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Updated Jun 20, 2024

n This Section
This section contains the following topics:
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1.  Basic Information on Rating Decisions

Introduction
This topic contains basic information on rating decisions, including

Change Date
May 10, 2016

V.iv.1.A.1.a. Definition: Decision
A decision means a formal determination on all questions of fact and law affecting the provision of Department of Veterans Affairs (VA) benefits to a claimant.
References:  For more information on statutory decision requirements see

V.iv.1.A.1.b. Definition: Rating Decision
A rating decision is a record purposes document detailing the formal determination made by the regional office (RO) rating activity regarding one or more issues of benefit entitlement.  The rating decision states the decisions made and provides an explanation supporting each decision.
References:  For more information on

V.iv.1.A.1.c. Components of the Rating Decision
The rating decision is composed of a Narrative explanation of the determination on benefit entitlement and a Codesheet containing information about the claimant, the current decision, past decisions, and the current state of entitlement to compensation and/or pension benefits.
References:  For more information on the

V.iv.1.A.1.d.  Rating Decision Sections
The table below provides information about the sections of a rating decision.
Rating Decision Sections
Description
Narrative
Contains the
  • Introduction
  • Decision for each issue considered
  • Evidence
  • Reasons for Decision for each issue considered, and
  • References.
Codesheet
Contains the
  • data table
  • Jurisdiction
  • coded conclusion
  • SPECIAL NOTATION and TEMPLATE fields, and
  • signature(s).
Reference:  For more information on the rating decision format, see the Veterans Benefits Management System-Rating (VBMS-R) User Guide.

V.iv.1.A.1.e. Rating Decision Automation Using VBMS-R
Rating decisions are prepared using VBMS-R, which
  • incorporates the latest rating decision format
  • includes tools to help ensure rating decision sufficiency, and
  • transfers disability and entitlement data into a corporate database of claimants who have applied for VA benefits.
Reference:  For more information on VBMS-R, see the VBMS Rating User Guide.

V.iv.1.A.1.f. Uniformity of Rating Decision Documents
To the maximum extent possible, rating decisions should be formatted to exclude physical mailing or RO-specific address information.
VBMS-R’s user configuration settings require mandatory entries in the REGIONAL OFFICE NAME and ADDRESS LINE 1 fields, which should be populated with the standardized values Veterans Benefits Administration and Regional Office, respectively, to promote uniformity.
Example:
VBMS-R user configuration settings showing RO name and address fields

2.  Introduction

Introduction
This topic contains information on the Introduction section of the rating decision, including

Change Date
January 20, 2015

V.iv.1.A.2.a. Purpose of the Introduction Section
The purpose of the Introduction section is to
  • identify the claimant, and
  • acknowledge the Veteran’s qualifying service, including any special considerations relevant to the claim, such as former prisoner of war status.
Note:  The level of detail in the introduction depends on the complexity of each issue.

V.iv.1.A.2.b. Generating the Introduction Section
The Introduction section may be generated using the narrative assistance function in VBMS-R or may be composed manually.  Use the guidelines listed below when manually composing the Introduction.
  • Write directly to the claimant.  “You” is acceptable usage.
  • Include all periods of service.  Use the format “month/day/year to month/day/year.”
Note:  Service dates must be checked for accuracy.
Reference:  For more information on using the narrative assistance function, see the VBMS Rating User Guide.

3.  Decision

Introduction
This topic contains information about the Decision section of the rating decision, including

Change Date
August 23, 2018

V.iv.1.A.3.a.  Purpose of the Decision Section
The Decision section lists the specific outcome for each issue addressed, such as the award or denial of
  • service connection (SC)
  • an increased evaluation, or
  • an ancillary benefit, such as special monthly compensation (SMC).
Where at least one (but not every) issue must be deferred, the Decision section will also list the deferred issue(s).
Notes:
  • For an award of SC, the disposition of the issue will include the evaluation assigned.
  • For issues of SC, evaluation, and other award issues, the decision on the issue will include the effective date of the award.
  • It is important that formatting of the text entered in VBMS-R’s DECISION field is audience-appropriate and professional with regard to spelling and capitalization because the exact text entered will be restated directly in the resulting Redesigned Automated Decision Letter (RADL).

