In This Section

This section contains the following topics:

Introduction

This topic contains information on developing presumptive SC claims for undiagnosed illness and MUCMI, including

• processing Gulf War disability claims
• Section 5103 notice for undiagnosed illness and MUCMI claims
• establishing Persian Gulf Veteran status
• documenting Persian Gulf Veteran status
• requesting service department records in a Persian Gulf Veteran claim
• requesting medical evidence in a Persian Gulf Veteran claim
• considering whether to clarify or corroborate lay statements, and
• action to take when the Veteran alleges exposure to environmental hazards but claims no disability.

Change Date

January 29, 2024

VIII.ii.1.B.1.a.  Processing Gulf War Disability Claims

Multiple theories of service connection (SC) could apply to claims for disabilities incurred by Veterans who served during the Gulf War era.  The Veteran does not have to identify a claimed disability as due to Gulf War service.  The Department of Veterans Affairs (VA) must broadly consider applicable legal avenues that may be available based on the facts – even if not specifically pleaded by the claimant.  

Use the table below to determine how to process claims for disabilities due to exposures incurred during Gulf War era service.

Note:  More than one provision may apply depending on the nature of the claim; therefore, claims processors must follow the relevant procedures for each applicable reference noted above.

References:  For more information on

• unclaimed theories of SC, see M21-1, Part II, Subpart iii, 1.A.2.e
• action to take when the Veteran alleges exposure to environmental hazards but claims no disability, see M21-1, Part VIII, Subpart ii, 1.B.1.h, and
• Gulf War service, see the Gulf War Era Service Areas Job Aid.

VIII.ii.1.B.1.b.  Section 5103 Notice for Undiagnosed Illness and MUCMI Claims

It is unnecessary to issue Section 5103 notice when a Veteran files a new claim for SC for an undiagnosed illness or MUCMI on a form that provides, or otherwise indicates the claimant received, the notice, such as VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.

Note:  If a Veteran alleges joint and/or muscle pain without specifying which joint(s)/muscle(s) is affected

• make an attempt to contact the Veteran by telephone to specify the joint(s) and/or area(s) affected, and
• even if telephone contact is unsuccessful, proceed with all necessary claims development procedures, including requesting an examination, if needed to decide the claim.

References:  For more information on

• circumstances under which it is necessary to issue Section 5103 notice, see
  • M21-1, Part III, Subpart i, 2.B.1.b, and
  • M21-1, Part X, Subpart ii, 2.A.1.c
• requesting evidence from the claimant, see M21-1, Part III, Subpart i, 2.D, and
• clarifying contentions, see M21-1, Part III, Subpart i, 2.D.1.c.

VIII.ii.1.B.1.c.  Establishing Persian Gulf Veteran Status

When processing a claim for an undiagnosed illness or MUCMI, verify the Veteran’s service qualifies for Persian Gulf Veteran status.  Verify service in a qualifying location by reviewing

• the Veteran’s corporate record for the Persian Gulf Veteran – Sec. 1117 flash as detailed in the PACT Act Implementation SOP content titled, Establishing Persian Gulf Veteran Status
• available service records, and
• Individual Longitudinal Exposure Record (ILER).

Important:  If qualifying service cannot be verified using the available evidence noted above, obtain all pertinent service records, if not already of record, prior to referring the claim for a decision.

References:  For more information on

• Persian Gulf Veteran service locations, see
  • 38 U.S.C. 1117, and
  • M21-1, Part VIII, Subpart ii, 1.A.1.d
• requesting service department records in a Persian Gulf Veteran claim, see M21-1, Part VIII, Subpart ii, 1.B.1.e, and
• ILER, see the ILER Guidance.

VIII.ii.1.B.1.d.  Documenting Persian Gulf Veteran Status

Document a Veteran’s service in a Persian Gulf location by either

• uploading the Individual Deployment History from ILER, or
• annotating other service records that establish service in a qualifying location.

References:  For more information on

• ILER, see the ILER Guidance, and
• annotating a record in the electronic claims folder (eFolder), see the Veterans Benefits Management System (VBMS) Core User Guide.

