In This Section

Introduction

• who may request an examination
• definition of an appropriate examination facility
• mandatory use of the Examination Request Routing Assistant (ERRA) tool
• scope of practice relative to examinations
• definition of
  • general medical examination
  • specialty examination, and
  • specialist examination
• Veteran’s legal rights at an examination
• contract examination exclusions, and
• examination requests for conditions affected by revised rating schedule criteria.

Change Date

IV.i.2.A.1.a.  Who May Request an Examination

IV.i.2.A.1.b.  Definition: Appropriate Examination Facility

• mandatory use of the Examination Request Routing Assistant (ERRA) tool, see M21-1, Part IV, Subpart i, 2.A.1.c, and
• splitting examination requests between VAMCs and contract providers, see M21-1, Part IV, Subpart i, 2.A.2.d.

IV.i.2.A.1.c.  Mandatory Use of the ERRA Tool

• 10 VA examination facilities nearest the zip code entered, and
• examination categories that should be routed to a contract examiner, if applicable.

• The ERRA tool’s use is not required at Integrated Disability Evaluation System (IDES) or Benefits Delivery at Discharge (BDD) intake sites where existing agreements specify the provider(s) responsible for local IDES or BDD examinations.
• The ERRA tool’s use is not required for requests involving
  • examination clarification
  • examination addenda
  • corrections to insufficient/inadequate examinations
  • medical opinions in support of claims filed under 38 U.S.C. 1151, or
  • acceptable clinical evidence (ACE) examinations completed by a VHA practitioner assigned to serve the RO.

IV.i.2.A.1.d.  Scope of Practice Relative to Examination

IV.i.2.A.1.e.  Definition: General Medical Examination

• document normal findings, or
• identify disabilities that are found or suspected.

• general medical examinations, see M21-1, Part IV, Subpart i, 2.A.5, and
• general medical examination DBQs, see the DBQ Switchboard.

IV.i.2.A.1.f. Definition:  Specialty Examination

• Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination.
• Specialty examinations may be (and usually are) performed by non-specialist clinicians, but in unusual cases, or as requested by a Board of Veterans’ Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a specialist.

IV.i.2.A.1.g. Definition: Specialist Examination

• All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist.
• In unusual cases, or as requested by a BVA remand, it may be necessary to request a specialist examination for other types of disabilities.

• specialist examinations, see M21-1, Part IV, Subpart i, 2.A.6, and
• requesting examinations for BVA remands, see M21-5, Chapter 7, G.4.c.

IV.i.2.A.1.h.  Veteran’s Legal Rights at an Examination

• be accompanied by counsel during an examination, or
• record an examination.

IV.i.2.A.1.i.  Contract Examination Exclusions

IV.i.2.A.1.j.  Examination Requests for Conditions Affected by Revised Rating Schedule Criteria

Introduction

• overview of examination request tools
• Exam Scheduling Assistant (ESA) tool
• ERRA tool
• interpreting the ERRA tool’s results 
• Index of DBQ/Exams by Disability tool, and
• selecting the appropriate application for entering examination requests.

Change Date

IV.i.2.A.2.a.  Overview of Examination Request Tools

• obtain assistance in determining whether an examination and/or medical opinion is warranted
• identify the examining facility location closest to the Veteran
• identify the DBQs for the claimed disabilities
• build the examination request, and
• enter the examination request to the VHA or VA contract examination facility.

IV.i.2.A.2.b. ESA Tool

• the ESA tool, see the Medical Disability Examination Office Policy and Program Management page, and
• reviewing evidence before determining an examination or opinion is necessary, see
  • M21-1, Part IV, Subpart i, 1.A.1.c, and
  • M21-1, Part IV, Subpart i, 1.B.1.a.

IV.i.2.A.2.c. ERRA Tool

• application to use for submitting the examination request
• facility routing location
• routing location and examination list comments
• examination type details, and
• approximate distance (from the zip code entered, including driving distance and estimated time).