V.iv.1.A.3.b.  Organizing the Decision Section
If there is more than one decision made, each decision will have a number corresponding with the numbered issues.
Organize the Decision section in a logical manner, ensuring to accomplish the following:
  • Address all issues.
  • Place award before denials.
  • Where consistent with the other guidance in this block, list awarded evaluations in descending order of evaluation.
  • Group together
    • similar decisions, such as awards and denials, and
    • related conditions, such as injuries from a single accident.
Examples:  List the award of SC for
  • a knee disability before listing the award of secondary SC for a back disorder based upon the knee disability, and
  • prostate cancer, status post prostatectomy before listing the award of SMC based on loss of use of a creative organ.

V.iv.1.A.3.c.  Handling Issues Within Scope of a Claim
When an issue within scope of a claim is considered in a rating decision, explicitly address the within-scope issue in the Reasons for Decision.
If the within-scope issue and the explicitly claimed issue
  • share the same fact pattern, then the subordinate issue may be incorporated in the same Issue, Decision, and Reasons for Decision numbered item as the primary issue, or
  • are each itemized in a separate Decision and Reasons for Decision paragraph, then the discussion of the common fact pattern may be confined to the Reasons for Decision of the primary issue.
Example:  The Issue statement on the rating decision could be worded as follows:  “1.  Evaluation of psychotic disorder currently evaluated as 30 percent disabling; competency to handle disbursement of funds.”
References:  For more information on
V.iv.1.A.3.d.  Using Diagnostic Terminology to Name Issues
When establishing issues for inclusion in the rating decision’s Decision section, use the diagnostic terminology provided by the medical examiner (or alternative medical evidence), as discussed in M21-1, Part V, Subpart iv, 1.C.7.b.
If the diagnostic terminology used to describe the condition is different than the terminology used by the claimant on his/her application, include the terminology that the claimant used as a parenthetical note in the following fields on VBMS-R’s ISSUE MANAGEMENT tab:
  • ISSUE, and
  • DECISION.
Example:  The Veteran claims ringing in the ears.  The medical examiner diagnoses the condition as tinnitus.  The rating decision Narrative should list the condition as tinnitus (claimed as ringing in the ears) in its corresponding Issue and Decision numbered items.
Note:  Do not include the parenthetical note, if indicated, in the DIAGNOSIS field on VBMS-R’s DISABILITY DECISION INFORMATION (DDI) screens.  The parenthetical note should not appear on the Codesheet.

V.iv.1.A.3.e.  Changes in DCs
The rating activity should not routinely change the previously assigned diagnostic code (DC) for a service-connected (SC) disability.
The rating activity should update a DC only when it is part of the current claim, and
  • progression of a disability has occurred, or
  • the previous DC is outdated.
Exception:  If the assigned DC is erroneous or otherwise causing a payment error, the rating activity must update the DC even if the condition is not part of the current claim.
Reference:  For more information on Codesheet errors that must be corrected, see M21-1, Part V, Subpart iv, 1.E.3.b.

V.iv.1.A.3.f.  Avoiding the Use of Free-Text Contentions in VBMS-R
Avoid the entry of free-text contentions on VBMS-R’s ISSUE MANAGEMENT screen to the extent possible.  Use free-text contentions only when existing decisional entry functionality is otherwise insufficient to accomplish the necessary rating action.
Reference:  For more information on VBMS-R functionality, see the VBMS Rating User Guide.

4.  Evidence

Introduction
This topic contains information on the Evidence section of the Narrative, including

Change Date
August 23, 2018

V.iv.1.A.4.a.  Overview of the Evidence Section of a Rating Decision
The Evidence section is a listing of each piece of evidence considered in arriving at the decision, which may include but is not limited to
  • service treatment records (STRs)
  • service personnel records
  • private and VA treatment records
  • VA or contract examination reports, to include disability benefits questionnaires
  • lay statements, and/or
  • written or oral testimony, to include hearing transcripts.
Reference:  For more information on evaluating evidence, see M21-1, Part V, Subpart ii, 1.A.