VIII.ii.1.B.1.e.  Requesting Service Department Records in a Persian Gulf Veteran Claim

Before deciding the Veteran was not in a qualifying 38 U.S.C. 1117 location, ensure that all military records, to include service treatment records (STRs) and the entire official military personnel file (OMPF) are of record.

Follow procedures in M21-1, Part III, Subpart ii, 2.A.4 to obtain STRs and the OMPF, when needed.

Reference:  For more information on requesting service records, see M21-1, Part III, Subpart ii, 2.

VIII.ii.1.B.1.f.  Requesting Medical Evidence in a Persian Gulf Veteran Claim

Request reports of all private and Department of Veterans Affairs (VA) medical treatment that is indicated by the Veteran, both during and after service, including records such as

• statements or reports from
  • doctors
  • hospitals
  • laboratories
  • medical facilities, and
  • mental health clinics
• x-rays, and
• physical therapy records.

Note:  If the Veteran indicates that a Gulf War Registry Health examination has been conducted, request the examination report from the appropriate medical facility.

References:  For more information on

• requesting VA medical records, see M21-1, Part III, Subpart ii, 1.A.2, and
• private medical records, see M21-1, Part III, Subpart ii, 3.

VIII.ii.1.B.1.g.  Considering Whether to Clarify or Corroborate Lay Statements

Unless there is reason to doubt the credibility of a lay statement, do not develop to corroborate it.  

References:  For more information on

• competency and credibility of evidence, see M21-1, Part V, Subpart ii, 1.A.2, and
• evaluating lay evidence, see M21-1, Part V, Subpart ii, 1.B.2.

VIII.ii.1.B.1.h.  Action to Take When the Veteran Alleges Exposure to Environmental Hazards but Claims No Disability

A claim is not substantially complete if a Veteran alleges exposure to environmental hazards during service but does not claim SC for a specific disability.  In cases such as these, follow the procedures for handling an incomplete application at M21-1, Part II, Subpart iii, 1.C.2.b and c.

Important:  When a Veteran with qualifying 38 U.S.C. 1117 service files a claim for a sign or symptom of undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI), it must be processed as a substantially complete claim.

References:  For more information on

• the signs and symptoms of undiagnosed illness and MUCMIs, see
  • 38 CFR 3.317(b), and
  • M21-1, Part VIII, Subpart ii, 1.A.1.j, and
• what constitutes a substantially complete application, see
  • 38 CFR 3.159(a)(3), and
  • M21-1, Part I, Subpart i, 1.A.4.f.

Introduction

This topic contains information on examinations for undiagnosed illness and MUCMI, including

• when an examination is necessary in claims for undiagnosed illness and MUCMI
• when to request a Gulf War general medical examination
• exceptions to ordering a Gulf War general medical examination
• Gulf War general medical examination and finality
• impact of known clinical diagnoses on whether a Gulf War examination is necessary
• example: Gulf War examination necessary with known clinical diagnosis
• example:  Gulf War examination not necessary with known clinical diagnosis
• example:  Gulf War examination is necessary with possible clinical diagnosis
• Gulf War examination unnecessary when the claim is substantiated
• example 1:  examination is unnecessary because claim is substantiated
• example 2:  examination is unnecessary because claim is substantiated
• Gulf War examination unnecessary – no potential 38 U.S.C. 1117 entitlement
• example:  examination unnecessary – no potential 38 U.S.C. 1117 or other entitlement
• undiagnosed illness and MUCMI examination procedures
• examination requirement for MUCMIs, and
• reviewing examiner’s determination of disability pattern.

Change Date

May 23, 2024

VIII.ii.1.B.2.a.  When an Examination Is Necessary in Claims for Undiagnosed Illness and MUCMI

When an examination is needed to decide a claim for an undiagnosed illness or MUCMI, 38 CFR 3.159(c)(4) provides that an examination must be requested when there is

• competent lay or medical evidence of a disease (or signs or symptoms of a disease) listed in 38 CFR 3.317, and
• Persian Gulf Veteran service as defined in 38 U.S.C. 1117.

The table below describes the stages in the examination process for undiagnosed illness and MUCMI claims.

Important:  The threshold for requiring an examination is low.  It is lower than the standard to prove entitlement to SC, because the purpose is only to determine whether VA has a duty to assist in substantiating the claim.