• This tool is designed as a guide to assist in the routing of compensation and pension (C&P) examination requests.  Its use is mandatory, as discussed in M21-1, Part IV, Subpart i, 2.A.1.c.  When routing an examination request to a VHA facility, take into account any
  • claimant preferences, or
  • topography/driving concerns.
• The ERRA tool’s data are refreshed daily.  Therefore, it is imperative to check zip codes daily, as the suitability of a claimant’s direction to a VHA or contract examination facility may vary in response to demand and facility availability.  Routing location and examination type comments may also be subject to daily updates.

• The ERRA tool identifies whether a VHA facility has capacity to complete examinations timely and suggests a contract provider/vendor be used if necessary.
• Any justifiable deviation from the ERRA tool’s recommendations must be explained as a remark in the examination request’s body.

• appropriate application for entering examination requests, see M21-1, Part IV, Subpart i, 2.A.2.f, and
• ERRA tool, see the Medical Disability Examination Office Policy and Program Management page.

IV.i.2.A.2.d.  Interpreting the ERRA Tool’s Results

• the ERRA tool’s functionality, see the Medical Disability Examination Office Policy and Program Management page, and
• EHRM and special claims processing, see M21-1, Part III, Subpart ii, 1.A.2.c.

IV.i.2.A.2.e. Index of DBQ/Exams by Disability Tool

IV.i.2.A.2.f. Selecting the Appropriate Application for Entering Examination Requests

Introduction

• definition of DBQs, and
• use and acceptance of DBQs for VA examination and opinion purposes.

Change Date

IV.i.2.A.3.a.  Definition:  DBQs

• elicit medical information needed to make decisions on claims, and
• provide a standardized report format for medical examinations and opinions.

IV.i.2.A.3.b.  Use and Acceptance of DBQs for VA Examination and Opinion Purposes

References:  For more information on

• examination requirements and sufficiency, see M21-1, Part IV, Subpart i, 3
• returning examination reports as insufficient for rating purposes in
  • general, see M21-1, Part IV, Subpart i, 3.C
  • CAPRI, see the CAPRI User Manual, and
  • VBMS, see the VBMS Core User Guide
• principles for reviewing and weighing evidence, see M21-1, Part V, Subpart ii, 1.A, and
• VA’s authority to develop for all evidence sufficient to render an informed decision, see Douglas v. Shinseki, 23 Vet.App. 19 (2009).

Introduction

• examinations based on ACE
• categories of examinations for which the ACE Process is prohibited, and
• examination requests and ACE.

Change Date

IV.i.2.A.4.a. Examinations Based on ACE

IV.i.2.A.4.b. Categories of Examinations for Which the ACE Process Is Prohibited

• examinations when necessary electronic medical records are not available for examiner review
• Separation Health Assessments (SHAs) in support of IDES and BDD claims
• general medical examinations
• initial and review traumatic brain injury (TBI) examinations, and
• mental disorder examinations.

IV.i.2.A.4.c. Examination Requests and ACE

• specifies that the ACE Process is permitted, or
• clearly states that the ACE Process may not be used, and an in-person examination is required to complete the DBQ.

Introduction

• when to request a general medical examination
• when a general medical examination is not necessary
• conducting a general medical examination, and
• citing medical conditions to be examined.

Change Date

IV.i.2.A.5.a.  When to Request a General Medical Examination

• an initial claim is received within one year of discharge from any period (original or non-original) of
  • active service, as defined in 38 CFR 3.6(a), or
  • full-time duty performed in the National Guard, as defined in 38 CFR 3.6(c)(3), or
• an ITF is received within one year of such discharge, and a substantially complete application is received within one year of the ITF.

• individual unemployability (IU)
• service connection (SC) under 38 CFR 3.317, or
• Veterans Pension.

