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Updated Sep 09, 2024

In This Section

  
 

1.  Applying the Standard for Determining Whether an Examination or Opinion Is Necessary

Introduction

  
This topic contains information on applying the regulatory standard for determining whether an examination or opinion is necessary under the duty to assist, including

Change Date

  
September 9, 2024

IV.i.1.B.1.a.  Using Medical Evidence in Lieu of Examination

  
As noted in 38 CFR 3.326 and M21-1, Part IV, Subpart i, 1.A.1.c, medical evidence of record may be deemed adequate for rating purposes to make a decision on a claim without requesting an examination or medical opinion.
 
Under the provisions of 38 U.S.C. 5103A(d) and 38 CFR 3.159(c)(4), an examination or medical opinion is necessary only if the evidence of record does not contain sufficient medical evidence to make a decision on the claim.  Accordingly, a review of the evidence of record to determine if it is adequate for rating purposes must be undertaken prior to determining whether an examination or opinion is necessary in accordance with the subsequent guidelines in this topic.
 
Generally, in claims for service connection (SC), for medical evidence of record to be considered adequate for rating purposes, the evidence must include sufficient details to determine whether SC can be established and, if SC is established, to determine the current level of disability.  If the evidence of record includes information sufficient to grant SC but insufficient to determine the appropriate evaluation, an examination would generally be needed prior to deciding the claim.
 
Use the guidelines in the table below to determine if evidence of record can be used to decide a claim in lieu of requesting an examination.  These guidelines should be applied to claims for SC where a nexus opinion is not needed (for example, with presumptive SC) and claims for increase.
 
If …
Then …
a claim is accompanied by medical evidence that is adequate for rating purposes as defined in 38 CFR 3.326
do not routinely request an examination for the issue(s) for which the evidence of record is sufficient to make a decision.
 
Notes:
  • This includes disability benefits questionnaires (DBQs) completed by a private or Department of Veterans Affairs (VA) provider that are deemed adequate for rating purposes.
  • Assess privately completed DBQs for sufficiency as described in M21-1, Part IV, Subpart i, 3.A.1.e.
the claim is for an increased evaluation
do not routinely request an examination without first assessing the medical evidence for sufficiency.
 
Important:
  • An examination is not automatically required for every claim for increase.
  • The existing evidence does not need to show that an increased evaluation is warranted in order to be adequate for rating purposes without an examination.
  • If the evidence of record is sufficient to determine the appropriate current evaluation, an examination is not necessary, even if the resulting decision will be to confirm and continue the current evaluation.
Exception:  If the evidence of record shows findings warranting a lower evaluation than that currently assigned, an examination generally would be necessary before any action could be taken to propose a reduced evaluation.
 
References:  For more information on
the claimed disability is currently evaluated at the schedular maximum evaluation
do not routinely request an examination.
 
Important:  An examination for potential extra-schedular evaluation is warranted only when medical or other evidence demonstrates symptoms that render the schedular criteria insufficient to evaluate the disability.
a surgical or hospital admission report was submitted or identified by the Veteran
do not routinely request an examination without first determining if the surgical or hospital admission report is sufficient to decide the claim.
 
Note:  In particular, a surgical or hospital admission report may provide sufficient evidence to decide claims for entitlement to increased benefits
the claimed disability is a type of cancer that the evidence of record shows
  • is currently active
  • is undergoing treatment, or
  • otherwise warrants a 100-percent evaluation under the applicable diagnostic code
do not routinely request an examination.
 
Note:  A decision to not order an examination shall be
Reference:  For more information on nexus evidence, including when a medical opinion is not necessary, in a claim for direct SC, see M21-1, Part V, Subpart ii, 2.A.1.

IV.i.1.B.1.b.  Current Disability or Symptoms

  
Element 1:  The first element, found in 38 CFR 3.159(c)(4)(i)(A), that must be met before an examination is necessary under the duty to assist is the presence of competent evidence of
  • a current disability, or
  • persistent or recurrent symptoms of disability.
Important:  This element is applicable to exams in relation to claims for SC on any basis (direct, aggravation, presumptive, secondary).
 