References:  For more information on

• Persian Gulf Veteran service locations, see M21-1, Part VIII, Subpart ii, 1.A.1.d
• determining when an examination or opinion is necessary under the duty to assist, see M21-1, Part IV, Subpart i, 1.A
• sufficient medical evidence in lieu of an examination, see 
  • M21-1, Part IV, Subpart i, 1.A.1.c, and
  • M21-1, Part IV, Subpart i, 1.B.1.h.

VIII.ii.1.B.2.b. When to Request a Gulf War General Medical Examination

Once the threshold for an examination is met, claims processors must determine whether a Gulf War general medical examination DBQ is needed.  As outlined in M21-1, Part VIII, Subpart i, 1.B.2.c, certain claim scenarios are exceptions to obtaining a Gulf War general medical examination.

Regardless of whether a Gulf War general medical examination exception applies, an examination for undiagnosed illness or MUCMI must request both

• the examiner’s medical statement with supporting rationale, characterizing the claimant’s disability pattern, and
• a medical opinion that considers TERA, if the disability pattern is either
  • a diagnosable chronic multi-symptom illness with a partially explained etiology, or
  • a disease with a clear and specific etiology and diagnosis.

Important:  When ordering an examination in a claim for an undiagnosed illness or MUCMI, claims processors must follow the procedures outlined in M21-1, Part VIII, Subpart ii, 1.B.2.n, to include consideration of TERA, unless one of the following exceptions applies:

• If the examination is being requested in support of a pre-discharge claim, do not request a TERA medical opinion.  In these cases, follow the guidance outlined in
  • M21-1, Part X, Subpart i, 6.C.1.b, for Benefits Delivery at Discharge (BDD) claims, and
  • M21-1, Part X, Subpart i, 6.F.2.d and f, for Integrated Disability Evaluation System (IDES) claims.
• If a claim is substantiated (such as when a clearly diagnosed MUCMI is documented), do not request a TERA medical opinion.  In these cases, follow the guidance in M21-1, Part VIII, Subpart ii, 1.B.2.i to determine if an examination is needed to establish the severity of the disability.

VIII.ii.1.B.2.c.  Exceptions to Ordering a Gulf War General Medical Examination

The table below lists exceptions to ordering a Gulf War general medical examination and provides the applicable alternative procedures to follow.

VIII.ii.1.B.2.d.  Gulf War General Medical Examination and Finality

Do not request a Gulf War general medical examination if one has been completed in response to a pending claim or a decision that has not yet become final per 38 CFR 3.160(d).  In these cases, only order the specialty DBQ specific to the claimed condition.

Example 1:  A claim is received for SC for irritable bowel syndrome (IBS) based on Persian Gulf Veteran service and hearing loss based on military acoustic trauma.  The claim did not include evidence of a confirmed digestive condition; therefore, a Gulf War general medical examination is requested.  Since it requires a specialist, a hearing loss DBQ is also ordered.  SC for hearing loss is granted, but the claim for SC for IBS is denied.  A claim for SC for CFS based on Persian Gulf Veteran service is received five months after the denial of SC for IBS.  The claim includes a competent lay description of the Veteran’s symptoms, but not a confirmed diagnosis.  The regional office (RO) determines a Gulf War examination is needed to decide the CFS claim.

Analysis:  In this case, do not request a new Gulf War general medical examination since the decision on the previous claim is not yet final per 38 CFR 3.160(d).  Request only the CFS DBQ to substantiate the diagnosis and follow the procedures outlined in M21-1, Part VIII, Subpart ii, 1.B.2.n to include consideration of TERA. 

Example 2:  Same scenario as in Example 1, except the claim for SC for CFS is received 15 months after the denial of SC for IBS.  The RO determines a Gulf War examination is needed to decide the CFS claim, as there is no confirmed diagnosis.

Analysis:  In this case, order the Gulf War general medical examination for the CFS claim since the decision on the previous claim is final per 38 CFR 3.160(d), and follow the procedures outlined in M21-1, Part VIII, Subpart ii, 1.B.2.n to include consideration of TERA. 