• When requesting a general medical examination to evaluate an initial compensation claim received within one year of discharge, do not request that the examiner also complete specific, individual DBQs for each claimed disability except in cases where claimed contentions require examination by a specialist, as discussed in M21-1, Part IV, Subpart i, 2.A.6.  This policy applies to examinations requested from VHA, as well as from private providers under VA contract.
• When an initial claim is received within one year of discharge as described above and an examination is needed for one or more claimed issues under the provisions of 38 CFR 3.317, follow the instructions in M21-1, Part VIII, Subpart ii, 1.B.2.  If a Gulf War General Medical Examination Disability Benefits Questionnaire is required, do not also request a General Medical – Compensation Disability Benefits Questionnaire, as this may result in duplication of DBQs completed as part of the general medical examination.

• ITF, see
  • 38 CFR 3.155(b), and
  • M21-1, Part II, Subpart iii, 2.A
• specialist examinations, see M21-1, Part IV, Subpart i, 2.A.6
• requesting examinations related to claims for IU, see M21-1, Part VIII, Subpart iv, 3.B.2
• when a rating determination of P&T disability for pension purposes is required, see M21-1, Part IX, Subpart i, 2.2.e
• acceptable medical evidence for pension rating purposes, M21-1, Part IX, Subpart i, 2.2.f, and
• when a VA examination is authorized for pension cases, see M21-1, Part IX, Subpart i, 2.2.g.

IV.i.2.A.5.b.  When a General Medical Examination Is Not Necessary

• an original claim for compensation is being rated many years after separation from service, or
• a Veterans Pension claim that requires a P&T disability determination contains sufficient medical evidence to decide the claim.

IV.i.2.A.5.c.  Conducting a General Medical Examination

• all disabilities listed in the examination request, and
• any other disabilities the Veteran identifies during the examination.

• Opinions addressing etiology and relationship to service are not typically provided by general medical examinations.
• Unclaimed disabilities that are not listed in the examination request, but that are reported or suspected during the examination, must be addressed in the applicable general medical DBQ along with any appropriate additional DBQ(s) when abnormal findings are identified.  However, the examiner is not required to complete additional DBQ(s) in conjunction with a general medical examination for subjective complaints reported at the time of examination if objective findings are not noted by the examiner.

• DBQs used for general medical examinations, see the DBQ Switchboard, and
• soliciting claims for unclaimed, chronic disabilities shown by the evidence, see M21-1, Part V, Subpart ii, 3.A.3.a.

IV.i.2.A.5.d.  Citing Medical Conditions to Be Examined

Introduction

• examinations routinely performed by specialists
• who may request other types of specialist examinations
• when to request a specialist examination, and
• who determines the choice of examiner.

Change Date

IV.i.2.A.6.a.  Examinations Routinely Performed by Specialists

• hearing
• vision
• dental, and
• psychiatric.

IV.i.2.A.6.b.  Who May Request Other Types of Specialist Examinations

• the development or rating activity
• the medical examiner, or
• BVA.

IV.i.2.A.6.c.  When to Request a Specialist Examination

• if an issue is unusually complex
• if there are conflicting opinions or diagnoses that must be reconciled, or
• based on a BVA remand.

IV.i.2.A.6.d.  Who Determines the Choice of Examiner

• Board-certified specialist in …, or
• specialist who is Board qualified.

Introduction

• who may request a medical opinion
• referring claims for complex medical opinion review
• completing medical opinion requests using the VBMS Exam Management System (EMS) with CAPRI
• procedure for identifying the evidence in a medical opinion request
• maintaining objectivity in medical opinion requests
• medical opinions required for remands
• requesting medical opinions in claims under 38 U.S.C. 1151
• medical opinions and the
  • Hearing Loss and Tinnitus Disability Benefits Questionnaire, and
  • Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, and
• avoiding asking for legal conclusions in medical opinion requests.

Change Date

IV.i.2.A.7.a.  Who May Request a Medical Opinion

• medical opinions based on stressors involving military sexual trauma
• compensation under 38 U.S.C. 1151
• aggravation (including Allen aggravation)
• diagnostic variation or conflicting medical evidence
• questions of credibility of evidence presented to the examiner, or
• any other matters specified by the VSCM or PMCM, such as
  • rare disorders/rare etiologies, or
  • sensitive or high priority claims.