Consider the points below when reviewing the evidence to determine whether Element 1 has been satisfied.
  • Element 1 does not always require that a disability be medically diagnosed.
    • Competent lay or medical evidence of current, persistent, or recurrent symptoms of disability may be sufficient to establish Element 1.
    • However, certain conditions, such as cancers, require competent medical evidence of a diagnosis; in such cases lay evidence of symptoms is insufficient, and a diagnosis, or confirmation of a diagnosis, cannot be made on a VA examination when an invasive clinical procedure is required.
  • For evidence to establish Element 1, it must be credible.  However, there is no presumption of credibility for the purposes of determining whether Element 1 has been satisfied.
  • Do not weigh evidence.  If there is contradictory evidence as to whether a disability or symptom of a disability is or is not present, consider that the evidentiary standard for Element 1 has been met.
  • A new examination may be required before a legacy appeal for service-connected (SC) hearing loss is transferred to the Board of Veterans’ Appeals if
    • the Veteran submits competent lay or medical evidence indicating a worsening of the hearing loss during the legacy appeal period, and
    • SC is denied solely based upon the hearing loss not meeting the disability thresholds of 38 CFR 3.385.
  • To meet Element 1, the current disability or symptoms must represent a disability pattern that is potentially eligible for SC.  Conditions that are legally ineligible for SC for compensation purposes do not warrant examination.
Example 1:  A statement from the claimant in support of a claim for SC for a low back condition reveals complaints of severe low back pain, spasms, and shooting pain through the buttocks.  Although there is no medical documentation of a low back condition, there is no evidence of record that otherwise contradicts the Veteran’s credible statement.
 
Analysis:  The Veteran is competent to describe the low back symptoms experienced, and the statement appears credible when reviewing it and all other evidence.  Thus, the Veteran meets the first element for determining whether an examination is warranted.
 
Example 2:  The Veteran files a claim for SC for a right knee condition but does not provide any lay evidence describing symptoms of the claimed right knee condition.  There is no medical evidence of record showing a diagnosis or any reported symptoms relating to the claimed condition.
 
Analysis:  The evidence does not establish the presence of a current disability or persistent or recurrent symptoms of disability.  The Veteran’s claim for a right knee condition, without a description of related symptoms, is insufficient on its own to establish Element 1.  Accordingly, an examination is not warranted, and the claim can be denied.
 
Example 3:  The Veteran files a claim for compensation for periodontal disease.  A review of current VA treatment records shows a diagnosis of this condition.
 
Analysis:  As provided in 38 CFR 3.381(b), periodontal disease is legally ineligible for SC for compensation purposes.  Therefore, a current disability sufficient to establish Element 1 is not shown and an examination is not warranted.
 
References:  For more information on

IV.i.1.B.1.c.  In-Service Event, Injury, or Disease

  
Element 2:  The second element, found in 38 CFR 3.159(c)(4)(i)(B), for determining whether an examination is necessary is establishment of one of the following in service:
  • an event
  • an injury, or
  • a disease.
Consider the points below when reviewing the evidence to determine whether Element 2 has been satisfied.
  • This element relates most clearly and directly to direct SC claims based on incurrence.  However, in-service findings and diagnoses are important to other claim types, specifically aggravation of a preservice condition and presumptive SC.  Application of the regulatory criterion in those claim types is addressed in subsequent blocks.
  • Whether there was an event, injury, or disease in service relevant to the claimed disability is a factual determination.  Making the determination requires evaluating factors including the competency of a witness as well as the probative value and potentially the relative weight of items of evidence.
  • In many cases, an entry in the service treatment records (STRs) of a specific treatment or injury satisfies this element.
  • The absence of specific documentation in the STRs does not automatically preclude finding the element is met.  The element may also be met with lay evidence when
    • a Veteran provides credible lay statement(s) that the disability occurred from an in-service event, injury, or disease, and
    • the statement(s) is consistent with the places, types, and circumstances of military service.
  • VA cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.
  • When direct SC has been claimed but evidence shows that the claimed disability clearly and unmistakably existed prior to service, follow the procedures at M21-1, Part IV, Subpart i, 1.B.1.f to determine whether examination and/or medical opinion for aggravation of a preservice disability is warranted.
Example 1:  Veteran claims SC for a right shoulder injury and asserts that the condition originated from loading heavy cargo onto an airplane during an exercise in Korea in June 2009.  A statement from the Veteran’s spouse indicated remembering that the Veteran complained of the injury upon returning home from the exercise.  Although the STRs are silent for treatment for a right shoulder injury, the personnel records verify the Veteran was a loadmaster and did participate in an exercise in Korea in June 2009.
 