V.iv.1.A.4.b.  Generating the Evidence Section of a Rating Decision
The Evidence section can be generated by importing evidence listed in VBMS or can be manually created through user input in VBMS-R.
Important:  When importing evidence from VBMS, the Evidence section should always be checked for accuracy and completeness.

V.iv.1.A.4.c.  Guidelines for the Evidence Section of a Rating Decision
Use the guidelines in the table below when generating the Evidence section.
If the Evidence section identifies …
Then list the evidence type and …
service records, such as STRs or personnel records
  • the date of receipt [MM-DD-YYYY], and
  • the period of service associated with the records [MM-YYYY to MM-YYYY].
Example:  STRs received on June 20, 2017, for the period October 2006 to November 2010.
VA treatment records
  • the name of the facility, and
  • dates covered by the records [MM-DD-YYYY to MM-DD-YYYY].
References:  For more information on the
private medical records
  • the name of the facility or physician
  • date of receipt, and
  • dates covered by the records [MM-YYYY to MM-YYYY].
Example:  Medical records, Dr. Jones, received February 1, 2017, for the period May 2012 to Feb 2016.
VA or contract examination(s)
identify the
  • examining facility/contractor, and
  • date the exam was conducted.
other government, including Federal and State records
  • the name of the source (agency, facility, etc.), and
  • date of receipt.
Example:  Social Security Administration records received on March 8, 2017.
lay statement(s)
  • the source of the statement, and
  • date of receipt.
forms
  • the full name of the form, and
  • date of receipt.
evidence requested, but not received
in the following format:  Private medical records requested from [provider’s or facility’s name], but not received.
evidence considered in a prior VA decision
by separately stating each piece of evidence considered in a format consistent with this table’s guidance.
Note:  Include the prior decision as an entry in the Evidence list if the decision itself is relevant for consideration in connection with the current decision.
any medical evidence that is confidential under 38 U.S.C 7332 (certain medical records relating to human immunodeficiency virus (HIV) infection, substance abuse, or sickle cell anemia)
by specifying only the relevant date and name of the medical facility.
non-relevant records not requested
follow the documentation requirements specified in M21-1, Part III, Subpart i, 2.E.1.f.
 
Reference:  For more information on the definition of evidence, see M21-1, Part V, Subpart ii, 1.A.1.a.

V.iv.1.A.4.d.  Establishing the Date of Receipt of Evidence 
The date VA received evidence is often a factor when determining legal entitlement to benefits; consequently, decision makers must ensure the receipt date listed in VBMS is as accurate as possible for any evidence listed in a decision.
If an earlier date of receipt is discovered, edit the document properties in the electronic claims folder to show the correct date.
References:  For more information on

5.  Basic Information on Reasons for Decision

Introduction
This topic contains basic information on the Reasons for Decision section of the Narrative, including

