In This Section

Introduction

This topic contains information about reviewing examination reports, including

• who must sign examination reports
• examiner qualifications and signature requirements
• TeleCompensation and Pension (Tele-C&P) and telemental health examinations
• review of disability benefits questionnaires (DBQs)
• assessing sufficiency of DBQs completed by non-Department of Veterans Affairs (VA) providers
• authenticity of DBQs
• potential indicators of DBQ inauthenticity
• DBQs completed by Veterans who are physicians/health care providers
• qualification requirements of examiners –
  • psychological examinations
  • traumatic brain injury (TBI) examinations, and
  • hearing loss and tinnitus
• requirements for
  • examination reports, and
  • acceptable clinical evidence (ACE) examination reports
• evaluating disability diagnoses
• questions from claimants or their representatives about competency and/or validity of examinations
• accepting a fee-based examiner’s report, and
• examiner statements that an opinion would be speculative.

Change Date

IV.i.3.A.1.a..Who Must Sign Examination Reports

All examination reports must be signed by the examining health care provider.

Notes:

• Examination reports transmitted electronically by either a Department of Veterans Affairs (VA) medical center or a contract examination provider must be digitally signed.
• Generally, examination reports and the required signatures are documented on disability benefits questionnaires (DBQs) specific to the body system or disability being examined.

Reference:  For more information on DBQs, see M21-1, Part IV, Subpart i, 2.A.3.

IV.i.3.A.1.b..Examiner Qualifications and Signature Requirements

VA medical facilities (or the medical examination contractor) are responsible for ensuring that examiners are adequately qualified.

Regional office (RO) employees are not expected to routinely scrutinize or question the credentials of clinical personnel to determine the acceptability of their reports, unless there is contradictory evidence of record.  However, examination reports (and DBQs, if they are to be used in lieu of examination) must include a valid signature by the certifying professional.

Use the table below to determine what certification elements are required to accept an examination provider’s signature and qualifications.

Notes:

• In all cases involving completion of a DBQ or examination report by a non-VA health care provider, the area of practice/specialty of the provider must be identified.  For a DBQ or examination report completed by a VHA or VBA contract examiner, the area of practice/specialty must be evident if a specialist examination is required or requested.
• Health care providers participating in the Clinicians in Residence program at ROs must be registered and certified VHA clinicians.
• Where the above-outlined signature and certification requirements are not met, follow the procedures discussed in
  • M21-1, Part IV, Subpart i, 3.C.1.e or f, to return the examination report as insufficient if it was completed by a VHA or VBA contract examiner, or
  • M21-1, Part IV, Subpart i, 3.A.1.e, to reconcile deficiencies in the DBQ if it was completed by a non-VA health care provider.

References:  For more information on

• who must sign examination reports, see M21-1, Part IV, Subpart i, 3.A.1.a
• the review of DBQs, see M21-1, Part IV, Subpart i, 3.A.1.d
• types of examinations that require a specialist, see M21-1, Part IV, Subpart i, 2.A.1.g, and
• insufficient examination reports, see M21-1, Part IV, Subpart i, 3.C.

IV.i.3.A.1.c..Tele-C&P and Telemental Health Examination

TeleCompensation and Pension (Tele-C&P) disability evaluations can provide accurate and fully descriptive face-to-face evaluations for VBA rating purposes through use of telehealth video technologies.

When an examiner elects to conduct a Tele-C&P (or telemental health) examination utilizing telehealth video technologies in lieu of performing an in-person examination, assess the report for sufficiency under the same standards applicable to in-person examinations.

Important:  When reviewing DBQs or medical/examination reports prepared by private, non-VA providers via means of telehealth/telemental health, for the purposes of determining adequacy for rating purposes, exercise prudent judgment by

• applying the general assessment principles discussed in M21-1, Part IV, Subpart i, 3.A.1.e, and
• considering the
  • credibility and probative value associated with variables disclosed in the DBQ/report, to include the
    • clinician’s knowledge of the claimant’s relevant history
    • length of time the clinician has treated the Veteran, and
    • extent to which medical records and/or other records were reviewed and considered, and
  • compatibility of the DBQ/report submitted with the types identified as suitable for performance via telehealth technology in the Office of Disability and Medical Assessment (DMA) Fact Sheet 20-002, Telehealth for Compensation and Pension (C&P) Examinations.