• M21-1, Part X, Subpart i, 6.F.2.g, authorizes MSCs to independently prepare medical opinion requests regarding in-service aggravation of pre-service disabilities as they pertain to IDES, BDD, and BDD-excluded claims.  If, however, MSCs recognize the need for other “complex” medical opinion types described above, they must refer them for review in accordance with guidance found in  M21-1, Part X, Subpart i, 6.F.2.h.
• When a BVA remand directs development for an aggravation opinion (including Allen aggravation), the development activity may prepare and order the medical opinion based on BVA’s instructions.  If, however, the development activity recognizes the need for other “complex” medical opinion types described above, the claim must be referred to the rating activity for review as discussed in M21-1, Part IV, Subpart i, 2.A.7.b.

• A VSCM or PMCM may authorize a medical opinion in any case in which they believe it is warranted.
• Generally, any development activity employee or MSC may order an examination using the Hearing Loss and Tinnitus Disability Benefits Questionnaire, which includes certain routine etiology opinions.  However, in cases where (1) a separate medical opinion DBQ is required to solicit an opinion not included on the audiological DBQ, or (2) the type of opinion needed is consistent with one of the “complex” exceptions identified above, the opinion request should be prepared by the rating activity.
• Most medical opinions regarding secondary causation are considered of sufficient simplicity to be requested by the development activity without rating oversight.  When, however, a Veteran contends entitlement on the basis of Allen aggravation, or a secondary claim is accompanied by competent medical evidence of the contended disability, such that aggravation may be implicated, follow the procedures in M21-1, Part IV, Subpart i, 2.A.7.b, to refer the claim for complex medical opinion review, unless the opinion request is directed by a BVA remand, as discussed above.

References:  For more information on

• determining when an examination or medical opinion is necessary, see M21-1, Part IV, Subpart i, 1
• medical opinions and the Hearing Loss and Tinnitus Disability Benefits Questionnaire, see M21-1, Part IV, Subpart i, 2.A.7.h, and
• medical opinion training requirements, see M21-3, Part I, A.3.g.

IV.i.2.A.7.b.  Referring Claims for Complex Medical Opinion Review

• special issue indicators, see M21-4, Appendix E, 2, and
• tracked items, see M21-4, Appendix D, 1.

IV.i.2.A.7.c.  Completing Medical Opinion Requests Using the VBMS EMS With CAPRI

• examination request in CAPRI, see M21-1, Part IV, Subpart i, 2.A.9, and
• medical opinion request in CAPRI, see the CAPRI User Manual.

IV.i.2.A.7.d. Procedure for Identifying the Evidence in a Medical Opinion Request

• EMS, see the
  • VBMS Core User Guide, and
  • EMS User Guide, and
• requirement to identify relevant evidence for an examiner’s review, see M21-1, Part IV, Subpart i, 2.A.8.d.

IV.i.2.A.7.e. Maintaining Objectivity in Medical Opinion Requests

• Use a neutral and unbiased tone.
• Do not slant the facts.
• Do not communicate that VA prefers one answer or outcome over another.

• requesting a medical opinion in an impartial manner, see Douglas v. Shinseki, 23 Vet.App. 19 (2009), and
• the attitude of rating officers, see 38 CFR 4.23.

IV.i.2.A.7.f. Medical Opinions Required for Remands

IV.i.2.A.7.g.  Requesting Medical Opinions in Claims Under 38 U.S.C. 1151

IV.i.2.A.7.h.  Medical Opinions and the Hearing Loss and Tinnitus DBQ

• who may request a medical opinion, see M21-1, Part IV, Subpart i, 2.A.7.a, and
• the body and content of the Hearing Loss and Tinnitus Disability Benefits Questionnaire, see the DBQ Switchboard.

IV.i.2.A.7.i. Medical Opinions and the Initial PTSD DBQ

• examinations in claims for SC for PTSD, see M21-1, Part VIII, Subpart iv, 1.C, and
• the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, see the DBQ Switchboard.