Change Date
June 20, 2024

V.iv.1.A.5.a.  Purpose of the Reasons for Decision Section
The purpose of the Reasons for Decision section is to concisely cite and evaluate all relevant facts considered in making the decision.
Use the table below to determine what decision elements the Reasons for Decision section must discuss.
If …
Then the Reasons for Decision section must address the …
awarding the claim
  • benefit being awarded and legal basis for the award (for example, secondary SC)
  • laws and regulations applicable to the claim
  • fact that all elements required to decide the issue were met, and all findings are favorable to the claimant
  • assigned evaluation, if applicable
  • effective date
  • basis for the current evaluation, if applicable
  • requirements for the next higher evaluation, if applicable
  • potential for routine future examination, if applicable, and
  • reason for the effective date.
Exceptions:  An effective date explanation is not required when
  • the assigned effective date is
    • the date of the claim’s receipt, or
    • the day following discharge from active duty service, or
  • granting SC for the cause of death/entitlement to Dependency and Indemnity Compensation (DIC).
confirming and continuing an existing evaluation
  • basis for the current evaluation
  • laws and regulations applicable to the claim
  • findings that are favorable to the claimant under 38 CFR 3.104(c), if any
  • requirements for the next higher evaluation
  • absence of evidence demonstrating sustained improvement, if applicable, and
  • potential for routine future examination, if applicable.
Note:  The VBMS-R glossary fragment CCEVAL may be selected to insert supplemental language into the Reasons for Decision.
denying the claim
  • theory of SC being addressed in the decision (for example, direct SC), if applicable
  • claimant’s contention(s)
  • benefit denied
  • laws and regulations applicable to the claim, and
  • reason for denial, including the
    • criteria required to grant SC
    • element(s) required to grant the claim that were not met, and
    • findings favorable to the claimant under 38 CFR 3.104(c), if any.
Note:  If there are multiple bases of SC and/or multiple denial reasons being addressed, relevant text must be added to the rating Narrative in order to discuss the unmet elements and favorable findings relative to each claimed and reasonably raised theory of SC.
Reference:  For more information on considering unclaimed theories of SC, see M21-1, Part II, Subpart iii, 1.A.2.e.
Exception:  Rating decisions for pension or survivor benefits prepared in pension management centers (PMCs) or decision review operations centers are not required to address favorable findings unless the rating is prepared for accrued benefits for disability compensation issues.  Aside from ratings for accrued benefits for disability compensation issues, favorable findings are addressed in the decision notices.
Reference:  For more information on the authorization activity’s sole jurisdiction in determining effective dates of DIC awards, see M21-1, Part VIII, Subpart i, 2.C.1.i.

V.iv.1.A.5.b.  Reasons for Decision Section Narrative Formats
There are two basic Reasons for Decision section formats:  a short- and a long-form rating narrative.  The distinction between the short- and long-form narrative formats is based on the level of analysis and case-specific detail required in the Reasons for Decision section of the rating decision.
The short-form rating narrative requires minimum explanation of the basic elements of the decision.  It is characterized by standardized automated language and limited free text.
The long-form rating narrative requires more detailed analysis and explanation of the facts of a case with reference to specific elements found in the evidence.  The Narrative section is generated by automated language from VBMS-R, with the addition of free text.
A rating decision may contain a mix of both the short-form narrative convention and the long-form.
References:  For more information on

V.iv.1.A.5.c.  Mandatory Use of VBMS-R Embedded Rules-Based Tools for Assigning Disability Evaluations
Use of the VBMS-R embedded rules-based tools, such as the Evaluation Builder, is mandatory.  These tools generate adequate explanation of an assigned evaluation and the requirements for the next higher evaluation.
Exception:  Mental disorder evaluations generated by the Evaluation Builder are a suggestion and may be adjusted either one step higher or lower upon consideration of the evidence in its entirety.
Reference:  For more information on using the Evaluation Builder and other embedded tools, see the VBMS Rating User Guide.

V.iv.1.A.5.d.  VBMS-R ANALYSIS Screen Fields and Text Population
Following the entry of all information in the VBMS-R DDI screens, the following two, relevant text fields appear on the ANALYSIS screen for use in preparing the rating decision narrative:
  • GENERATED TEXT, and
  • REASONS FOR DECISION.
Important:  The entry of text in the third and fourth displayed text fields, labeled NOTIFICATION LETTER TEXT and NOTIFICATION LETTER USER TEXT, respectively,
  • is not necessary to support successful generation of the RADL, and
  • may be disregarded during the decision-making process.
The table below describes the origin and destination of the text that populates the two relevant fields described in this block.
Field Name
Source of Text
Destination of Text
GENERATED TEXT
system-generated text based on user input in the
  • DDI screens, and
  • Evaluation Builder
  • copied or appended by the user to the REASONS FOR DECISION field, and
  • does not directly populate the rating decision.
REASONS FOR DECISION
  • initially generated as a blank field
  • text from the GENERATED TEXT field is copied or appended to this field, and
  • user supplements this text with glossary text and/or free text
Note:  Text field is limited to 32,000 characters.
populates the rating decision document that is retained in the claims folder and sent to the claimant.
Reference:  For more information on decision notices prepared using the RADL process, see M21-1, Part VI, Subpart i, 1.B.3.

