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Updated Aug 19, 2024

In This Section

  

1.  Handling Examination and Other Medical Reports That Are Insufficient for Rating Purposes

Introduction

  
This topic contains information about handling insufficient examination reports, including

Change Date

   June 6, 2024

IV.i.3.C.1.a. Insufficient Examination Reports

  
A Department of Veterans Affairs (VA) examination report submitted to the rating activity must be as complete as possible.
 
Any missing, required information on the report makes the examination report insufficient for rating purposes.  The following are examples of deficiencies that would render an examination report insufficient:
  • The examination report is unsigned.
  • The examination report does not address all disabilities for which an examination was requested.
  • The required question(s) on the disability benefits questionnaire (DBQ) is/are unanswered.
  • The required review of the claims folder was not accomplished, when applicable.
  • The report is missing information pertinent to the specific disability under review, such as the impact of musculoskeletal pain on the functional loss of an affected joint.
  • A medical opinion is not properly supported by a valid rationale and/or by the evidence of record.
  • A requested medical opinion was not furnished.
Note:  If the rating activity determines that a necessary examination was canceled without a valid reason, it must submit a new examination request to the examining facility and specify why the previous cancellation was inappropriate.
 
Example:  An examination requested in connection with a claim for a knee condition was not completed because “the claimed condition was not documented and diagnosed in the service treatment records on examiner review.”  If the rating activity determines that such examination is needed, the existing report or cancellation notice should be returned to the examining facility as insufficient for rating purposes.
 
Important:  There are instances where missing information in an examination report does not make the examination itself insufficient.  However, claims processors must seek and obtain the missing information via communication with and clarification by the examiner, as discussed in M21-1, Part IV, Subpart i, 3.C.1.c, before issuing a final decision on the underlying claim.
 
References:  For more information on

IV.i.3.C.1.b. Handling Insufficient Examination Reports That Were Erroneously Requested

  
In Barr v. Nicholson, 21 Vet.App. 303 (2007), the Court of Appeals for Veterans Claims held that if VA provides an examination when developing a claim for service connection (SC), even if not statutorily obligated to do so,
  • the examination must be adequate, or
  • the Veteran must be notified as to why one will not or cannot be provided.
Exception:  The above requirement for adequacy does not apply to examination reports initiated by the Veterans Health Administration (VHA) that do not
  • relate to the contentions under consideration in the pending claim, or
  • potentially impact existing benefit entitlement.

IV.i.3.C.1.c.   Clarification of Examination Reports

  
An examination report which needs clarification must be discussed with or returned to the examiner.  Such instances include, but are not limited to, the following:
  • The same disability is diagnosed differently by different examiners.
  • Conclusions or findings have been expressed in ambiguous or equivocal terms.
  • An examination report shows a change in the diagnosis or etiology for a disability previously recognized as service-connected.
  • An examination was conducted prior to the issuance of an amendment to the rating schedule, and additional information is needed to fully consider and properly evaluate the disability at issue in light of newly implemented criteria.
  • An examination report provides information that
    • contradicts or conflicts with other information within the same DBQ, or
    • requires additional context for rating purposes.
Note:  It is not uncommon for VA to receive evidence both in favor of and against a claim.  The mere presence of both positive and negative evidence does not necessarily require clarification or reconciliation by an examiner.  It is the responsibility of the rating activity to review and weigh all relevant evidence and to make determinations as to the probative value and persuasiveness of the evidence.  Clarification or reconciliation by an examiner is only necessary if the medical evidence of record is insufficient to support a conclusion.
 
Reference:  For more information on reviewing and weighing evidence, see M21-1, Part V, Subpart ii, 1.A.
 

IV.i.3.C.1.d.  Resolving Inconsistencies

  
If any inconsistency or conflicting findings of various medical examiners renders the evidence of record insufficient for rating purposes, resolve the inconsistency or conflict by requesting a medical opinion from a different examiner.
 
References:  For more information on requesting

IV.i.3.C.1.e.  Returning Examination Reports Requested Through CAPRI

  
Refer to the table below to determine how to return an insufficient or inadequate examination report to the appropriate provider when the examination was originally requested through the Compensation and Pension Record Interchange (CAPRI).
 
