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Updated Jan 28, 2022

In This Section

  
This section contains the topic “Reviewing Examination Reports for Rating Criteria.”

1.  Reviewing Examination Reports for Rating Criteria

Introduction

  
This topic contains information about examination considerations specific to certain disabilities and body systems, including

Change Date

   May 27, 2020

IV.i.3.B.1.a.   Eye Examination Report Review

  
When a visual field defect is perceived, examiners must perform any necessary visual field testing using either
  • Goldmann kinetic perimetry, or
  • automated perimetry using Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability.
If the examination was not performed using the proper testing method, then the examination report should be returned as insufficient.  An examination sufficient for rating purposes must include, at minimum,
  • documentation of numerical values for all required fields as measured by a perimetric device, or
  • results documented on a Goldmann chart.
Important:  Irrespective of the eye condition being examined, no visual field testing is required if the examiner indicates that the Veteran does not suffer a visual field defect.  The absence of visual field testing results does not, in these instances, render an examination report insufficient for rating purposes.
 
Reference:  For more information about eye conditions, see

IV.i.3.B.1.b.  Headache Examination Report Review

  
A neurological headache examination report will be considered insufficient if it does not indicate the frequency of prostrating headaches and whether the headaches are migraine-type or non-migraine type.
 
Reference:  For more information on rating migraines, see

IV.i.3.B.1.c.  Hearing Loss and Tinnitus Examination Report Review

  
A hearing loss and tinnitus examination report may be considered insufficient if an opinion was requested by the RO and is not provided in the report.
 
Unusual circumstances may arise during the examination, requiring the examiner to
  • identify any audiometric frequencies that could not be tested (CNT) and explain why testing could not be done
  • provide an explanation of why speech discrimination testing was not performed on the Veteran, or why a speech discrimination score is not appropriate in his/her case, and/or
  • state the functional impact of tinnitus.
Reference:  For more information on requesting audiometric examinations and medical opinions, see  M21-1, Part V, Subpart iii, 2.B.1.d.

IV.i.3.B.1.d.  Mental Health Examination Report Review

  
Mental health examinations can be complex when there are psychological symptoms existing simultaneously with and usually independently of another medical condition, such as posttraumatic stress disorder and traumatic brain injury (TBI) symptoms of memory loss.
 
An examination report may be insufficient if
  • there is more than one mental disorder diagnosed, and the examiner does not address the criteria for all the diagnoses
  • there is a diagnosis of a mental disorder and TBI, and the examiner does not
    • differentiate and list which symptom(s) is/are attributable to each diagnosis, or
    • provide a reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis
  • the Occupational and Social Impairment section of the report is not completed, or
  • the examiner fails to address the question of the claimant’s competency.
Reference:  For more information on considering a change in the diagnosis of a psychiatric disorder, see M21-1, Part V, Subpart iii, 13.

IV.i.3.B.1.e.  Heart Conditions Examination Report Review for METs

  
The metabolic equivalents of task (METs) score for heart conditions can be provided as an estimate, as indicated on the disability benefits questionnaires (DBQs).  If the Veteran has co-morbid conditions that prevent the examiner from performing METs testing or providing an interview-based METs estimate, then the
  • examiner must indicate why
    • METs testing could not be performed, or
    • a METs estimate could not be provided, and
  • regional office will evaluate the condition based on the remaining examination results and evidence of record.
Reference:  For information on rating heart conditions, see M21-1, Part V, Subpart iii, 5.

IV.i.3.B.1.f.  Musculoskeletal Examination Report Review for ROM

  
In order to address the Court of Appeals of Veterans’ Claims (CAVC’s) interpretation of Department of Veterans Affairs regulations in DeLuca and Mitchell, musculoskeletal joint examination reports must address range of motion (ROM) criteria for repetitive motion and flare-ups.
 
Following the initial assessment of ROM, the examiner must perform repetitive-use testing to the extent permitted by the disability under evaluation.  After the initial measurement, the examiner must reassess ROM after three repetitions and report the post-test measurements.
 