VIII.ii.1.B.2.e.  Impact of Known Clinical Diagnoses on Whether a Gulf War Examination Is Necessary

When a Veteran has sought treatment for claimed chronic signs and symptoms listed in 38 CFR 3.317, it is likely that the medical provider has rendered a diagnosis for those symptoms.  However, the existence of a clinical diagnosis with specific etiology, which may weigh against 38 U.S.C. 1117 entitlement, does not preclude the ordering of an examination unless all symptoms claimed by the Veteran are clearly attributable to the diagnosis.

If there is a question as to whether the claimed signs and symptoms are attributable to an established clinical diagnosis, and if the criteria specified in M21-1, Part VIII, Subpart ii,1.B.2.a have been met, an examination is necessary. 

In such cases when an examination is warranted, the VA examiner’s workup must include an assessment of whether signs and symptoms represent a disease with a clear and specific etiology or whether they fall into a different disability pattern.

Reference:  For more information on ordering an examination in this claim scenario, see M21-1, Part VIII, Subpart ii,1.B.2.f–h.

VIII.ii.1.B.2.f.  Example:  Gulf War Examination Necessary With Known Clinical Diagnosis

Facts:  A Persian Gulf Veteran claims SC for “upper respiratory problems” and “sleep disturbance.”  A review of the medical evidence reveals various diagnoses over the last three years, to include asthma, sleep apnea, and seasonal allergies.  The Veteran indicates he has trouble sleeping, and experiences wheezing and shortness of breath when exerting himself.  He has received inhalers and other medications for his symptoms.  It is not clear if comprehensive clinical testing has been performed to support the diagnoses.

Result:  Although there is a potential that the Veteran’s claimed symptoms are attributable to a known diagnosis, a Gulf War examination is warranted to determine the cause of the Veteran’s symptoms.  The different diagnoses of record raise questions about what condition is specifically producing the symptoms, and the evidence is not clear as to whether the appropriate testing was conducted to support the diagnoses.

VIII.ii.1.B.2.g.  Example:  Gulf War Examination Not Necessary With Known Clinical Diagnosis

Facts:  A Persian Gulf Veteran claims SC for “sleep disturbance.”  STRs do not show any relevant treatment or diagnoses.  Private medical evidence reveals the Veteran awakes several times a night, snores loudly, and has episodes of breathing cessation during sleep.  A sleep study showing a diagnosis of obstructive sleep apnea was provided.  In the medical report, it was noted that the described symptoms were consistent with sleep apnea.

Result:  In this case, a Gulf War examination is not warranted since it is clear that the sole cause of “sleep disturbance” is sleep apnea.  Further, sleep apnea is not a recognized qualifying, chronic disability under the provisions of 38 CFR 3.317.  As no other presumptive provision applies, the claim must be processed as a non-presumptive disability claim based on TERA participation in accordance with the PACT Act Implementation SOP.

VIII.ii.1.B.2.h.  Example:   Gulf War Examination Is Necessary With Possible Clinical Diagnosis

Facts:  A Veteran has qualifying service as defined in 38 U.S.C. 1117.  He files a claim for SC for fatigue and multiple-joint pain.  STRs do not show any relevant treatment or diagnoses.  Current medical records show complaints of regular fatigue and soreness in the knees, elbows, and wrists for the last year without any noted injury or other specific cause listed.  Assessments over the last year from the Veteran’s internist have included rule out arthritis, rule out bursitis, and likely overuse syndrome. 

Result:  An examination must be ordered following the procedures outlined in M21-1, Part VIII, Subpart ii, 1.B.2.n.  Although the Veteran did not specifically state that he was filing a “Gulf War” claim, he has the required service for consideration of SC under 38 U.S.C. 1117.  There is also lay and medical evidence of chronic signs or symptoms that are listed as potential manifestations of undiagnosed illness or MUCMI in 38 CFR 3.317(b).  Even though there is the possibility that the symptoms could be attributable to a disability with a clear and specific etiology, an examination is necessary to determine the etiology of the Veteran’s symptoms. 

