Updated Dec 05, 2024
In This Section |
This section contains the topic “Determining Relevance of Records.”
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1. Determining Relevance of Records
Introduction |
This topic contains information on determining whether identified evidence is relevant for purposes of providing assistance under 38 U.S.C. 5103A, including
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Change Date |
December 5, 2024
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III.i.2.E.1.a. Definition: Relevant Records |
Relevant records for the purpose of the duty to assist are those records that
For the purpose of 38 U.S.C. 5103A, the court held in Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) that not all medical records have a reasonable possibility of helping substantiate a pending claim and that the duty to assist applies only to relevant records.
Important: For purposes of determining relevance, the same principles apply to both private and Federal records.
The court further held in Raugust v. Shinseki, 23 Vet.App. 475 (2010), that the Department of Veterans Affairs (VA) has no duty to obtain records without a specific reason to believe that the records identified by the Veteran would contain necessary information to substantiate the claim.
Example: A Veteran files a claim for an increased evaluation for residuals of a service-connected (SC) left ankle fracture. He reports treatment at the Mayo Clinic for headaches.
Analysis: The information available on its face shows that the identified private records would not be relevant as they do not relate to the Veteran’s SC disability nor do they have a reasonable possibility of substantiating the claim.
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III.i.2.E.1.b. Relevance Determined on Case-by-Case Basis |
Because each case presents unique circumstances, relevance of records shall be determined on a case-by-case basis. It is not possible to offer “one-size fits all” guidance on the issue of determining whether an identified piece of evidence is relevant to the issue being adjudicated.
Exercising common sense and sound judgment is critical in determining relevance. In addition to the two prongs of the standard in M21-1, Part III, Subpart i, 2.E.1.a, consider the following questions when making such determinations:
Reference: For more information on relevant records, see M21-1, Part I, Subpart i, 1.A.4.a. |
III.i.2.E.1.c. Importance of Golz Decision in Determining Relevance of Evidence |
See the following example of a situation in which records would not be considered relevant. This example is modeled after Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010).
Example: A Veteran files a claim for service connection (SC) for posttraumatic stress disorder. He reports that he is in receipt of Social Security Administration (SSA) disability benefits and attaches a copy of an SSA decision that found him to be disabled due to back and leg pain from a 2001 injury. There is no mention of mental health symptoms or treatment in the SSA decision.
Analysis: The Federal Circuit, in Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010), held that if an SSA decision pertains to a completely unrelated medical condition and the Veteran makes no specific allegations that would give rise to a reasonable belief that the medical records may nonetheless pertain to the injury for which the Veteran seeks benefits, relevance is not established.
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III.i.2.E.1.d. Other Examples When Records Are Considered Not Relevant |
Example 1: A Veteran is SC for hypothyroidism evaluated at 30 percent since 1982, and submits a claim for increase in 2014. She indicates she was treated twice by a private physician for fatigue and constipation in 1984 but no treatment since then. No other rating decisions have been completed since the original award of SC in 1982. An examination is ordered without development for the 1984 records.
Analysis: Although the records from 1984 relate to the claimed issue, they do not present a reasonable possibility of substantiating the claim 30 years later for an increased evaluation. In other words, there is no reasonable possibility that an earlier effective date or higher evaluation will be assigned if these records are obtained. Therefore, the records are not relevant.
Example 2: A Veteran claims SC for low back disability. A review of the claims folder indicates the military dental treatment records are missing.
Analysis: Since those service treatment records (STRs) are not likely to relate to the back claim, it is reasonable to conclude that the dental records are not relevant to the claim for low back.
Example 3: Presumptive SC for Type 2 diabetes is awarded based on an original claim for SC. A current VA examination and private medical evidence showing treatment for diabetes over the last three years was considered. While the rating decision awaits promulgation, a signed release is received from the Veteran indicating diabetes treatment for a short period of time nine years ago. The individual who issued the decision determines that the evidence identified by the Veteran is not relevant.
Analysis: The records from nine years ago do in fact relate to the claimed condition. However, since the claim has already been substantiated and there is no reasonable possibility of establishing an earlier effective date or higher evaluation for diabetes, the records are considered not relevant and therefore do not need to be obtained.
Example 4: In Example 3, the Veteran passes away in June 2014 (no claim pending at death). The surviving spouse submits a VA Form 21P-530, Application for Burial Benefits, as well as a death certificate documenting diabetes was a contributing factor for the cause of death. She claims on the application that the Veteran’s death was related to his military service. The spouse also submits a medical release form with the attached VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), and a statement asking VA to obtain records related to the Veteran’s diabetic treatment prior to death.
Analysis: Although the records relate to the claimed issue, the Veteran’s death certificate is sufficient to link the cause of death to the Veteran’s SC disability, therefore, the medical release form submitted with the claim is not relevant and records do not need to be obtained.
Example 5: A Veteran submits an original claim for pension. The Veteran served in the Navy from 1971-1974. The Veteran submits a report from his family physician for his back condition that is sufficient to grant pension. The Veteran also submits a separate VA Form 21-4142a and statement specifying treatment for the back, and they reveal treatment for the low back by a different physician two weeks after the date of treatment by his family physician.
Analysis: Because the current evidence is sufficient to substantiate the claim and grant pension, the records from the second physician are not considered relevant since obtaining such records would not likely result in a greater benefit or earlier effective date.
Example 6: A surviving spouse claims the Veteran’s death (shown as liver failure) is related to his service. The Veteran was SC for bilateral hearing loss evaluated at 30 percent at the time of death. Review of the STRs is silent for any treatment or complaint of a liver condition in service. The surviving spouse submits a medical release form with the attached VA Form 21-4142a and a statement with her claim requesting we retrieve records surrounding the Veteran’s liver failure in the year preceding his death.
Analysis: Since it is highly unlikely that retrieval of the records for liver failure would provide a nexus between the Veteran’s hearing loss and his cause of death, nor likely to aid in substantiating the SC death claim, these records are not relevant unless the surviving spouse provides a specific reason why they are relevant.
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III.i.2.E.1.e. Clinical Mental Health Records Considered Relevant |
For the purposes of adjudicating claims for SC for mental disorders, all clinical records from military service are considered relevant and shall be obtained. See Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009).
Reference: For information on clinical records and guidance for requesting such records, see
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III.i.2.E.1.f. Documenting the Claims Folder When Identified Evidence Is Not Considered Relevant |
When it is determined that records identified by the claimant are not relevant, a formal documentation of this determination must be completed and made part of the claims folder.
Claims processors shall document the claimant’s record when evidence identified by the claimant is not considered relevant and VA’s duty to assist under 38 U.S.C. 5103A does not require VA to obtain those records.
Follow the steps below when documenting the claimant’s record.
Notes:
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