IV.i.3.A.1.d..Review of DBQs

Review DBQs to ensure

• the health care provider meets any specialty requirement for the examination conducted, and
• the DBQ is sufficient for rating purposes.

Note:  DBQs completed by a licensed health care provider, to include a nurse practitioner or physician’s assistant, are acceptable for VA examinations.

References:  For more information on

• DBQs approved for public use, see the Public Disability Benefits Questionnaires page
• requirements for examination reports, see M21-1, Part IV, Subpart i, 3.A.1.l
• examiner qualifications and signature requirements, see M21-1, Part IV, Subpart i, 3.A.1.b
• use and acceptance of DBQs for VA examinations and opinions, see M21-1, Part IV, Subpart i, 2.A.3.b ,and
• qualification requirements for
  • psychological examinations, see M21-1, Part IV, Subpart i, 3.A.1.i
  • traumatic brain injury (TBI) examinations, see M21-1, Part IV, Subpart i, 3.A.1.j, and
  • audiology examinations, see M21-1, Part IV, Subpart i, 3.A.1.k.

IV.i.3.A.1.e..Assessing Sufficiency of DBQs Completed by Non-VA Providers

If the evidentiary record contains a privately completed DBQ, generally, claims processors must

• assess the authenticity of the information reported, as described in M21-1, Part IV, Subpart i, 3.A.1.f and g, bearing in mind that it should generally be accepted at face value unless there is reason to doubt or question it
• evaluate it under the evidentiary principles discussed in M21-1, Part V, Subpart ii, 1.A, and
• determine if a VA examination is still warranted in accordance with
  • M21-1, Part IV, Subpart i, 3.A.1.d
  • M21-1, Part IV, Subpart i, 2.A.3.b, and
  • M21-1, Part IV, Subpart i, 1.B.

Use the table below to determine what action must be taken after receiving a DBQ that has been

• completed by a private, non-VA provider, and
• deemed insufficient for rating purposes for the reasons described in the table.

Notes:

• No action to develop an insufficient privately completed DBQ need be taken if the facts of the case would not otherwise necessitate providing an examination and/or opinion.
• When a privately completed DBQ is deemed insufficient for rating purposes and a VA examination is requested as a result, claims processors must add a permanent VBMS note explaining the reason for finding the privately completed DBQ insufficient.

IV.i.3.A.1.f..Authenticity of DBQs

In general, as with other items of evidence, DBQs from treatment providers should be taken at face value.

However, all DBQs completed by treatment providers are subject to review to ensure the information provided is seemingly authentic, consistent with the evidentiary record, and free from improper alteration.

DBQs released for public use inform the provider that

• the patient is applying for VA benefits and VA will consider the information provided in processing the claim
• the physician’s signature constitutes a certification that the information provided on the form is accurate, complete, and current, and
• VA may request medical information, including additional examinations, if necessary to complete VA’s review of a claimant’s application.

Where a review of the DBQ raises questions of authenticity or improper alteration, determine whether additional development is necessary.  This may include

• validation of results by the treatment provider
• obtaining medical records, and/or
• a VA examination.

Informal contact with the Office of Inspector General or a fraud referral may also be appropriate, particularly if the record shows any of the potential indicators of inauthenticity described in M21-1, Part IV, Subpart i, 3.A.1.g.

Important:

• Claims processors may not dismiss a privately completed DBQ without a justifiable and documented reason.
• If a claims processor determines that a privately completed DBQ is potentially inauthentic and a VA examination is needed, then the claims processor must add a permanent VBMS note stating PDBQ followed by the reason the DBQ appears inauthentic.

Example:  PDBQ – Provider contact information unverifiable.

References:  For more information on

• when development to obtain additional evidence may be needed, see M21-1, Part V, Subpart ii, 3.B.1.a
• taking evidence at face value, see M21-1, Part V, Subpart ii, 1.A
• handling fraudulent cases, see M21-1, Part X, Subpart iv, 3.A
• potential indicators of DBQ inauthenticity, see M21-1, Part IV, Subpart i, 3.A.1.g, and
• adding a permanent VBMS note, see
  • M21-1, Part II, Subpart ii, 2.A.1.c, and
  • the VBMS Core User Guide.