The examination report is insufficient if the examiner does not
  • repeat ROM testing during the examination and report any additional functional loss, or
  • provide a rational explanation for why repetitive-use testing could not be accomplished, if applicable.
In order to address CAVC’s holdings in Corriea and ensure adequacy for rating purposes, musculoskeletal examination reports must also reflect testing of
  • involved joints for pain
    • on both active and passive motion, and
    • in states of weight-bearing and nonweight-bearing, and
  • ROM of the opposite, undamaged joint, if applicable and medically feasible.
Musculoskeletal examination reports containing self-evident contradictory findings, conclusions, and/or terminology will also be rendered insufficient or require additional clarification.  Examples of such contradictory examination features include, but are not limited to, the following:
  • annotations of “unaffected gait” and “walks with a cane” in the same report
  • indication that a joint has required surgery, accompanied by the annotation “scar not addressed”, and
  • conclusion that a joint warrants no clinical diagnosis, accompanied by coexisting objective findings of unqualified
    • irregular limitation of motion (LOM)
    • pain on ROM testing, and/or
    • degenerative changes or arthritis.
References:  For more information on

IV.i.3.B.1.g.  Musculoskeletal Examination Report Review for Functional Loss

  
The clinician conducting a musculoskeletal examination must address additional functional limitation or LOM during flare-ups or following repeated use over time, based on the Veteran’s history and the examiner’s clinical judgment.
 
The examination report must address whether the functional ability of a joint is significantly limited during flare-ups or when the joint is used repeatedly over a period of time due to
  • pain
  • weakness
  • fatigability, and/or
  • incoordination.
If such opinion is not feasible, then the examiner must state so and provide an explanation as to why the opinion cannot be rendered.
 
Example:  John Smith reports severe knee pain with repeated use over time when walking back and forth to the store several times a day.  During those flare-ups, the capacity for knee flexion is demonstrated/reported to be 0-110 degrees.
 
Important:  The examiner conducting an initial or review musculoskeletal examination must consider all the evidence of record when estimating functional loss due to flare-ups.  The examiner must review the claims folder in order to adequately meet this requirement.
 
References:  For more information on

IV.i.3.B.1.h.  Musculoskeletal Examination Report Review for X-Rays

  
During review of musculoskeletal examination reports, check to ensure that x-rays were obtained when necessary.
 
A diagnosis of arthritis must be confirmed by x-ray or other radiographic testing before service connection may be established.
 
Where there is a claim of non-specific joint pain in a joint or multiple joints, x-rays will not be provided prior to the Veteran being seen by the examiner.
  • The examiner will determine if x-rays are needed in order to provide a diagnosis consistent with the history and symptomatology.
  • If there is a diagnosis other than arthritis or a determination that no diagnosable disability exists, do not return the examination as insufficient merely because x-rays were not provided.
However, when arthritis is claimed or diagnosed, the examination and/or medical evidence of record must include x-rays of the joint at issue.  If the examination does not include x-rays, and none are otherwise available for consideration, then return the examination report as insufficient.
 
Note:  Once arthritic changes are shown in a joint, no further x-rays will ever be required for that joint to support a diagnosis of arthritis.
 
References:  For more information on musculoskeletal examination report review for

IV.i.3.B.1.i.  Nerves Examination Report Review

  
Examiners must, to the extent possible, identify the nerve that best correlates to the area affected even if the condition is a spinal cord nerve condition.
 
This information will allow the rating decision to address the functional impairment of the area affected.
 
Reference:  For more information on diseases of the peripheral nerves, see

IV.i.3.B.1.j.  Respiratory Examination Report Review for PFTs

  

Pulmonary function tests (PFTs) are required for most respiratory conditions unless

  • there is a recent study in the Veteran’s records that accurately reflects the Veteran’s current condition, or
  • the examiner provides an explanation on the special exceptions listed in 38 CFR 4.96(d)(i) through (iv).
Obtaining and reporting the PFT is only half of the requirement.  The other half of the requirement is for the examiner to interpret the PFT in relation to the claimed condition.
 
References:  For more information on

IV.i.3.B.1.k.  Skin and Scars Examination Report Review

  
Use the table below to ensure a skin or scar examination report is not considered insufficient for rating purposes.
 