VIII.ii.1.B.2.i.  Gulf War Examination Unnecessary When the Claim Is Substantiated

Do not order a Gulf War examination when the evidence is adequate to substantiate the claim under 38 CFR 3.317 or on another basis (for example, 38 CFR 3.303, 3.306, 3.307, 3.309, 3.310) – even if the threshold for an examination as stated in M21-1, Part VIII, Subpart ii,1.B.2.a is met.

When there is a current diagnosis of a MUCMI from 38 CFR 3.317(a)(2)(i)(B)(1) to (3) (CFS, fibromyalgia, or any listed functional gastrointestinal disorder) and the evidence is fully sufficient to rate, including assignment of a disability evaluation, an examination is not necessary. 

Important:  Claims processors must request a specialist or specialty examination, whichever is appropriate based on the specific disability, if the evidence is not fully sufficient to rate, including assignment of a disability evaluation. 

References:  For more information on

• the definition of a MUCMI, see M21-1, Part VIII, Subpart ii, 1.A.1.g
• specialty and specialist examinations, see M21-1, Part IV, Subpart i, 2.A.1.f and g, and
• sufficient medical evidence in lieu of an examination, see
  •  M21-1, Part IV, Subpart i, 1.A.1.c, and
  • M21-1, Part IV, Subpart i, 1.B.1.h.

VIII.ii.1.B.2.j.  Example 1: Examination Is Unnecessary Because Claim Is Substantiated

Facts:  A Veteran has qualifying service as defined in 38 U.S.C. 1117.  The claims folder contains a competent medical assessment of CFS.  The evidence of record contains enough information to assign an evaluation for CFS.

Result:  Do not request an examination.  The claim is substantiated under 38 U.S.C. 1117.  The evidence shows a claimant with qualifying service has a qualifying MUCMI.  The evidence is sufficient to award SC and assign an evaluation.

VIII.ii.1.B.2.k.  Example 2: Examination Is Unnecessary Because Claim Is Substantiated

Facts:  A Veteran has qualifying service as defined in 38 U.S.C. 1117.  The evidence shows chronic bilateral knee pain developing during service without a specific injury.  The assessments in service were bilateral knee strain, rule out arthritis, and bilateral knee pain.  X-rays were negative.  The current medical evidence shows a complaint of bilateral knee pain and a diagnosis by a private doctor of bilateral knee strain.  The doctor has offered the opinion that the strain had its onset in service.  There is no superseding post-service injury.  The record contains enough information to assign an evaluation.

Result:  Do not request an examination.  Although there is a question as to whether this is truly a disability with a clear and specific etiology (a bilateral knee strain) or whether there is an undiagnosed illness manifested by multiple joint pain, the claim for SC is substantiated on a direct basis under 38 CFR 3.303.  The evidence is sufficient to award SC for bilateral knee strain and to assign an evaluation.

VIII.ii.1.B.2.l.  Gulf War Examination Unnecessary – No Potential 38 U.S.C. 1117 Entitlement

A Gulf War examination is not necessary in a limited variety of cases where there is no potential entitlement under 38 U.S.C. 1117. 

Examples:

• Do not order a Gulf War examination when a Persian Gulf Veteran claims neurological symptoms but there is a competent medical diagnosis of multiple sclerosis (MS) and competent medical evidence attributing the symptoms to MS.  MS is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained.  Also, the condition is typically diagnosed only after a neurological examination and hallmark tests such as magnetic resonance imaging (MRI) and cerebrospinal fluid testing.
• Do not order a Gulf War examination when a Persian Gulf Veteran claims fatigue, neurological, skin or other listed symptoms but there is a competent medical diagnosis of diabetes and competent medical evidence attributing the symptoms to diabetes.  Diabetes is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained.  Also, the condition is typically diagnosed only after clinical evaluation and hallmark testing such as blood glucose testing or hemoglobin A1C tests.
• Do not request a Gulf War examination when the claim is for a single joint injury – not an undiagnosed illness or medically explained multi-symptom illness – and the evidence shows
  • trauma to the joint in service or thereafter, and
  • a known clinical diagnosis such as traumatic arthritis or meniscal tear indicating an injury etiology.

