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Updated Apr 19, 2022

In This Section
This section contains the topic “Determining Secondary SC, Including by Aggravation.”

1.  Determining Secondary SC, Including by Aggravation

Introduction
This topic contains information on determining secondary SC, including by aggravation, including

Change Date
August 6, 2019

V.ii.2.D.1.a. Provisions for SC Under 38 CFR 3.310(a) and (b)
Award service connection (SC) for the following under the provisions of 38 CFR 3.310(a) and 38 CFR 3.310(b).
  • disabilities that are proximately due to, or the result of, a service-connected (SC) condition, or
  • the increase in severity of a non-service-connected (NSC) disability that is attributable to aggravation by an SC disability, and not to the natural progression of the NSC disability.
Note:  Permanent worsening of an NSC disability by an SC disability is not required to establish SC on the basis of aggravation under 38 CFR 3.310(b).
References:  For more information on
  • SC for aggravation of NSC disabilities by SC disabilities, see
  • determinations about non-permanent worsening of an NSC disability in claims based on aggravation of an NSC disability by an SC disability, see Ward, Neal v. Wilkie (2019).

V.ii.2.D.1.b.  Establishing Causation for Secondary SC
SC on a secondary basis requires a showing of causation.  A showing of causation requires that the secondary disability be shown to be proximately due to, or the result of, an SC condition.
To establish causation, the primary disability need not be SC, or even diagnosed, at the time the secondary condition is incurred.
Example:  SC was granted for a back disability with radiculopathy effective in 2015.  Credible evidence showed that the Veteran had a 20-year history of back pain and progressively worsening radiculopathy dating back to roughly 2001.  The formal diagnosis of radiculopathy was not made until 2010.
The Veteran claimed SC for a shoulder disability in 2016, stating that his early symptoms of radiculopathy caused him to lose his balance, fall, and tear his rotator cuff in 2008.  He provided a medical opinion linking his rotator cuff tear to a fall, and the fall to sensory impairment and difficulty with proprioception due to early symptoms of radiculopathy.
Result:  As the medical opinion establishes causation for the rotator cuff tear in the shoulder due to the radiculopathy, the requirements for SC on a secondary basis are satisfied.
  • Although the radiculopathy was not formally diagnosed until after the fall, the credible evidence adequately establishes a history of back problems and gradual onset of radiculopathy dating back to 2001.  A finding of causation does not require that the primary disability be formally diagnosed at the time the secondary condition is incurred.
  • Additionally, although SC had not been established for the back condition and radiculopathy at the time of the fall and subsequent rotator cuff tear, a finding of causation does not require that the primary disability be SC at the time the secondary condition was incurred.
References:  For more information on the
  • establishment of causation prior to a finding of SC or formal diagnosis for the primary disability, see Frost v. Shulkin, Vet.App. 15-3102 (2017), and
  • effective date assigned when a claim for SC for a secondary disability precedes a claim for SC for the primary disability, see M21-1, Part V, Subpart ii, 4.A.3.f.

V.ii.2.D.1.c.  Medical Evidence Required to Show an NSC Disability Was Aggravated by an SC Disability
Do not concede an NSC disability is aggravated by an SC disability unless the baseline level of severity of the NSC disease or injury is established by
  • medical evidence created before the onset of aggravation, or
  • the earliest medical evidence created between the
    • onset of aggravation, and
    • receipt of medical evidence establishing the current level of severity of the NSC disability.

V.ii.2.D.1.d.  Developing for Medical Evidence of Baseline Disability in NSC Aggravation Claims
The responsibility for submitting evidence to establish a baseline level of disability for a claim for secondary SC based on aggravation of a NSC disability by an SC disability rests with the claimant.
Medical evidence adequate to establish the baseline level of disability must show its level of severity
  • before aggravation by the SC disability, or
  • as soon as possible after aggravation, but before the date of receipt of the evidence establishing the current level of severity of the NSC disability.
Important:  General development for medical records, such as that included on a standard EZ application form or in automated Section 5103 notice, is sufficient to satisfy the duty to assist the claimant.  Establishment of a baseline level of disability is a legal determination made by a Rating Veterans Service Representative (RVSR) or Decision Review Officer, while submission of medical evidence is the responsibility of the claimant.  However, the Department of Veterans Affairs will fulfill the duty to assist the claimant with requesting medical evidence.
Upon receipt of evidence satisfactory to establish a baseline level of disability, request a medical examination and opinion, to include a review of the claims folder by the examiner, to establish whether increased manifestations of the NSC disability are proximately due to an SC disability.
Notes:
  • Do not request an examination if the Veteran has failed to furnish medical evidence establishing a baseline level of the severity of the NSC disability.  If no baseline can be established, no aggravation can be demonstrated and the claim should be denied.
  • The examiner must have all available evidence for review when providing an opinion on the issue of aggravation.
  • Identify the evidence of particular relevance in the claims folder for the examiner.
  • The purpose of the disability benefits questionnaire opinion request asking an examiner to describe the baseline level of severity is for the examiner to provide, to the extent possible, a description of the baseline level of severity as shown in medical evidence.  Even if an examiner cannot provide this opinion, the RVSR must assess the evidence to determine a baseline based on all available medical evidence either before aggravation occurred or as soon as possible after aggravation but before the date of receipt of medical evidence establishing the current level of severity of the NSC disability.

V.ii.2.D.1.e.  Information That Must Be Included in the Examiner’s Report for Secondary SC Based on Aggravation
The examiner’s report must separately address all of the following medical issues in order to be considered adequate for rating a claim for secondary SC based on aggravation
  • the current level of severity of the NSC disease or injury
  • an opinion as to whether an SC disability proximately caused the NSC disability to increase in severity, and
  • an adequate analysis with medical considerations supporting the opinion.
Reference:  For more information on requesting examinations for claims based on secondary service connection and aggravation, see M21-1, Part IV, Subpart i, 1.B.1.d.

V.ii.2.D.1.f.  Determining the Extent to Which an NSC Disability Was Aggravated by an SC Disability
To determine the extent to which, if any, an NSC disability was aggravated by an SC disability
  • determine the baseline and current levels of severity of the NSC disability under 38 CFR Part 4, Schedule for Rating Disabilities, and
  • deduct the baseline level of severity of the NSC disability, as well as any increase of the disability due to natural progression, from the current level.
Note:  This policy applies even when the current level of severity of the NSC disability is 100 percent, including temporary 100-percent evaluations assigned under 38 CFR 4.29 and 38 CFR 4.30.

V.ii.2.D.1.g.  Aggravation With a Zero Percent Evaluation
Aggravation is established by any increase in severity, regardless of whether it would result in a schedular increased evaluation.
Whenever there is competent and credible evidence of an increase in severity of the disability from the baseline, but the current and baseline disability would be assigned the same level of evaluation under 38 CFR Part 4, Schedule for Rating Disabilities, grant SC and assign a noncompensable evaluation.
To justify SC, the degree of disability after aggravation does not have to be at least one level of evaluation higher than the baseline.
Reference:  For more information on increased impairment in earning capacity that does not rise to the level of meeting the criteria for the next-higher schedular rating, see