In This Section

This section contains the following topics:

Introduction

This topic contains information about A&A and housebound examinations, including

• purpose of an A&A and housebound examination
• when an A&A and housebound examination may be useful
• requesting an A&A and housebound examination, and
• locally devised checklists.

Change Date

IV.i.2.E.1.a..Purpose of an A&A and Housebound Examination

The aid and attendance (A&A) and housebound examination is designed to

• pinpoint findings relevant to A&A determinations under 38 CFR 3.351 and 38 CFR 3.352, and
• provide a basis for determining if the housebound benefit may be paid if the need for A&A is not shown.

IV.i.2.E.1.b..When an A&A and Housebound Examination May Be Useful

It may be useful to request an A&A and housebound examination before a final determination is made, especially if the evidence of record demonstrates a reasonable probability of entitlement to A&A or housebound benefits but is not sufficient to allow the benefit.

Note: As provided in 38 CFR 3.326, an examination is not required and should not be pursued if the evidentiary record is otherwise sufficient to independently support entitlement to A&A or housebound benefits.

IV.i.2.E.1.c..Requesting an A&A and Housebound Examination

Use the table below when requesting an A&A and housebound examination.

Notes:

• A disability benefits questionnaire (DBQ) does not exist at this time for A&A and housebound examinations.
• A&A examinations do not require condition-specific DBQs unless a claim for an increased rating is received or found to be within scope of the claim for special monthly compensation (SMC) as noted in M21-1, Part II, Subpart iii, 1.A.3.c.

References: For more information on

• developing for A&A and housebound status under 38 CFR 3.351, see M21-1, Part IX, Subpart ii, 1.A.3, and
• requesting examinations in
  • general, see M21-1, Part IV, Subpart i, 2.A
  • CAPRI, see the CAPRI User Manual, and
  • VBMS Exam Management System (EMS), see the
    • VBMS Core User Guide, and
    • EMS User Guide.

IV.i.2.E.1.d..Locally Devised Checklists

Regional offices (ROs) are not authorized to create local checklists for A&A and/or housebound examinations.

Checklists created and submitted by individual treatment providers should be evaluated as any other item of evidence. However, Yes or No blocks do not provide sufficient descriptive information to assess the extent of a claimant’s incapacitation.

Introduction

This topic contains information about other types of examination requests, including

• examinations of non-Veteran claimants and beneficiaries
• hospital observation
• field examinations
• examinations of incarcerated Veterans
• board examinations
• reexaminations by a different examiner
• homeless Veterans examination requests, and
• examinations in claims involving foreign residence.

Change Date

IV.i.2.E.2.a..Examinations of Non-Veteran Claimants and Beneficiaries

As the facts of an individual case demand, the rating activity may schedule examinations of non-Veteran claimants and beneficiaries

• only after approval by the Veterans Service Center Manager or Pension Management Center Manager or their designated reviewer, or
• to determine if a
  • claimant is entitled to A&A or housebound benefits
  • Chapter 18 birth defect diagnosis exists
  • claimant was insane at the time they caused the death of the Veteran
  • dependent child or child claimant is incapable of self-support and/or incompetent, and/or
  • beneficiary is competent to handle funds.

References: For more information on

• Chapter 18 birth defects eligibility and development, see M21-1, Part VIII, Subpart i, 3.C
• determining when an examination is required to resolve the question of permanent incapacity for self-support, see M21-1, Part X, Subpart ii, 6.B.2.b
• the facts to be considered in a wrongful and intentional death, see M21-1, Part X, Subpart iv, 2.B.3, and
• submitting ESRs in VBMS for non-Veteran claimants/beneficiaries, see the EMS User Guide.

IV.i.2.E.2.b..Hospital Observation

IV.i.2.E.2.c..Field Examinations

Request a field examination when it is not possible, through the routine examination process, to

• determine the competency of the beneficiary
• assess employment and social adjustment, or
• substantiate items of evidence regarding the existence of disease or injury prior to enlistment.