V.iv.1.A.5.e.  Using VBMS-R to Produce Text for the Rating Narrative
The rating decision narrative is composed entirely of text entered in the REASONS FOR DECISION field of the VBMS-R ANALYSIS screen, including language that is
  • system-generated and copied or appended from the GENERATED TEXT field, and
  • user-generated, in the form of glossary text and/or free text, to supplement the underlying decision.
Because the rating narrative is maintained in the claims folder, and a copy of the rating decision is sent to the claimant, modify its language as needed, depending on the type of rating format (short- or long-form) deemed appropriate.
In the REASONS FOR DECISION field of the VBMS-R ANALYSIS screen, edit the rating narrative by inserting glossary text and/or free text to further explain the system-generated or glossary text, if needed, bearing the following in mind:
  • in the long-form rating format, a significant amount of additions to the system-generated language may be required, but
  • in the short-form rating format, additions to the system-generated language should be limited.
Notes:
  • Only use free text if appropriate automated or glossary text does not already exist.
  • System-generated language will typically be sufficient to satisfy the requirement (as stated in M21-1, Part V, Subpart iv, 1.A.5.a) for inclusion of any laws and regulations applicable to the claim.  In the event, however, that all applicable laws or regulations are not cited via system automation, identify those outstanding laws or regulations by inserting free-text parenthetical annotations.
References:  For more information on

V.iv.1.A.5.f.  Definition:  Favorable Finding
As stated in 38 CFR 3.104(c), a favorable finding means a conclusion either on a question of fact or on an application of law to facts made by an adjudicator concerning the issue(s) under review.
References:  For more information on

V.iv.1.A.5.g.  Requirement to Notify Claimant of Favorable Findings
Each notice of a decision affecting benefits must address any findings made by the adjudicator that are favorable to the claimant.
Note:  This requirement applies to decision notices issued on or after February 19, 2019.
References:  For more information on providing notice of favorable findings in a

V.iv.1.A.5.h.  Addressing Favorable Findings in the Rating Narrative
Rating decisions generated on or after February 19, 2019, must address, as a narrative element for each decided issue, any findings made by the adjudicator that are favorable to the claimant under 38 CFR 3.104(c).
Use the table below to determine how to properly address and document favorable findings in the rating decision narrative.
If …
Then address favorable findings in the Reasons for Decision section by …
awarding the claim
relying on system-generated grant language automated by VBMS-R’s DDI screen entries and selections.
denying the claim
adding and saving individual entries for each finding that was favorable to the claimant, if any, using the FAVORABLE FINDINGS screen under VBMS-R’s ISSUE MANAGEMENT tab.
Important:  Favorable findings must be specific enough so that a claimant, upon reading the notification and rating decision, will be able to determine what evidence was used to make the finding.  Users must edit a favorable finding to address the specific evidence that supports the favorable finding.
increasing, reducing, or continuing an existing evaluation
relying on system-generated language automated by evaluation builder entry and selections.
Exception:  As noted in M21-1, Part V, Subpart iv, 1.A.5.a, rating decisions for survivor benefits need only document favorable findings in accrued cases involving disability compensation.
Reference:  For more information on favorable finding generation in VBMS-R, see the VBMS Rating User Guide.

V.iv.1.A.5.i.  General Language Standards for the Rating Narrative
Certain language standards apply for preparation of the rating decision narrative.  Specifically, when populating the REASONS FOR DECISION field,
  • avoid the use of abbreviations
  • use language that is appropriate to the audience
  • avoid complex medical or legal terminology, or explain the underlying concept in layman’s terms when such use is unavoidable
  • never include citations to case law unless required to do so by other, more specific procedural guidance
  • keep sentences direct, concise, and clear, and
  • draft the rating decision using
    • second person point of view, and
    • active voice.
Note:  In situations where automatically generated text does not meet with these standards, make any necessary edits to text in the REASONS FOR DECISION field.