If the examination report …
Then …
is deemed insufficient within 45 days of its receipt
return the examination as insufficient through CAPRI.
is deemed insufficient more than 45 days following its receipt
prepare and submit a new examination request using CAPRI.
requires additional clarification
  • call or e-mail the examiner or point of contact at the examination facility to try to resolve the issue(s), or
  • input a medical opinion DBQ request for the necessary supplemental information in CAPRI if the issue(s) is/are complex or cannot be resolved by telephone or e-mail.
presents an opinion or diagnosis that conflicts with other evidence of record and the conflict cannot be resolved via review of the evidentiary record
input a new medical opinion DBQ request in CAPRI.
 
Important:
  • Avoid using language that can be construed as adversarial when returning reports for clarification.  Use the term insufficient for rating purposes rather than inadequate examination.
  • Clearly describe the issue(s) needing clarification or resolution.
Notes:
  • For VHA examinations, try to resolve any questions or need for clarification with regional office resident clinicians as often as possible in order to promote timely claims processing and efficient customer service.
  • When the best interest of the Veteran will be advanced by a personal conference or e-mail with the examiner, such measures should always be considered.
References:  For more information on

IV.i.3.C.1.f.  Returning Examination Reports Requested Through VBMS

  
Refer to the table below to determine how to return an insufficient or inadequate examination report to the appropriate provider when the examination was originally requested through the Veterans Benefits Management System (VBMS).
 
If the examination report …
Then …
is deemed insufficient
return the examination report by
  • accessing the EXAMS chevron in VBMS, and
  • selecting
    • Rework from the ACTIONS menu
    • each contention requiring additional attention
    • Insufficiency as the rework type, and
    • one or more bases for the report’s return from the AVAILABLE REWORK REASONS drop-down menu, and
  • entering a clear description of the issue(s) needing clarification or resolution in the DETAILED RATIONALE FOR REWORK field.
Important:
  • When a contract examination report is found to be insufficient, it should not be resolved by VHA examiners.
  • A rework request must be routed to the vendor that produced the insufficient examination report.  Rework requests must not be routed to a new vendor.
Note:  Insufficient examination reports include those which are missing
  • information on the requested DBQ that is needed for rating purposes, or
  • an entire requested DBQ.
Reference:  For more information on deficiencies that would render an examination report insufficient, see M21-1, Part IV, Subpart i, 3.C.1.a.
requires clarification
return the examination report by
  • accessing the EXAMS chevron in VBMS, and
  • selecting
    • Rework from the ACTIONS menu
    • each contention requiring additional attention
    • Clarification as the rework type, and
    • one or more bases for the report’s return from the AVAILABLE REWORK REASONS drop-down menu, and
  • entering a clear description of the issue(s) needing clarification or resolution in the DETAILED RATIONALE FOR REWORK field.
Important:  When submitting a clarification rework request for a contract examination, it is recommended to cite the exact language in the DBQ that requires clarification and specify the clarification(s) needed.
 
Reference:  For more information on when an examination report would need clarification, see M21-1, Part IV, Subpart i, 3.C.1.c.
presents an opinion or diagnosis that conflicts with other evidence of record and the conflict cannot be resolved via review of the evidentiary record
input a new medical opinion DBQ request in VBMS.
 
Important:
  • Avoid using language that can be construed as adversarial when returning reports for clarification.  Use the term insufficient for rating purposes rather than inadequate examination.
  • An examination scheduling request (ESR) must be in a Completed status before a rework request can be submitted in VBMS.
Note:  Contract examination providers have a maximum of 14 days to clarify any insufficiency to avoid an insufficiency call.  If the insufficiency or need for clarification is not rectified within the time allotted, the examination will be deemed insufficient.
 
References:  For more information on

IV.i.3.C.1.g.  Determining Whether a Rework Request or New ESR in VBMS Is Required

  
If necessary information was not requested in the original ESR, a new ESR must be submitted.  It is not appropriate to return an examination report as a rework request in VBMS to obtain new information that was not requested on the original ESR.
 