Reference: For more information on requests for field examinations, see M21-1, Part X, Subpart v, 1.E.

IV.i.2.E.2.d..Examinations of Incarcerated Veterans

An incarcerated Veteran is entitled to a Department of Veterans Affairs (VA) compensation examination as part of the duty to assist.

When examination of an incarcerated Veteran is required, the RO, Veterans Benefits Administration (VBA) contract examination provider, and/or local Veterans Health Administration (VHA) Medical Examination Coordinator must confer with prison authorities to determine whether the Veteran should be

• escorted to a VA medical facility for examination by VHA personnel, or
• examined at the prison by
  • VBA contract examination providers
  • VHA personnel, or
  • fee-basis providers contracted by VHA.

Important:

• Because some State laws restrict the movement of and access to prison inmates, the above options may not be possible. In such cases, documentation of substantial efforts to schedule and conduct the examination must be added to the claims folder.
• ROs must include the following information, to the extent that it is known, in examination requests for incarcerated Veterans:
  • name of the correctional facility
  • location of the correctional facility
  • circumstances of confinement (nature/type of conviction, level of institutional security, etc.), and
  • whether the Veteran is considered violent.
• ROs must document all efforts made to schedule an examination, including identifying and requesting the assistance of the appropriate prison officials.
• VHA compensation clinics and VBA contract examination vendors are required to provide documentation that they have
  • made substantial attempts to schedule and conduct the examination, and
  • exhausted all possible avenues for obtaining access to the incarcerated Veteran for the examination.
• If the examination provider has exhausted examination efforts to no avail, treat a Veteran’s inability to attend a necessary examination (claim-related or review) by reason of incarceration as the equivalent of a failure to report, and take appropriate action in accordance with M21-1, Part IV, Subpart i, 2.F. If the evidence shows that failures in scheduling or conducting an examination are associated with the Veteran’s release from incarceration or transfer to another facility, then a showing of good cause should be liberally construed.

Notes:

• When requesting an examination for an incarcerated Veteran, ensure that the Incarceration corporate flash discussed in M21-1, Part VI, Subpart iii, 1.A.3.f, has been properly applied to the associated corporate record.
• When requesting an examination for an incarcerated Veteran through VBMS, claims processors must select Incarcerated Veteran from the VETERAN PRIORITY ISSUES drop-down menu under the CLAIM INFORMATION tab.
• Request any examination(s) needed in support of an incarcerated Veteran’s claim for individual unemployability (IU) benefits, as discussed in M21-1, Part VIII, Subpart iv, 3.B.2, even though there may be no award of such benefits while the Veteran is incarcerated.

References: For more information on

• requesting examinations in VBMS, see the VBMS Core User Guide
• limitations on payment of compensation for incarcerated Veterans, see
  • M21-1, Part VI, Subpart iii, 1.A.2.a, and
  • 38 U.S.C. 5313
• effect of incarceration on ratings of IU, see
  • M21-1, Part VI, Subpart iii, 1.A.2.b, and
  • M21-1, Part VIII, Subpart iv, 3.C.4.c
• VA’s duty to examine incarcerated Veterans, see
  • Bolton v. Brown, 8 Vet.App. 185 (1995), and
  • Wood v. Derwinski, 1 Vet.App. 190 (1991), and
• VHA policy on incarcerated Veteran examinations, see the DMA C&P Disability Examinations Procedure Manual.

IV.i.2.E.2.e..Board Examinations

There should be at least two physicians, preferably three, on “board examinations,” and at least one (but preferably all) should be a recognized specialist in the particular field involved.

The rating activity has the authority to request board examinations to

• reconcile differing diagnoses, or
• resolve particularly complex issues concerning
  • awards of SMC, or
  • entitlement to specially adapted housing.

IV.i.2.E.2.f..Reexaminations by a Different Examiner

The rating activity may request that the claimant be reexamined by another medical examiner if compelling reasons exist.

To request a reexamination

• prepare another examination request
• annotate it to show that reexamination is necessary
• identify any specific information needed in the examination report, and
• include the name and the facility of the medical examiner who conducted the prior examination.

