as the letter type.5 Click the ADD LETTERS button in the top, right-hand corner of the

screen6 Select a title appropriate to the Veteran’s gender and/or educational

credentials to populate the SALUTATION field.7 In the FREE TEXT section of the screen, select Important Information

from the available drop-down menu.8 Enter the following text in the last field of the FREE TEXT section:

On [Month dd, yyyy], we sent you a letter informing you that you would soon be contacted to attend one or more examination appointments intended to assist us in better determining your entitlement to VA benefits. That letter mistakenly indicated that you would be expected to attend (an) examination appointment(s) for your [specific disability(ies) for which examinations were requested]. Upon further review of available evidence, we have determined that no examination for [specific disability(ies)] need be conducted. We apologize for this miscommunication and any confusion it may have caused.

9 Click the ADD PARAGRAPH button.

III.iv.3.D.1.b – contact info to obtain outstanding contract exam reports from QTC, VES, VetFed, LHI & MSLA

From: VAVBASDC/RO/VSC Sent: Wednesday, July 26, 2017 1:36 PMSubject: FW: Quick Start Exam Notification

Good Afternoon,

Effective August 1, 2017, disability examinations for Quick Start claims will no longer be conducted under the District 6/National Mission contract.

This change will mean that QTC will no longer be the only vendor allowed to conduct examinations for Quick Start claims within the continental United States.

Quick Start examinations should be routed to the appropriate vendor under according to the ERRA tool.

A Job Aid with guidance on how to enter contract examination requests in CAATS for Quick Start claims is attached to this email message for your support.

Quick Start Job Aid 082017_2.0 is saved at H:\VSC\Rating Reference

My Notes: Quick Start discontinued 10/1/17

From: VAVBASDC/RO/VSC Sent: Friday, May 05, 2017 1:57 PMSubject: FW: Exam Portals

Good Afternoon,

For those who order exams, please see the following exam portals for your reference:LHI - https://customers.logisticshealth.com/Login.aspx#d=1484167962483

QTC - https://vbaclient.qtcm.com/

VETFED – https://vetfedclient.qtcm.com/  Please note: VETFED exams are not located in the QTC examtrack.  The VETFED portal does not require additional access because you can use your QTC password to login.

MSLA - https://poc.mslacms.com/MSLACMS/MainLogin.aspx

VES access is currently being requested for those who order exams. 

This information is also available on the Compensation Service Intranet.

From: VAVBASDC/RO/VSC Sent: Wednesday, October 05, 2016 10:29 AMSubject: FW: VHA Exam Cancellation Guidance

Good Morning,

Effective October 1, 2016, Veterans Health Administration (VHA) Compensation & Pension disability exam clinics may begin cancelling contract-eligible exam requests for which they do not have the resources to complete timely.  This VHA directive coincides with an expansion of VBA’s Mandatory Disability Exam (MDE) contract and the transfer of VHA’s Disability Examination Management (DEM) contract to VBA.  At this time, VBA’s exam contracts cover Veterans who live in the United States and OCONUS locations (see attached for MDE coverage).  ERRA and CAATS have been updated to reflect the geographic expansion of VBA’s exam contracts and the current availability of vendors (i.e., ERRA and CAATS only reflect vendors with connectivity to VBA systems). 

To help ensure Veterans continue to receive timely examinations, please be reminded of the following:

All employees must utilize ERRA to determine where to route compensation-related disability exams.  ERRA has been updated to reflect the geographic expansion of VBA’s exam contracts and the current availability of vendors.

o It is required to associate the ERRA tool’s inquiry results with the claims folder (III.iv.3.A.1.d.  Mandatory Use of the ERRA Tool).  Instructions on how to convert documents to a portable document format (PDF) for upload, see M21-1, Part III, Subpart ii, 4.G.2.b

o When recommended by ERRA, employees must use CAATS to submit contract exam requests.  ERRA will provide employees the information they need to use CAATS to submit contract exam requests to the correct vendor (i.e., name of vendor and station number aligned with the Veteran’s location).

o When recommended by ERRA and/or required based on a contract exclusion, employees must use CAPRI to submit VHA exam requests.  For exam requests submitted based on a contract exclusion, employees should use the comments section in CAPRI to clearly describe the contract exclusion (e.g., Do not cancel; Veteran is incarcerated and not eligible for a contract exam).

All employees must take the next appropriate action upon receipt of notification of a cancelled exam.  Employees may resubmit exam requests, update tracked items, and add VBMS notes while a claim remains at 499.  Please note, VHA may not cancel the entire 2507 examination referral.  Please only reschedule/reorder the specific DBQ exam that was cancelled.

VHA may cancel exams submitted based on an ERRA routing recommendation.  If this occurs, employees should use ERRA to obtain the name of the vendor and the station number aligned with the Veteran’s location.  Employees should then submit the exam via CAATS, regardless of ERRA’s routing recommendation.  ERRA compliance is based solely on exam requests submitted to VHA. 

Reminders: For all Quick Start exam requests that ERRA refers through an exam vendor, please be sure to indicate the

following:o Special Program: Quick Start o Quick Start Sites :992:Quick Start,CA

Note: the Quick StartSite field should not be left blanko Contractor: QTC MED SVCS INC

If ERRA recommends routing any required DBQ to a vendor and all DBQs are contract eligible, submit the exam request through CAATS.

My Notes: Quick Start discontinued 10/1/17

June 2014 “Evaluating Lay Evidence (TMS 3879907)” [PowerPoint] is saved at H:\VSC\Rating ReferencePage 16 - A lay person is:

NOT qualified to provide a diagnosis without medical evidence (to include cancers, cause of death, bronchial asthma, Meniere’s disease, rheumatic fever, chondromalacia, disk herniation, any other medical condition which requires training to diagnose)

IS qualified to describe symptoms (asthma symptoms, tinnitus, headaches, dizziness, pain in feet, flat feet, joint symptoms, dislocations, broken bones, varicose veins, psych symptoms, fall injury/trauma, some skin disorder/rashes, frostbite residuals)

VSRs & RVSRs have the authority to determine whether a claim is incredible or without merit (like hammer toes secondary to SC tinnitus, or PTSD due to combat when veteran has no foreign or combat service).

Competent, Plausible, Consistent statements, Consistent with service

REASONABLE DOUBT - BD1

3.102 Reasonable doubt – when “a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant”

III.iv.5.A.1.j III.v.1.A Overt v. Brown – “may” is too speculative & inadequate

Malby v. Brown – “could” is sufficient to establish a nexus

Tirpak v. Derwinski (7/20/92) – “may” or “may not” is inadequate to establish a nexus

Russell v. Principi (10/6/92) – cannot apply benefit of the doubt in CUEs

Martinez v. Brown (5/27/94) – benefit of the doubt does not apply to reopening claims that are finally denied, as the evidence is not weighed

Watai v. Brown (10/10/96) – “probably” and “very well might have been” are sufficient medical nexus evidence

Alemany v. Brown (11/20/96) – error in standard of proof; to deny need 50+1, to grant need 50/50 (equipoise)

4.3 Resolution of reasonable doubt – “administer the law under a broad interpretation,” reasonable doubt in degree of disability “will be resolved in favor of the claimant”

SERVICE CONNECTION FOR CAUSE OF DEATH, DIC UNDER 1318 & ACCRUED DECISIONS can be found in Rating References ARCHIVE