Refer to the table below for guidance on whether an examination rework request in VBMS is appropriate or a new ESR is required.
 
If a(n) …
Then a …
specific DBQ is deemed necessary but was not included in or triggered by the request on the original ESR
  • new ESR is required, and
  • rework request in VBMS is not appropriate.
Example:  The original ESR requested a Shoulder and Arm Conditions Disability Benefits Questionnaire for the claimed condition of arm pain, but the claims processor determines an Elbow and Forearm Conditions Disability Benefits Questionnaire is required instead.
medical opinion is deemed necessary but the specific opinion required was not requested on the original ESR
  • new ESR is required, and
  • rework request in VBMS is not appropriate.
Example:  A direct medical opinion was requested on the original ESR but, after review, the claims processor determines an aggravation medical opinion is needed.
examination is needed for a contention not included on the original ESR
  • new ESR is required, and
  • rework request in VBMS is not appropriate.
Examples:
  • The claims processor missed a contention that requires an examination when entering the original ESR.
  • After the original ESR was entered, a subsequent claim was received for an additional contention that requires an examination.
  • examination is needed for one or more contention(s) and/or specific DBQ(s) not included on the original ESR, but
  • examination for the additional contention(s) and/or completion of the additional DBQ(s) is triggered by the findings and examiner instructions on the originally requested DBQ(s)
  • new ESR is not required, and
  • rework request in VBMS is appropriate.
Example:  The original ESR requested a Diabetes Mellitus Disability Benefits Questionnaire for the claimed condition of diabetes.  At the time of examination, the Veteran reported symptoms of peripheral neuropathy, which would trigger the examiner to also complete the Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire.  However, the examiner failed to complete the Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire.
 
Analysis:  This is an insufficient examination as the examiner did not follow the instructions in the Diabetes Mellitus Disability Benefits Questionnaire, and a rework request should be submitted in VBMS as directed in M21-1, Part IV, Subpart i, 3.C.1.f.
 
Note:  If a rework request is submitted in VBMS to a contract vendor but a new ESR should have been submitted instead, the vendor will send the ESR rework request back as a request for clarification with instructions seeking the submission of a new ESR.
 
Reference:  For more information on requests for clarification on examinations requested through VBMS, see M21-1, Part IV, Subpart i, 2.A.10.c.

IV.i.3.C.1.h.  Handling Non-VA Hospital Reports That Are Insufficient for Rating Purposes

  

Request clarification of any hospital report that is insufficient for rating purposes and is received from a

  • State hospital
  • county hospital
  • municipal hospital
  • contract hospital, or
  • private hospital.

Important:  Authorize a VA examination if a satisfactory corrected report cannot be obtained within a reasonable period of time.

IV.i.3.C.1.i.  Requesting Clarification From Private Physicians

  
VA, pursuant to 38 U.S.C. 5103A(a), has a duty to return for clarification unclear or insufficient private examination reports or VA progress notes if it reasonably appears that a request for clarification could provide relevant information necessary to properly decide a claim that is otherwise not in the record and cannot be obtained in some other way.  VA’s duty is limited to those instances in which the missing information is relevant, factual, and objective – not a matter of opinion – and bears greatly on the probative value of the private medical examination report.
 
If a private medical examination report reasonably appears to contain information necessary to properly decide a claim, but is unclear or not suitable for rating purposes and the information contained in the report otherwise cannot be obtained, VA has a duty to either
  • ask the private examiner to clarify the report
  • request that the claimant obtain the necessary information to clarify the report
  • request a VA examination or medical opinion to remedy the lacking element(s), or
  • explain why clarification is not needed.
Any request for clarification to a private examiner or claimant should clearly indicate what further action needs to be taken to make the insufficient private examination report acceptable for VA consideration.  If no response is received from the private examiner or claimant, continue adjudicating the claim.
 
Note:  When an examination or opinion is requested to remedy a lacking element, the exam and/or opinion may be requested specific to only the lacking element.  A complete examination need not be requested to remedy a lacking element when the evidence of record will otherwise be sufficient once the examination or opinion is received.
 
References:  For more information on