Reference: For more information on preparing examination requests, see M21-1, Part IV, Subpart i, 2.A.

IV.i.2.E.2.g..Homeless Veteran Examination Requests

ROs must expedite the processing of all claims submitted by Veterans who are

• homeless, or
• at immediate risk of homelessness.

Depending upon the Examination Request Routing Assistant (ERRA) tool’s recommendations, use the appropriate system to request these examinations, and ensure that the following comment (or its near equivalent) is included in the body of the examination request:

Claim for a homeless or at imminent risk of homelessness Veteran. Expeditious processing is requested.

References: For more information on

• priority processing of claims from homeless Veterans, see M21-1, Part X, Subpart i, 1
• interpreting the ERRA tool’s results, see M21-1, Part IV, Subpart i, 2.A.2.d, and
• selecting the appropriate application for requesting examinations, see M21-1, Part IV, Subpart i, 2.A.2.f.

IV.i.2.E.2.h..Examinations in Claims Involving Foreign Residence

Examinations in claims involving foreign residence should only be requested by claims processors at a station with jurisdiction to process the foreign claim.

After a designated foreign claims processor has requested an examination for a claimant residing in a foreign country, a contract examination vendor may generate a request for clarification indicating that particular contentions require examination outside of the contract vendor’s network. In such cases, the contract vendor will identify one of the following processes as required to examine the specified contention(s):

• Alternative Medical Evidence (AME) Process, or
• Single Source Subcontracted Examination (SSSCE) Process.

Following receipt of this communication from the contract vendor, a foreign claims processor will apply the appropriate Foreign Out-of-Network (FOON) special issue indicator to the specified contention(s), either the FOONAME or FOONSSSCE special issue indicator.

Important:

• The FOONAME and FOONSSSCE special issue indicators should only be applied by designated foreign claims processors at stations with jurisdiction over foreign claims.
• If one or more of the FOON special issue indicators is discovered upon review of a claim, verify the location of the claimant’s address. If the claimant has a domestic address, remove the special issue indicator(s) from all contentions.

References: For more information on

• jurisdiction of claims involving foreign residence, see
  • M21-1, Part II, Subpart ii, 3.1.b, and
  • M21-1, Part X, Subpart i, 3.A.2.a
• requests for clarification, see M21-1, Part IV, Subpart i, 2.A.10.c, and
• special issue indicators, see M21-4, Appendix E, 2.

Introduction

This topic contains information about pre-discharge examinations, including

• who is eligible for pre-discharge examination
• what the Separation Health Assessment (SHA) covers and its usage, and
• general medical examinations and the SHA.

Change Date

IV.i.2.E.3.a..Who Is Eligible for Pre-Discharge Examination

Pre-Discharge claim submission is available to service members with no more than 180 days remaining until discharge.

References: For more information on

• who may file a pre-discharge claim, see M21-1, Part X, Subpart i, 6.A.1.b, and
• claims that are not processed prior to discharge, see M21-1, Part X, Subpart i, 6.B.1.b.

IV.i.2.E.3.b..What the SHA Examination Covers and Its Usage

The Separation Health Assessment (SHA) is a single examination that supports transitioning service members seeking VA disability compensation under the Benefits Delivery at Discharge (BDD) or Integrated Disability Evaluation System (IDES) programs. The SHA also

• satisfies Department of Defense (DoD) requirements for separation/retirement, and
• provides service members with an improved general medical examination, to include an audiogram and a full laboratory analysis via VA examination protocols.

To reduce duplication of agency efforts, VA will provide DoD an electronic copy of the SHA for BDD and IDES participants. For those not participating in the BDD or IDES programs, DoD will conduct its Separation History Physical Examination and include the assessment in the service member’s service treatment records (STRs). Prior to VA conducting the SHA, the service member must submit a Separation Health Assessment – Part A Self Assessment (SHA, Part A).

Pre-discharge claims processors must ensure an SHA, Part A, is in the service member’s electronic claims folder prior to requesting the SHA in VBMS.