IV.i.3.A.1.g..Potential Indicators of DBQ Inauthenticity

While privately completed DBQs should generally be accepted at face value, as discussed in M21-1, Part IV, Subpart i, 3.A.1.e and f, there may be factors that warrant closer scrutiny to assess the authenticity of the information provided.

Indicators of potential inauthenticity include, but are not limited to, the following:

• The non-VA provider identified on the DBQ
  • has contact information that is unverifiable or contains discrepancies, or
  • is located an unreasonable distance (generally, more than 100 miles) from the Veteran’s place of residence, yet the provider reported
    • regularly seeing the Veteran as a patient, and/or
    • that the examination was completed in person.
• The privately completed DBQ contains
  • information that conflicts with the overall evidentiary record, particularly concerning details that impact the outcome of the claim, or
  • signs of improper alteration (for example, inconsistent appearance of text and formatting, such as the examiner certification and signature section being visually different than other sections of the DBQ).
• VA determines the privately completed DBQ is insufficient for rating purposes and orders an examination, but the Veteran refuses to report for the examination.

Important:

• The presence of one or more of these potential indicators of inauthenticity does not automatically mean that a privately completed DBQ is inauthentic or fraudulent.  However, the presence of one or more of these indicators may call into question the authenticity of the information provided and may warrant additional development, as discussed in M21-1, Part IV, Subpart i, 3.A.1.f, and/or referral for possible fraud review.  This is necessarily a case-by-case determination.
• The distance between the non-VA provider’s location and the Veteran’s place of residence should not be considered an indicator of potential inauthenticity, as described above, if the Veteran
  • lives in a remote area, such that driving more than 100 miles to see a health care provider would not be considered unreasonable, or
  • regularly or periodically travels more than 100 miles to see the particular health care provider for a specific reason (for example, to receive specialized treatment at a cancer center or research hospital).
• A privately completed DBQ should not be routinely rejected or automatically deemed potentially inauthentic or fraudulent solely because it supports entitlement to a maximum schedular (or other increased) evaluation for the condition, unless such a disability picture is clearly inconsistent with the overall evidentiary record.

Notes:

• Claims processors have a duty to evaluate and weigh all evidence of record, including privately completed DBQs.  If it is determined that a privately completed DBQ contains indicator(s) of inauthenticity that are substantive enough to deem it potentially inauthentic or fraudulent, claims processors have the authority to assign low or no probative value to the privately completed DBQ.
• If a privately completed DBQ is erroneously deemed insufficient and the Veteran fails to report for an examination that was requested on the basis of the DBQ being inadequate for rating purposes, then the privately completed DBQ should not be assigned lower probative value.

References:  For more information on

• reviewing DBQs prepared by private, non-VA providers via telehealth technology, see M21-1, Part IV, Subpart i, 3.A.1.c
• a Veteran’s submission of evidence and refusal to attend a VA examination, see Kowalski v. Nicholson, 19 Vet.App. 171 (2005)
• the definition of fraud, see
  • 38 CFR 3.901(a), and
  • M21-1, Part X, Subpart iv, 3.A.1.a
• handling cases of fraud, see M21-1, Part X, Subpart iv, 3.A.2, and
• evaluating evidence and determining probative value, see M21-1, Part V, Subpart ii, 1.A.

IV.i.3.A.1.h..DBQs Completed by Veterans Who Are Physicians/Health Care Providers

VA cannot summarily discount otherwise competent medical evidence from a Veteran who is a physician or health care provider.  DBQ reports completed by these individuals will be reviewed under the same criteria for reviewing DBQs submitted by a third-party health care provider.

In effect, VA claims adjudicators must subject the evidence of record to some degree of scrutiny to determine its probative worth.  It is improper in VA practice to “exclude” evidence.  Decision makers must weigh the probative value of the evidence and discuss its probative value in the decision narrative.

Note:  Exercise the same weighing of probative value for internal-use DBQs that are completed by an external non-VA provider.

Important:  Ensure the Disability Benefits Questionnaire (DBQ) – Veteran Provided DOCUMENT TYPE under VBMS UNSOLICITED EVIDENCE tab has been updated for DBQs submitted from non-VA providers.