Analysis:  Because the Veteran’s and spouse’s statements are credible and consistent with the circumstances of service, the second element for an in-service injury, disease, or event is established for purposes of ordering an examination.  Assuming that the Veteran has submitted evidence of a current disability or symptoms as well as indication of an association between the current condition and the in-service event, an examination is warranted.
 
Example 2:  Veteran claims eyesight deterioration due to exposure to gas and chemical tests during two months of active duty in the Navy.  Service records do not reveal any treatment for the condition nor do they document any exposure to gas or chemicals during service.  The Veteran does provide sufficient evidence of a current disability and association to service.
 
Analysis:  The Veteran’s statement of an in-service event is rejected because the statement is found incredible and not consistent with circumstances of service.  The Veteran’s statement regarding an in-service event is weighed along with other facts of the case (i.e., no documentation of tests in service and short period of active-duty time).  The preponderance of evidence weighs against the Veteran, and the statement is rejected.  Thus, the standard for evidence of an in-service event, injury, or disease is not met and examination is not warranted.
 
References:  For more information on
  • concepts and principles related to evidence, see M21-1, Part V, Subpart ii, 1.A
  • the factual assessment necessary in determining if the evidentiary standard is met for evidence of an in-service event, see McLendon v. Nicholson, 20 Vet.App. 79 (2006), and
  • considering lay evidence, see

IV.i.1.B.1.d.  Indication of Association

  
Element 3:  The third element that must be met to warrant an examination under 38 CFR 3.159(c)(4)(i)(C) is an indication that the diagnosis or symptoms may be associated with the established event, injury, or disease in service.
 
This language primarily contemplates claims for direct SC.  Guidance on reviewing for indication of association in other claim types is addressed in subsequent blocks.
 
Consider the points below when reviewing the evidence to determine whether Element 3 has been satisfied.
  • The threshold for determining whether an association may be present is low.  Medical assessments that do not support a decision on the merits can still be sufficient to establish an indication of an association for the purposes of requesting an examination.
  • Medically competent evidence is not required to serve as an indication of an association for purposes of determining whether an examination is necessary.
    • Lay evidence only has to indicate a possible connection to the in-service event, injury, or disease to warrant an examination.
    • Examples of adequate lay evidence include
      • an assertion that the condition has existed since service, or
      • a statement indicating continuous symptoms since service.
    • A generalized statement merely asserting a conclusion that a condition is related to an in-service event, injury, or disease is not sufficient to establish an indication of an association.
    • Consider and assign weight to lay evidence in determining whether there is sufficient indication of an association to warrant requesting an examination.
Example 1:  The Veteran claimed SC for a knee disability.  There was one complaint of knee pain in service with a negative separation examination.  No other lay or medical evidence was submitted in support of the claim.
 
Analysis:  The Veteran’s current claim provided no medical evidence indicating an association and no statement alleging continuous symptoms since service or that the current disability persisted since military service.  Therefore, Element 3 has not been satisfied.  Further, there is no medical or lay evidence of a current disability, so Element 1 is also not satisfied.  Element 2 is satisfied based on the single indication of knee pain in service.  As all three elements must be satisfied before examination is warranted, the claim can be denied without an examination/opinion.
 
Example 2:  STRs show a single complaint of knee strain in service with a negative separation examination.  The Veteran’s claim states, “I hurt my knee when I fell off of a truck in Vietnam, and it has hurt ever since that time.”  The Veteran claims SC for knee pain.
 
Analysis:  An examination with a nexus opinion is warranted as all three elements have been satisfied.  Element 1 is satisfied based on the Veteran’s lay complaint of current knee pain.  The Veteran is competent to attest to symptoms of pain.  Element 2 is satisfied by the single indication of treatment for in-service knee strain.  Element 3 is satisfied by the Veteran’s lay description of persistent symptoms since service.
 
References:  For more information on
  • the low threshold for requesting examinations, see McLendon v. Nicholson, 20 Vet.App. 79 (2006)
  • considering lay evidence to establish indication of an association for the purposes of requesting examination, see Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), and
  • why the competency standard does not apply when establishing indication of an association for the purposes of requesting examinations, see Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010).

IV.i.1.B.1.e.  Secondary SC and Aggravation Claims

  
Determinations as to the need for examination or medical opinions in claims for secondary SC are governed by 38 CFR 3.159(c)(4)(i).  Therefore, the three evidentiary elements, as discussed in M21-1, Part IV, Subpart i, 1.B.1.b–d, must be satisfied prior to requesting an examination on a secondary claim.  The three elements are
  • lay or medical evidence of a current disability or symptoms
  • evidence of an SC primary disability (which substitutes for the in-service event, injury, or disease), and
  • indication that the claimed secondary condition may be associated with the primary disability.