Notes:

• All claimed and reported issues at the SHA examination must be addressed by VA completing the appropriate DBQ for each issue; however, in order to add any conditions to a pending claim, the claimant is required to file a claim on the appropriate form.
• All unclaimed but reported or suspected issues at the examination must be addressed in the General Medical – Separation Health Assessment Disability Benefits Questionnaire, along with any abnormal findings identified and any appropriate additional DBQ(s). There is no requirement, however, for the examiner to complete additional DBQs in conjunction with the General Medical – Separation Health Assessment Disability Benefits Questionnaire for subjective complaints rendered at the time of examination without objective findings noted at that time.
• If a service member complains of ringing in the ears or tinnitus during the examination, a Hearing Loss And Tinnitus Disability Benefits Questionnaire must be completed by the examiner. A specific claim for tinnitus is not required in order for the audio examination to be required, or for the audio examiner to be required to address tinnitus.

References: For more information on

• hearing loss and tinnitus medical opinions, see M21-1, Part IV, Subpart i, 2.A.7.h, and
• special claims-handling procedures for BDD claims, see M21-1, Part X, Subpart i, 6.C.1.b.

IV.i.2.E.3.c..General Medical Examinations and the SHA

Effective October 2013, all eligible BDD claimants receive an SHA in lieu of a general medical examination. Those claimants who file pre-separation claims that are excluded from the BDD program, however, will continue to require a general medical examination and should not be examined under the SHA protocol.

When ordering an examination for a BDD claim, select the General Medical – Separation Health Assessment Disability Benefits Questionnaire and add the following comment: BDD claim.

References: For more information on

• the General Medical – Separation Health Assessment Disability Benefits Questionnaire, see DMA Fact Sheet 24-001, Pre-Discharge Examinations and Referral of Service Members for Mental Health Services During Transition
• pre-discharge claims, eligibility requirements, and exclusion from BDD processing, see M21-1, Part X, Subpart i, 6.A and B
• the responsibility of BDD coordinators in ensuring that appropriate examinations are conducted, see M21-1, Part X, Subpart i, 6.B.3.b
• handling when an initial examination for a pre-discharge claim is requested after discharge, see M21-1, Part X, Subpart i, 6.B.3.f
• claims-handling procedures for BDD claims, including entering examination requests, see M21-1, Part X, Subpart i, 6.C.1.b
• follow-up requirements for BDD examinations, see M21-1, Part X, Subpart i, 6.C.1.e
• special considerations on requesting examinations for BDD-excluded claimants, see M21-1, Part X, Subpart i, 6.C.2.e , and
• responsibilities in the SHA exchange with DoD, see M21-1, Part X, Subpart i, 6.C.3.c.

Introduction

This topic contains information about examinations for pregnant claimants, including

• general information on examinations for pregnant claimants
• ancillary conditions of pregnancy
• tests not recommended for pregnant claimants
• how pregnancy affects participation in pre-discharge programs, and
• options for processing claims for pregnant claimants.

Change Date

IV.i.2.E.4.a..General Information on Examinations for Pregnant Claimants

Many pregnant claimants submit claims for conditions that are either

• directly related to pregnancy, or
• acute and transitory and expected to resolve upon delivery.

Some physical examinations and routine tests required to accurately evaluate the disabilities identified in claims are complicated and not recommended for or normally performed on pregnant women since they may pose a significant health risk to the woman or baby.

Note: To the extent permissible and/or possible, utilize the Acceptable Clinical Evidence (ACE) Process to examine pregnant claimants.

IV.i.2.E.4.b..Ancillary Conditions of Pregnancy

Some ancillary conditions common to pregnancy are

• anemia
• back pain
• edema in the legs
• gestational diabetes
• hypertension
• shortness of breath, and
• urinary tract infections.

IV.i.2.E.4.c..Tests Not Recommended for Pregnant Claimants

The prevention of unnecessary risks or negative outcomes is a priority for both the mother and unborn child. Examination validity during pregnancy is also a concern due to mechanical, hormonal, and metabolic changes in the mother during pregnancy.