IV.i.2.A.7.j.  Avoiding Asking for Legal Conclusions in Medical Opinion Requests

• Do not request the medical authority to determine if there is “loss of use” of an extremity.  Instead, ask for a description of the remaining function of the extremity.
• Do not ask the medical authority to determine if a particular disability is “service-connected” or “SC.”  Instead, identify the in-service injury, event, or illness, as well as current disability, and ask the examiner to provide an opinion as to whether or not the current disability was caused by or the result of the identified in-service injury, event, or illness.
• Do not ask the medical authority to provide an opinion as to whether a Veteran is “unemployable” or “entitled to individual unemployability.”  Instead, in the REMARKS section of the examination request, ask the examiner to comment on the Veteran’s ability to function in an occupational environment and to describe functional limitations.

• to determine loss of use of an extremity, see M21-1, Part VIII, Subpart iv, 4.A.1.c, and
• in IU claims, see M21-1, Part VIII, Subpart iv, 3.B.2.

Introduction

• importance of claims folder review
• examinations requiring claims folder review
• requesting examiner review of the claims folder, and
• requirement to identify relevant evidence for the examiner’s review.

Change Date

IV.i.2.A.8.a.  Importance of Claims Folder Review

IV.i.2.A.8.b.  Examinations Requiring Claims Folder Review

• SC under 38 CFR 3.317
• cold injury residuals
• former prisoner of war (FPOW) protocol
• Gulf War general medical
• medical opinions, including etiology opinions in hearing loss and tinnitus claims
• mental health examinations
• TBI examinations
• musculoskeletal examinations involving the
  • ankle
  • back (thoracolumbar spine)
  • elbow/forearm
  • foot, including pes planus
  • hand/finger(s)
  • hip/thigh
  • knee/lower leg
  • neck (cervical spine)
  • shoulder/arm
  • temporomandibular joint, and/or
  • wrist
• BVA remands
• 1151 claims
• ACE
• environmental hazards in Iraq, Afghanistan, and other military installations, and
• IDES claims.

• For pension claims, sending the claims folder for review is not required.  However, medical records received with the claim relevant to the issue of whether the claimant is currently permanently and totally disabled due to non-service-connected causes must be uploaded into the electronic claims folder (eFolder).
• Privately completed DBQs are not subject to the requirement for claims folder review for the DBQs or claim types listed above.  Additionally, medical evidence not in a DBQ format that is deemed adequate for rating purposes in lieu of examination, as discussed in M21-1, Part IV, Subpart i, 2.A.3.b, is not subject to the requirement for claims folder review.  This is an internal requirement that applies only to examinations and medical opinions requested by VBA.

• requesting medical opinions, see M21-1, Part IV, Subpart i, 2.A.7
• requesting examinations in claims for SC under 38 CFR 3.317, see M21-1, Part VIII, Subpart ii, 1.B.2
• ordering initial FPOW protocol examinations, see M21-1, Part VIII, Subpart iv, 2.C.2
• examinations based on ACE, see M21-1, Part IV, Subpart i, 2.A.4
• maintenance of eFolders, see M21-1, Part II, Subpart ii, 2.A
• assessing privately completed DBQs and action to take when a decision cannot be made without additional information that requires an examiner’s claims folder review, see M21-1, Part IV, Subpart i, 3.A.1.e, and
• review of evidence in connection with medical opinions involving speculation, see
  • M21-1, Part IV, Subpart i, 3.A.1.q, and
  • Sharp v. Shulkin, 29 Vet.App. 26 (2017).

IV.i.2.A.8.c. Requesting Examiner Review of the Claims Folder

IV.i.2.A.8.d.  Requirement to Identify Relevant Evidence for the Examiner’s Review

• obtaining VA medical records, see M21-1, Part III, Subpart ii, 1.A.2
• timing of the duty to obtain an examination or opinion, see M21-1, Part IV, Subpart i, 1.A.1.d
• the definition of relevant records, see M21-1, Part III, Subpart i, 2.E.1.a
• review of evidence to determine when an examination or medical opinion is necessary, see M21-1, Part IV, Subpart i, 1.B
• procedures for identifying medical opinion evidence, see M21-1, Part IV, Subpart i, 2.A.7.d
• VBMS functionality available to maintain the eFolder, see M21-1, Part II, Subpart ii, 2.A.1.h
• categories of examinations for which the ACE Process is prohibited, see M21-1, Part IV, Subpart i, 2.A.4.b, and
• annotating evidence in VBMS, see the EMS User Guide.