SC on the basis of aggravation of a non-service-connected (NSC) disability may be specifically claimed or may be considered as a part of the claim for secondary SC as provided in M21-1, Part V, Subpart ii, 3.A.3.a.  Pursuant to 38 CFR 3.310(b) and M21-1, Part V, Subpart ii, 2.D.1.d, the following additional factors apply when determining whether examination is warranted:

  • a baseline level of disability, as shown by medical evidence, must be present for an examiner to opine whether aggravation has occurred, and
  • the Veteran’s statement alone, without medical evidence of record showing the baseline level of the claimed disability, is not sufficient to order an examination.
Medical expertise is ultimately required to establish entitlement to SC on a secondary basis, but the threshold for ordering an examination is low.  However, there is still a threshold that must be met before an examination is provided.
  • Medical examinations are not to be automatically provided in all cases.  Some degree of judgment must be used in determining whether the threshold has been met to schedule an examination.
  • Consider whether satisfactory evidence exists that shows the presence of the claimed disability and its association with the existing SC disability.
  • A medical diagnosis up front is not always required to show
    • the presence of the claimed disability, or
    • its link to an 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.
  • To determine whether the evidence shows that the claimed condition may be associated with the primary SC disability, review the specificity of the claimant’s statement and other evidence of record.
    • Assess the credibility and merit of the claim prior to ordering an examination.
    • The following types of evidence may give credibility to the claim:
      • medical evidence showing a relationship between the primary SC disability and the claimed secondary disability
      • the Veteran’s lay statement describing the symptoms present and how they are related to the claimed primary disability
      • medical treatise establishing a known relationship between the primary SC disability and the claimed secondary disability, or
      • a VA regulation or procedure exists that defines a relationship between the primary SC disability and the claimed secondary disability.
Example 1:  A Veteran claims stomach problems secondary to an SC heart condition.  A statement in support of claim contends that since starting prescribed medications two years ago for the heart condition, the Veteran has experienced stomach problems to include constipation, pain, and indigestion.  There are no specific diagnoses relating to stomach symptoms noted in the evidence of record.
 
Analysis:  While the Veteran’s lay statement is not sufficient to ultimately prove the claim, it is sufficient in this instance to warrant an examination.  The Veteran is competent to describe symptoms and the possible association of symptoms to the SC condition.  Furthermore, the statement appears credible when considering the evidence at hand.
 
Example 2:  A Veteran submits a statement claiming hypertension secondary to an SC low back condition.  Medical evidence of record shows no treatment for hypertension and normal blood pressure readings over the last three years.
 
Analysis:  Although the claimant is competent to describe symptoms of a disability, the statement reporting hypertension secondary to the low back condition is not credible, because competent medical evidence in this case is required to show elevated blood pressure readings or establish a diagnosis of hypertension.  Although Veterans are competent to attest to their symptoms, they are not generally competent to make their own medical diagnoses.  The Veteran could attest to symptoms potentially associated with hypertension, such as dizziness or headaches, but a lay person is not competent to make a medical diagnosis of hypertension.  The reason medical evidence would be required in this case is because the medical evidence of record shows normal blood pressure readings over the last three years and no diagnosis of hypertension.  Consequently, the Element 1 standard requiring medical or lay evidence of a current disability has not been met.  The substitute evidence from the Element 2 standard is met on the basis that there is an SC disability, a low back condition, present and the claim is being made on a secondary basis.  However, the Element 3 standard is not met because the Veteran has submitted a generalized statement suggesting the conclusion that the hypertension is secondary to the back condition, but there is no specific discussion or evidence correlating the hypertension to the back condition.  Additionally, there is no VA regulation, procedure, or medical treatise establishing an association.  Because the three evidentiary elements are not satisfied, no examination is warranted.
 