V.iv.1.A.5.j. Summarizing Medical Evidence From a 38 U.S.C. 7332 Record
Medical records relating to drug abuse, alcohol abuse, infection with HIV, or sickle cell anemia require special protection and handling under 38 U.S.C. 7332.
Summarize information from a 38 U.S.C. 7332 record that is directly pertinent to the issue in the Reasons for Decision section.  Do not incorporate quotations from a 38 U.S.C. 7332 record.
Example:  If a Veteran claims to have been treated for an SC disorder and records show treatment for substance abuse instead, state simply that there is no evidence of treatment for the claimed condition without mentioning the actual object of treatment.

V.iv.1.A.5.k.  Danger of Paraphrasing
Paraphrasing in easy-to-understand language requires care because the paraphrase might
  • misstate the law, or
  • misstate or mistake medical facts.
Example:  Use paraphrased language to help explain why the claim has been denied, but do not expressly state, The law says that…  Simply insert the paraphrase.

6.  Short-Form Rating Narrative

Introduction
This topic contains information about the short-form rating narrative, including

Change Date
October 27, 2023

V.iv.1.A.6.a.  General Information on the Short-Form Rating Narrative
The short-form rating narrative does not have to contain the entire explanation of the analysis or specifically cite each piece of the evidence; however, each element of the decision should be adequately explained.
Use of VBMS-R generated language, glossary fragments, Evaluation Builder, favorable finding functionality, and limited free text will usually contain adequate explanation of the essential elements of the decision.

V.iv.1.A.6.b. Including Free Text in a Short-Form Rating Narrative
In some cases, a limited amount of free text may be used to supplement the short-form rating narrative.
Use free text in situations where it is
  • required by the selected glossary fragment to supplement the explanation of the denial reason, or
  • needed because automated language does not exist.
Note:  Any free text used must be clear, succinct, and written in lay terms.
References:  For more information on

V.iv.1.A.6.c.  Short-Form Award
For most awarded issues, the short-form rating narrative is sufficient.  Using text generated by selections made in VBMS-R, the embedded glossaries and tools, and limited free text, explain the essential components of the decision as listed in M21-1, Part V, Subpart iv, 1.A.5.a.
Note:  When awarding SC in the short-form narrative style, discussion of specific treatment in service or post-service is not necessary.  Simply citing the legal basis for awarding SC and the symptoms that are the basis of the assigned evaluation is sufficient.
References:  For more information on

V.iv.1.A.6.d.  Example:  Short-Form Award
Below is an example of a short-form rating Narrative awarding a claim for SC.
Service connection for arthritis of the cervical spine has been established as directly related to military service.  (38 CFR 3.303, 38 CFR 3.304)
The effective date of this grant is August 1, 2017.  Service connection has been established from the day VA received your claim.  When a claim of service connection is received more than one year after discharge from active duty, the effective date is the date VA received the claim.  (38CFR 3.400)
An evaluation of 20 percent is assigned from August 1, 2017.
We have assigned a 20 percent evaluation for your arthritis of the cervical spine based on: • Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees
Additional symptom(s) include: • X-ray evidence of traumatic arthritis • Combined range of motion of the cervical spine greater than 170 degrees but not greater than335 degrees • Painful motion upon examination
The provisions of 38 CFR §4.40 and §4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown and Mitchell v. Shinseki, have been considered and are not warranted.
This is the highest schedular evaluation allowed under the law for traumatic arthritis.
Additionally, a higher evaluation of 30 percent is not warranted for cervical strain unless the evidence shows: • Favorable ankylosis of the entire cervical spine; or, • Forward flexion of the cervical spine 15 degrees or less. (38 CFR 4.71a)