Tests and procedures that are not recommended for pregnant claimants include

• x-rays
• pulmonary function tests (PFTs)
• range of motion examinations
• gait testing
• laboratory testing, and
• any other examination or procedure that may place the mother and/or unborn child at risk.

Note: When pregnancy is known, include in the examination request a comment indicating that the claimant is pregnant.

IV.i.2.E.4.d..How Pregnancy Affects Participation in Pre-Discharge Programs

Pregnant service members may file pre-discharge claims up to 180 days prior to separation/retirement.

Since pregnancy prohibits certain diagnostic tests and procedures, the examiner may be unable to accurately assess the claimant’s medical condition. This may preclude completion of an examination and the rating process for certain issues until conclusion of the pregnancy.

Claims processors must include the following remarks in any examination request for a pregnant pre-discharge claimant:

Please be advised that this individual has indicated a current pregnancy. If the examining physician determines that this examination (or any part of this examination) is medically contraindicated, please clearly indicate which parts of the examination were not completed due to the pregnancy.

Further, the examiner should indicate the earliest date that the examination may be safely completed.

For pre-discharge claims, the receiving RO will rate any claimed conditions that may be awarded based on the existing STRs, evidence of record, and examination findings, and defer consideration of any additional disabilities that could not be examined until conclusion of the pregnancy.

Note: For examination purposes, conclusion of the pregnancy is generally considered to be three months following delivery.

References: For more information on

• partial rating decisions and deferrals, see M21-1, Part V, Subpart ii, 3.B, and
• handling cases involving pregnant IDES participants, see M21-1, Part X, Subpart i, 6.K.3.

IV.i.2.E.4.e..Options for Processing Claims for Pregnant Claimants

There are three options for processing claims for pregnant claimants. The receiving RO should determine, on an individual basis, which of the following actions is appropriate based on the claimed contentions:

• defer the entire examination until conclusion of the pregnancy
• rate the entire claim based on existing STRs and evidence of record, or
• rate any claimed conditions that may be awarded based on existing STRs and evidence of record, and defer consideration of any additional disabilities that may not be examined until conclusion of the pregnancy.

Example: Service connection for an amputated finger can be awarded based on STRs, but the other claimed issues require specific tests that are prohibited due to pregnancy and must be deferred until the pregnancy concludes and a full examination can be conducted.

Exception: If the pregnant claimant is a participant in a pre-discharge program, refer to guidance in M21-1, Part IV, Subpart i, 2.E.4.d.

Reference: For more information on partial rating decisions and deferred issues, see M21-1, Part V, Subpart ii, 3.B.

This topic contains information about IMOs, including

• definition of an IMO
• who may initiate a request for an IMO
• submitting a request for an IMO, and
• processing requests for an IMO.

IV.i.2.E.5.a..Definition: IMO

An independent medical opinion (IMO), as discussed in 38 CFR 3.328, is

• a type of advisory medical opinion that may be obtained from one or more recognized medical experts who are not VA employees, and
• only warranted in connection with
  • claims of significant medical complexity and/or controversy, and/or
  • fulfillment of instructions contained in a remand order from the Board of Veterans Appeals (BVA).

Note: As discussed in M21-1, Part IV, Subpart i, 2.E.5.d, VA Central Office has the responsibility for deciding if the IMO is warranted.

IV.i.2.E.5.b..Who May Initiate a Request for an IMO

A request for an IMO under 38 CFR 3.328, in conjunction with a pending claim, may be initiated by the

• RO
• claimant
• claimant’s representative, or
• BVA.

IV.i.2.E.5.c..Submitting a Request for an IMO

Submit a request for an IMO

• in writing
• through a designated reviewer, and
• by stating, in detail,
  • the reasons why the opinion is necessary, and
  • the specific information or opinion required.

IV.i.2.E.5.d..Processing Requests for an IMO

The table below describes how to process a request for an IMO under 38 CFR 3.328 and identifies the responsible parties.