References:  For more information on

• reviewing DBQs, see M21-1, Part IV, Subpart i, 3.A.1.d
• evidentiary concepts, see M21-1, Part V, Subpart ii, 1.A.2
• written testimony submitted by the claimant, see 38 CFR 3.200(b), and
• case law supporting adequacy of examination completed by a Veteran-health care provider, see Pond v. West, 12 Vet.App. 341 (1999).

IV.i.3.A.1.i..Qualification Requirements of Examiners –  Psychological Examinations

The following credentialed mental health professionals are qualified to perform C&P psychological 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:
  • non-licensed doctorate-level psychologists working toward licensure
  • psychiatry residents, and
  • 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 service connection (SC) for posttraumatic stress disorder 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 qualifications of examiners for psychological examinations, see the DBQ Switchboard.

IV.i.3.A.1.j..Qualification Requirements of Examiners – TBI Examinations

The initial diagnosis of TBI must be made by one of the following specialists:

• physiatrists
• psychiatrists
• neurosurgeons, or
• neurologists.

Note:  A generalist clinician who has successfully completed the Disability Examination Management Office TBI training module may conduct a TBI examination, if a TBI diagnosis is of record and was established by one of the aforementioned specialty providers.

Reference:  For more information on qualifications of examiners for TBI examinations, see the Initial Evaluation of Residuals of Traumatic Brain Injury (TBI) Disability Benefits Questionnaire in the DBQ Switchboard.

IV.i.3.A.1.k.. Requirements of Examiners –Hearing Loss and Tinnitus

Hearing loss examinations must be completed by a state-licensed audiologist.

If only a tinnitus examination is being requested, the examination may be conducted by either an audiologist or non-audiologist clinician, if a hearing loss examination is of record.

Notes:

• It is appropriate to request an examination for tinnitus alone when
  • a Veteran claims SC for tinnitus on the basis that it is due to a disability other than hearing loss, and/or
  • tinnitus was treated during military service.
• For other situations – particularly those in which the etiology of tinnitus is unclear or unspecified – it is necessary to request both hearing loss and tinnitus examinations.

References:  For more information on

• qualifications of examiners for hearing loss and tinnitus examinations, see the Hearing Loss and Tinnitus Disability Benefits Questionnaire in the DBQ Switchboard, and
• evaluating hearing loss and tinnitus, see
  • 38 CFR 4.85
  • 38 CFR 4.87, and
  • M21-1, Part V, Subpart iii, 2.B.

IV.i.3.A.1.l..Requirements for Examination Reports

VA examinations are to be conducted using DBQs which are disease- and condition-specific, organized as a documentation tool to provide the precise medical evidence needed to rate specific disabilities.  The examiner is asked to

• complete the form step by step
• answer the questions posed, and
• provide additional information as required by examination findings.

Note:  The report must have a definite and unambiguous description of the disability for each complaint or claimed condition.

Common features of DBQs include

• a diagnosis section
• medical history
• objective findings
• results of diagnostic testing performed, and
• a remarks section for any necessary explanation.

Additional sections may be found on some DBQs, depending on the specialty involved.

Reference:  For more information on DBQs, see the DBQ Switchboard.

IV.i.3.A.1.m..Requirements for ACE Examination Reports

When an examination provider uses acceptable clinical evidence (ACE) in lieu of conducting an in-person examination, review the report for sufficiency.

The report must

• note use of the ACE Process
• clearly identify the specific evidence material to the report’s findings or opinion, with as much detail as necessary, and
• document the rationale for relying on ACE rather than an in-person examination.

Reference:  For more information on ACE examinations, see M21-1, Part IV, Subpart i, 2.A.4.

IV.i.3.A.1.n..Evaluating Disability Diagnoses

The precise cause of a disability is often difficult to determine.  It is important that

• the same disability is not covered by more than one diagnosis, and
• a definite and unambiguous diagnosis is made for each complaint or symptom having a medical cause.

The table below describes various examination scenarios and what is required for a sufficient diagnosis.

Reference:  For more information on handling examinations insufficient for rating purposes, see M21-1, Part IV, Subpart i, 3.C.