References:  For more information on

IV.i.1.B.1.f.  Preservice Aggravation Claims

  
Determinations as to the need for examination or medical opinions in claims for SC under 38 CFR 3.306 for a disability that existed prior to service and permanently increased in severity beyond natural progression are governed by 38 CFR 3.159(c)(4)(i).  Therefore, the three evidentiary elements, as discussed in M21-1, Part IV, Subpart i, 1.B.1.b–d, must be satisfied prior to requesting an examination for a claim based on aggravation of a preservice disability.
  • Element 1 requires lay or medical evidence of a current disability or symptoms.
  • Element 2 requires evidence showing that a disability which clearly existed prior to service required treatment or otherwise worsened in service.
    • In Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002), the United States Court of Appeals for the Federal Circuit held that recurrence and/or temporary flare-ups of symptoms do not constitute an increase in severity of the preservice condition.
    • In Maxson v. Gober, 230 F.3d 1330 (Fed. Cir 2000), the United States Court of Appeals for the Federal Circuit held that evidence of a prolonged period without medical complaint, along with other factors concerning the Veteran’s health and medical treatment during and after military service, may be considered in determining whether a disability increased during service.
    • In Verdon v. Brown, 8 Vet.App 529 (1996), the Court of Appeals for Veterans Claims (CAVC) held that if medical or surgical treatment in service worsened an aspect of the preexisting condition, this would constitute evidence of an increase in severity.
    • In Jensen v. Brown, 19 F.3d 1413 (Fed. Cir. 1994), the United States Court of Appeals for the Federal Circuit found that the evidentiary presumption created by 38 CFR 3.304(d) in favor of combat Veterans applies in preservice aggravation claims.  Aggravation will be established if a Veteran produces satisfactory lay or other evidence of symptomatic manifestations of a preexisting disability during or proximate to combat.  Once a combat Veteran provides lay testimony or other informal evidence of symptomatic manifestations, whether temporary or otherwise, of incurrence or aggravation, the government has the burden to rebut by clear and convincing proof that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression.
    • In Paulson v. Brown, 7 Vet.App. 466 (1995), CAVC held that independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service.
  • Element 3 is satisfied, so long as the evidence for Element 2 is present, by the presumption of aggravation in claims associated with active service unless the evidence clearly and unmistakably shows the worsening of the condition was due to natural progression.
Use the table below to determine proper actions to take when reviewing for examinations pertaining to preservice aggravation.
 
When SC on the basis of preservice aggravation is …
Then conduct an examination review to determine whether the evidentiary elements have been satisfied for examination on …
claimed, and
  • no preservice disability is shown in the records, and/or
  • the presumption of soundness is applicable
  • the basis of direct SC, and
  • request examination and/or opinion on a direct basis if the elements are satisfied.
not claimed, but
  • a preservice disability is clearly shown to have existed, and
  • the presumption of soundness is rebutted
  • the basis of preservice aggravation, and
  • request examination and/or opinion on the basis of preservice aggravation if the elements are satisfied.
 
Example:  A Veteran claims SC for a right knee condition with chronic knee pain on a direct basis.  Enlistment examination revealed history of slight right knee pain with excessive running due to meniscal injury and repair from a high school football injury but indicated the condition was asymptomatic.  The STRs show recurrent treatment for right knee pain and, later in service, the development of arthritis.  STRs do show an orthopedic specialist suspected the arthritis was likely due to the meniscal injury.
 
Analysis:  Although the Veteran claimed SC on a direct basis, the evidence shows that a knee condition clearly and unmistakably existed prior to service, although it was asymptomatic on enlistment.  The presumption of soundness is overcome by clear evidence of the preservice injury.  Since the Veteran was treated for recurrent right knee pain and developed arthritis during service, which the STRs show was suspected to be due to the prior meniscal injury, the presumption of aggravation applies and can only be rebutted by medical evidence showing that the increase in severity was due to natural progression.  An examination and opinion is warranted on the basis that
  • Element 1 is satisfied by the Veteran’s lay reports of chronic knee pain
  • Element 2 is satisfied by the evidence of in-service treatment for the knee condition reflecting more than temporary or intermittent flare-ups of symptoms, and
  • Element 3 is satisfied on the basis that
    • the evidence is present for Element 2
    • the presumption of aggravation applies, and
    • there is no clear evidence that the worsening was due to natural progression.
Important:  When considering claims based on aggravation of a preservice disability, the presumption of soundness applies when deciding whether a claimed condition clearly and unmistakably existed prior to service.
 