Introduction

• steps to requesting an examination in CAPRI
• completing a CAPRI examination request, and
• mandatory entry of requestor’s contact information.

Change Date

IV.i.2.A.9.a. Steps to Requesting an Examination in CAPRI

IV.i.2.A.9.b. Completing a CAPRI Examination Request

• The examination location selected should be the appropriate facility identified using the guidance in M21-1, Part IV, Subpart i, 2.A.2.c and d.
• Under LIST OF EXAMS, select all appropriate DBQs.  Do not check DBQs for specific body systems if requesting a general medical examination unless the claim also requires the performance of one or more specialist examination(s) discussed in M21-1, Part IV, Subpart i, 2.A.6.a.
• Under the CLAIM TYPE field, select the relevant claim type.  Only one selection can be made.
• Under the SPECIAL CONSIDERATIONS field, select any priority processing reason(s) that applies, including
  • AGE OF CLAIM
  • FDC
  • HOMELESS
  • NOT APPLICABLE
  • POW, and/or
  • TERMINAL.
• For the LAST RATING EXAM DATE field, the default entry is N/A.  However, where there was a prior examination pertinent to the examination being entered, delete N/A and enter the date of the pertinent prior examination.
• In REMARKS
  • include all generated and manually entered text
  • do not use manual, regulation, or code citations
  • avoid using acronyms or VBA jargon, and
  • if the examinee is rated incompetent, note that fact.

• completing a CAPRI examination request, see the CAPRI User Manual
• examinations of non-Veteran claimants, see M21-1, Part IV, Subpart i, 2.E.2, and
• the Supplemental Language Matrix, see M21-1, Part IV, Subpart i, 2.A.10.b.

IV.i.2.A.9.c.  Mandatory Entry of Requestor’s Contact Information

• first and last name
• e-mail address, and
• 10-digit telephone number.

IV.i.2.A.10.a.  Entering an ESR

• Requests for VHA examinations must still be entered in CAPRI.
• As is required with all automated tools, users must ensure that all VBMS system-generated language is legally and procedurally adequate before finalizing an ESR.  This includes ensuring that the ADDITIONAL INFORMATION field is completed so as to include information needed by the examiner, but not automatically generated.
• Report any
  • corrected information needed by submitting a trouble ticket, or
  • additional questions or concerns via e-mail to VAVBAWAS/CO/Contract Examination Inquiries.

Notes:

• ESR submission and acceptance in VBMS will automate the creation of one tracked item for each contention identified in the request.
• If unique circumstances exist in a particular case (for example, the Veteran is immobile or unable to drive due to advanced age), these situational factors should be referred in accordance with the Contract Examination Inquiry Guidelines for assistance in determining if, and what, contract examination mitigation may be necessary.

• types of requests requiring supplemental language, see M21-1, Part IV, Subpart i, 2.A.10.b
• examination suspense dates, see M21-1, Part IV, Subpart i, 2.C.1.a
• contract examination exclusion reasons, see M21-1, Part IV, Subpart i, 2.A.1.i, and
• tracked item suspense and automation relative to examination management, see the
  • VBMS Core User Guide, and
  • EMS User Guide​​​​​​​.

IV.i.2.A.10.b.  Types of Requests Requiring Supplemental Language

• M21-1, Part IV, Subpart i, 2.A.10.a
• the VBMS Core User Guide, and
• EMS User Guide​​​​​​​.

IV.i.2.A.10.c.  Definition:  Request for Clarification

• M21-1, Part IV, Subpart i, 2.A.10.d, and
• the VBMS Core User Guide.

IV.i.2.A.10.d.  Responding to a Request for Clarification for Vendor Examinations