Exception:  Obtain a Gulf War examination where the criteria in M21-1 Part VIII, Subpart ii,1.B.2.a are otherwise met when there is

• an equivocal or provisional diagnosis, such as “rule out MS” or “possible diabetes mellitus”
• a diagnosis of MS or diabetes is questionable due to lack of workup, or
• claimed symptoms are not clearly attributed to the clinical diagnosis. 

Note:  It is possible in cases involving MS, diabetes, or specific joint injuries that although a Gulf War examination based on qualifying Persian Gulf Veteran service is not indicated, the facts may support that an examination on another basis is necessary under 38 CFR 3.159(c)(4) to determine whether the condition had its onset in service or within another applicable presumptive period.  If the claim does not fall under other presumptive provisions, follow the non-presumptive claims processing guidance outlined in the PACT Act Implementation SOP content regarding TERA.

VIII.ii.1.B.2.m.  Example:  Examination Unnecessary – No Potential 38 U.S.C. 1117 or Other Entitlement

Facts:  A Veteran has qualifying service as defined in 38 U.S.C. 1117.  The Veteran claims right wrist pain from an injury in service in Iraq in 2008 related to mechanic duties.  Service records are negative for any wrist injury, complaints, or diagnosis.  Post-service records show complaints of wrist pain starting two years after service discharge in 2010.  Several of the earliest of those post service records note that the Veteran related a history of pain after a recent fall playing basketball.  The assessments include fall on an outstretched hand with possible wrist fracture, rule out traumatic arthritis and wrist strain.  X-rays were negative.

Result:  Do not request an examination.  The Veteran had qualifying service and demonstrated chronic joint pain – a listed sign or symptom of undiagnosed illness or MUCMI.  However, this was explicitly a claim for an injury and the facts show both a reported post-service injury and known clinical diagnoses indicative of injury etiology.  There is no potential entitlement under 38 U.S.C. 1117 or any other basis.  There is no potential for a MUCMI or undiagnosed illness based on the facts.

VIII.ii.1.B.2.n.  Undiagnosed Illness and MUCMI Examination Procedures

After obtaining all relevant records, to include required service records, complete the steps in the table below when requesting an examination for an undiagnosed illness or MUCMI claim.

Exceptions:

• For pre-discharge claims, follow the examination procedures outlined in
  • M21-1, Part X, Subpart i, 6.C.1.b, for BDD claims, and
  • M21-1, Part X, Subpart i, 6.F.2.d and f, for IDES claims.
• If a claim is substantiated, follow the guidance in M21-1, Part VIII, Subpart ii, 1.B.2.i.

VIII.ii.1.B.2.o.  Examination Requirement for MUCMIs

In general, when a Persian Gulf Veteran claims symptoms fitting the description of an MUCMI, as described in 38 CFR 3.317(a)(2)(ii), before proceeding with a decision, ensure that an examination with a medical opinion has been obtained. 

The opinion must classify the symptom as an MUCMI without conclusive pathology or etiology before SC under 38 U.S.C. 1117 can be awarded. 

Exception:  If the diagnosis shown in medical records involves one of the MUCMIs described in 38 CFR 3.317(a)(2)(i)(B) (CFS, fibromyalgia, or functional gastrointestinal disorders), then SC is appropriate and a VA examination may only be necessary to determine current level of severity as noted in M21-1, Part VIII, Subpart ii, 1.B.2.i.

VIII.ii.1.B.2.p.  Reviewing Examiner’s Determination of Disability Pattern

Before sending the claim for a decision, ensure the examination report contains the examiner’s determination of disability pattern with supporting rationale.

If the examination report does not contain the required determination of disability pattern by the examiner and supporting rationale,

• send the examination report and claims folder back to the examiner, and
• ask the examiner to characterize the specific claimed issue(s), and provide supporting rationale.

Exception:  If the diagnosis shown in the examination report involves one of the MUCMIs described in 38 CFR 3.317(a)(2)(i)(B) (CFS, fibromyalgia, or functional gastrointestinal disorders), then the examiner’s determination of a disability pattern is not required.

Important:  The Federal Circuit, in Joyner v. McDonald, 766 F.3d 1393 (Fed. Cir. 2014) held that a medical professional does not have to have eliminated all possible diagnoses before the Veteran can be compensated for a disability due to an undiagnosed illness.