References:  For more information on

IV.i.1.B.1.g. Presumptive SC Claims

  
Determining whether examinations are necessary as part of the duty to assist in claims for presumptive SC still warrants application of the regular three-element standard, although Elements 2 and 3 are satisfied differently in presumptive claims than in claims for direct SC.  38 CFR 3.159(c)(4)(i)(B) provides that in claims for presumptive SC, part of the standard for determining whether an examination or opinion is necessary is the establishment of
  • required service or triggering event qualifying for the presumption (which substitutes for the in-service injury, event, or disease), and
  • manifestation during the presumptive period (which substitutes for the indication of an association) of either
    • a disease listed in a regulatory presumptive provision, or
    • symptoms of a disease listed in a regulatory presumptive period.
The evidence in support of the claim must still include lay or medical evidence of a current disability or symptoms as provided in M21-1, Part IV, Subpart i, 1.B.1.b.
 
Example:  A Veteran claims SC for hypertension on a presumptive basis.  STRs show no evidence of a diagnosis of hypertension or evidence of elevated blood pressure readings.  VA treatment records do show that 11 months following discharge, the Veteran underwent a five-day blood pressure screening that did confirm a diagnosis of hypertension.  Medication was prescribed.
 
Analysis:  VA treatment records showing a diagnosis of hypertension satisfy the Element 1 standard for evidence of a current disability.  The Element 2 standard is satisfied on the basis of the Veteran’s active duty service which meets the qualifying criteria for chronic diseases subject to presumptive SC as defined in 38 CFR 3.307 and 38 CFR 3.309(a).  The Element 3 standard is satisfied on the basis of the legally established presumption of SC as defined in 38 CFR 3.309(a).  As all three elements have been satisfied, an examination is warranted (if the evidence of record is insufficient to assign an evaluation).  Note that no nexus opinion is necessary because the presumptive relationship establishes the nexus.

IV.i.1.B.1.h.  Increased Evaluation Claims

  
In a claim for increase in the evaluation of an SC condition, the three specific elements identified in 38 CFR 3.159(c)(4)(i)(A-C) are neither applicable to, nor required to be demonstrated for, examination purposes.  There is no prescribed standard for evidence that must be present prior to requesting an examination in a typical claim for increase, except that 38 CFR 3.159(c)(4)(i) directs that the examination will be provided if VA determines there is insufficient competent medical evidence to decide the claim.
 
When a claim for increase is received, review the evidence of record to determine if it is sufficient to assign the appropriate current evaluation, as discussed in M21-1, Part IV, Subpart i, 1.B.1.a.  If the available evidence is insufficient to assign an evaluation, then request an examination for the claimed condition, regardless of whether a statement of worsening is received or whether an examination for the claimed condition was completed within the last year.
 
Notes:
  • For issues under legacy appeal, VA is not required under its duty to assist obligation to order an examination solely because of the passage of time since an otherwise adequate examination was performed.  However, when the appellant asserts that the disability in question has undergone an increase in severity since the time of the prior examination, additional examination may be warranted.
  • Claims for a total rating based on individual unemployability (IU) are a type of claim for increased compensation.  However, a medical examination is not automatically required in every IU claim.  An examination is required if the information and evidence of record do not contain sufficient competent medical evidence to decide the claim.
Example 1:  The Veteran submits a claim for increased evaluation of an SC back disability.  The back disability has been evaluated as 10-percent disabling.  There is no medical evidence submitted showing any recent treatment for the back.
 
Analysis:  There is no evidentiary standard that must be met prior to requesting the examination for increase.  As there is no evidence of record that is adequate to evaluate the claim, request an examination.
 
Example 2:  The Veteran submits a claim for increased evaluation of an SC knee condition, noting recent surgery and submitting the surgical report showing a total knee replacement that occurred five months prior.
 
Analysis:  Although the Veteran is claiming an increased evaluation, since the surgical report was submitted and shows that a surgery has occurred, no examination is warranted.
 
Example 3:  The Veteran submits a claim for increased evaluation of SC hypothyroidism, currently evaluated as 30-percent disabling.  The Veteran did recently have an examination within the past year for a prior claim for increased evaluation.  Veterans Health Administration (VHA) treatment records obtained in connection with the claim show that the Veteran is treated for hypothyroidism.  The treatment records dated within one year prior to the claim show no indication that symptoms have increased or that the hypothyroidism has required treatment other than the continued prescription of Synthroid.  Particularly, there is no evidence in the treatment records showing that the Veteran has been treated for myxedema-related symptoms or mental disturbances attributed to hypothyroidism.
 
Analysis:  VHA treatment records in this case are sufficient to establish that the criteria for the higher evaluation are not shown.  No examination is warranted, and the evaluation of hypothyroidism should be confirmed and continued.
 
References:  For more information on