IV.i.3.A.1.o..Questions From Claimants or Their Representatives About Competency and/or Validity of Examinations

Duly consider concerns raised by the claimant or recognized representative about a completed examination or opinion.  Communications raising concerns may take the form of (but are not necessarily limited to)

• complaints about the examiner
• requests for information about the examiner’s qualifications
• assertions that records or other relevant information or evidence was not considered, and/or
• requests for another examination or opinion.

Important:  The mere fact that such a communication is received does not mean that the examination is insufficient or in need of clarification, or that there is a further duty to assist to obtain records or another examination.  However, consideration must be given to whether one or more of those remedies is appropriate.  Do not request a new examination or return an examination as insufficient solely on the basis of a complaint from the claimant or representative.  The substance of the communication must be analyzed as discussed below.

The table below provides guidance on interpreting communications from claimants or a representative raising concerns about examinations and what action to take, as applicable.

Notes:

• VA’s C&P claim adjudication system does not have a procedure for completion of interrogatories by VA personnel.  Interrogatories are written questions that, in some court proceedings, must be answered under oath. If the claimant or representative submits a communication characterized as an interrogatory
  • do not
    • complete and return the document, or
    • refer it to the examiner, but
  • do
    • look at the substance of the communication as indicated above in this block, and
    • determine if it is raising questions about examiner competency, adequacy of the examination, or satisfaction of the duty to assist.
• When needed to fulfill a claimant’s request or a requirement of the Board of Veterans Appeals, the curriculum vitae (CV) of a VHA or VBA contract examiner must be requested via e-mail to VAVBAWAS/CO/Contract Examination Inquiries.
  • Each request should contain as much detail as possible, to include
    • the name of the examiner
    • the examiner’s title, credentials, and/or area of practice/specialty (such as M.D., Ph.D., psychology, or dentistry)
    • the geographic location in which the examination in question took place (with attention to such information as the Veterans Integrated Services Network (VISN) of jurisdiction (if known), State, and facility name)
    • the year in which the examination in question took place
    • indication as to whether the request pertains to a VHA or VBA contract examiner, and
    • for VBA contract examiners, the individual vendor with whom they contract.
  • Enter a permanent note in VBMS to document when a CV is requested or received.
  • Upload the CV to the electronic claims folder upon receipt, as applicable.

Exception:  If a request is received directly from a private attorney for the CV of a VHA or VBA contract examiner, send the CV request to the VBA Freedom of Information Act (FOIA) Office at VAVBAWAS/CO/FOIA.

References:  For more information on a claimant’s

• request for information, or complaints, about a VA examination or opinion, see Nohr v. McDonald, 27 Vet.App. 124 (2014), and
• rights to access an examiner’s CV, see Francway v. Wilkie, 930 F.3d 1377 (Fed. Cir. 2019).

IV.i.3.A.1.p..Accepting a Fee-Based Examiner’s Report

IV.i.3.A.1.q..Examiner Statements That an Opinion Would Be Speculative

Pay careful attention to any conclusion by the examiner that an opinion could not be provided without resorting to mere speculation (or any similar language to that effect).

VA may only accept a medical examiner’s conclusion that an opinion would be speculative if

• the examiner has
  • explained the basis for such an opinion, identifying what facts cannot be determined, and
  • demonstrated consideration of all procurable and relevant information (to include medical treatment records and/or lay testimony), or
• the basis for the opinion is otherwise apparent in VA’s review of the evidence.

The medical opinion may be insufficient for rating purposes if an examiner’s conclusion

• is not adequately justified, or
• implies a general lack of knowledge or an aversion to opining on matters beyond direct observation.

In such instances, seek clarification of the conclusion.

Note:  If the examiner specifically states that a medical opinion cannot be provided unless specific evidence is made available, VA’s duty to assist requires that VA determine whether that evidence may be reasonably obtained.  If so, VA is to make efforts to obtain it and then seek an additional medical opinion which considers the relevant information.

Reference:  For more information on speculative opinions, see

• Daves v. Nicholson, 21 Vet.App. 46 (2007)
• Jones (Michael H.) v. Shinseki, 23 Vet.App. 382 (2010), and
• Sharp v. Shulkin, 29 Vet.App. 26 (2017).