If the disability being assessed is a …
Then the …
skin condition (e.g. dermatitis, eczema, etc.) whose evaluation criteria involve consideration of its effects on bodily areas
Skin Diseases Disability Benefits Questionnaire must identify the total body surface area and exposed body surface area (both expressed as percentages) affected.
scar
Scars/Disfigurement Disability Benefits Questionnaire must identify the scar’s
  • location (e.g. left lower extremity, right upper extremity, etc.)
  • type (e.g. linear, superficial non-linear, painful, etc.), and
  • dimensions of measurement (i.e. length and width).
Note:  Non-scar DBQs identifying residual scars that are not painful/unstable or greater than 39 square centimeters in area are also sufficient for rating purposes.
 
Notes:
  • If color photographs are not included with a skin or scar examination report, do not return the examination report as insufficient to request photographs unless the report clearly indicates that photographs were captured at the time of examination, but fails to provide them.  In this instance, the photographs must be obtained for rating consideration.
  • If photographs are included, then consider the evidence when evaluating the condition(s) at issue.
Reference:  For more information on rating skin conditions and scars, see

IV.i.3.B.1.l.  Sleep Disorders Examination Review

  
Sleep apnea must be diagnosed with a sleep study.  Review the sleep study to ensure the condition is interpreted in relationship to the claimed condition.
 
If there is a service-connected (SC) condition that is co-morbid to the sleep apnea that requires a PFT, like asthma, ensure that such testing was completed.
 
Sleep disturbances, such as insomnia, may be claimed as secondary manifestations of other primary conditions, including, but not limited to,
  • mental health disorders
  • pain experienced from an SC disability, and/or
  • signs or symptoms of undiagnosed illness and medically unexplained chronic multi-symptom illnesses.
Notes:
  • When the Sleep Apnea Disability Benefits Questionnaire is negative for a diagnosis of sleep apnea, but the examiner provides information about sleep disturbances, such as insomnia, then review the report in accordance with M21-1, Part V, Subpart iii, 13.1.l to determine if any additional medical opinion is required.
  • As expressed in M21-1, Part V, Subpart iii, 4.A.5.f, upper airway resistance syndrome is neither synonymous with sleep apnea nor considered a ratable disability for compensation purposes.  As such, its diagnosis does not warrant requesting any examination, medical opinion, or clarification of existing examination results.
References:  For more information on

IV.i.3.B.1.m.  TMD Examination Report Review

  
There is no need to return a temporomandibular disorder (TMD) examination report simply because a dentist did not perform the examination.  TMD is musculoskeletal in nature.
 
Important:  As part of the musculoskeletal requirements, the Temporomandibular Disorders (TMDs) Disability Benefits Questionnaire requires the examiner to address
  • flare-ups that impact the function of the temporomandibular joint
  • initial ROM measurements
  • ROM measurement after repetitive-use testing
  • functional loss and additional limitation in ROM, and
  • pain (pain on palpation) and crepitus.
References:  For more information about

IV.i.3.B.1.n.  TBI Examination Report Review

  
Ensure the initial TBI diagnosis is provided by a qualified examiner.
 
The examiner must address
  • all the facets of the TBI diagnosis, and if any facets are left blank, it must be indicated in the Remarks section of the DBQ that the symptoms are related to a non-TBI condition, with an explanation provided
  • any additional residuals, other findings, diagnostic testing, functional impact of the diagnosis, and an explanation regarding conflicting diagnoses from medical versus mental health clinicians, if applicable
  • other pertinent physical findings, scars, complications, conditions, signs and/or symptoms, such as mental, physical, or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere’s disease), and
  • the functional impact on the Veteran’s ability to work.
A mental health evaluation alone is not sufficient in addressing TBI.  A TBI examination completed by a medical clinician, with input from a mental health examiner, needs to be completed when attributable signs and symptoms co-exist.
 
Objective evidence and neuropsychiatric testing may be required when cognitive impairment symptoms are identified.  Some examples of cognitive impairment symptomology include
  • memory loss, and
  • reduced attention, concentration, and executive functioning.
References:  For more information on