V.iv.1.A.6.e.  Short-Form Denials
Explanation of the reason for a denied benefit in a short-form rating narrative is generated by selections made while inputting the decision in VBMS-R and supplemented with paragraphs from the embedded glossary fragments and limited free text.
The Reasons for Decision section should discuss the decision elements listed in M21-1, Part V, Subpart iv, 1.A.5.a.  Findings favorable to the claimant under 38 CFR 3.104(c), if any, must be identified using procedural guidance found in M21-1, Part V, Subpart iv, 1.A.5.h.
In a short-form denial, the reason for denial should provide succinct reasoning explaining the elements not present which are needed to award the benefit.
Important:  If there is evidence both for and against the claim, the short-form narrative should discuss how the evidence was weighed and any discrepancies resolved.  For most claims where evidence was weighed, the denial rationale glossaries in VBMS-R contain adequate explanation.
References:  For more information on

V.iv.1.A.6.f.  Example:  Short-Form Denial
Below is an example of a short-form rating denial Narrative addressing the Veteran’s claim of direct SC.
Service connection may be granted for a disability which began in military service or was caused by some event or experience in service.  Service connection for left shoulder condition is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.  (38 CFR 3.303)
While your service treatment records reflect complaints, treatment, or a diagnosis similar to that claimed, the medical evidence supports the conclusion that a persistent disability was not present in service.  (38 CFR 3.303)  We have been informed that you have missed the VA examination scheduled in support of your claim.  There is no information presently indicating good cause for absence on the scheduled appointment date.  As a result, medical evidence that could have been used to support your claim was not available to us.  (38 CFR 3.655)  Please notify us when you are ready to report for an examination, or you may submit a disability benefits questionnaire (DBQ) which must be completed and signed by a health care provider.
Favorable Findings identified in this decision:
The evidence shows that a qualifying event, injury, or disease had its onset during your service.
Your service treatment records show that you injured your left shoulder in June 1998.

7.  Long-Form Rating Narrative

Introduction

 This topic contains information on the long-form rating narrative, such as

Change Date

 February 19, 2019

V.iv.1.A.7.a.  Issues Requiring a Long-Form Rating Narrative

 A long-form rating narrative must be used in decisions involving any of the following types of claims:
  • award of an issue on legacy appeal
  • higher-level reviews (HLRs)
  • Nehmer
  • denials of SC for posttraumatic stress disorder based on
    • military sexual trauma, or
    • fear of hostile military or terrorist activity
  • traumatic brain injuries
  • denials of benefits under 38 U.S.C. 1151
  • adverse action proposals, including, but not limited to
    • severance of SC
    • discontinuance or reduction of benefits currently being paid
    • incompetency, and
    • those made under the Integrated Disability Evaluation System
  • final effectuation of severance, discontinuance, or reduction of benefits being paid
  • final determinations of incompetency
  • potential fraud
  • survivor benefits
  • live pension, and
  • clear and unmistakable error (to include determinations made in any of the categories above or claims seeking earlier effective dates).
Notes:
  • Legacy appeal decisions awarding benefits and HLR decisions will use the long-form decision format regardless of whether or not the underlying issues are complex and/or included on the list above.
  • Decision makers should use their best judgment when deciding to use a long-form rating narrative for any type of claim not listed.
Reference:  For more information on what constitutes adequate analysis in a long-form rating narrative, see M21-1, Part V, Subpart iv, 1.A.7.b.

V.iv.1.A.7.b.  Adequate Analysis in a Long-Form Narrative Format

 The long-form rating narrative format must be used in certain types of claims to more thoroughly and adequately discuss the reason a decision was made.  In general, the narrative should
  • address the decision elements noted in M21-1, Part V, Subpart iv, 1.A.5.a
  • discuss evidence that is relevant and necessary to the determination, including specific treatment details both during and after service
  • clearly explain why that evidence is found to be persuasive or unpersuasive, and
  • address all pertinent evidence and all of the claimant’s contentions.
The reason for denial should be based on a review of the available facts and how they relate to the statutory and regulatory requirements for the benefit sought.  The key factors involve
  • the claimant’s stated belief or contentions
  • the pertinent facts, to include those that address the condition or circumstances claimed
  • what we may have asked for but did not receive, and
  • succinct reasoning explaining the elements not present which are needed to award the benefit.
Note:  Cite both favorable and unfavorable evidence without partiality, especially when a decreased benefit is under consideration.  Compare relevant findings at the time of the previous rating with present findings.
References:  For more information on