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Updated Jan 23, 2025

In This Section

  
This section contains the following topics:
  
Topic
Topic Name
1
2
 

 

1.  Requesting Examinations and Medical Opinions in Claims for SC for PTSD

 
 

Introduction

  
This topic contains information about requesting examinations and medical opinions in claims for SC for PTSD, including 

Change Date

  
January 23, 2025

VIII.iv.1.C.1.a.  When to Proceed With an Examination in a PTSD Claim

  
In claims for service connection (SC) for posttraumatic stress disorder (PTSD), request an examination if 
  • there is
    • credible supporting evidence that the claimed stressor occurred, or
    • evidence of “markers” (in claims based on personal trauma when the personal traumatic event cannot otherwise be established by sufficient documentary evidence)
  • evidence (to include lay statements) indicates the Veteran currently suffers from symptoms consistent with a diagnosis of PTSD, and
  • medical evidence adequate for rating purposes is not already of record.
Notes: 
  • For PTSD claims based on a traumatic event(s) not related to personal trauma, do not request an examination until credible supporting evidence sufficient to establish the claimed stressor(s) is of record, as outlined in M21-1, Part VIII, Subpart iv, 1.A.3 and 4.
  • As outlined in M21-1, Part VIII, Subpart iv, 1.B, for PTSD claims based on military sexual trauma (MST) or other personal trauma, do not request an examination until either
    • credible supporting evidence sufficient to establish the claimed personal traumatic event(s) is of record, or
    • development for credible supporting evidence has been completed and the personal traumatic event(s) cannot be established without relying on marker evidence.
  • Request a claims folder review as part of the examination process any time the issue is SC for PTSD.
Important: 
  • When the evidence shows an initial diagnosis of PTSD during service, it is not necessary to meet all of the criteria described above for an examination to be warranted.  An Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire may be required to assess the current severity of the condition unless medical evidence adequate for rating purposes is already of record. 
  • When SC for PTSD has previously been established, any subsequent claim would warrant an examination request using the Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire to assess the current severity of PTSD, unless medical evidence adequate for rating purposes is already of record.  Do not request an initial PTSD disability benefits questionnaire (DBQ) when PTSD is already service-connected, regardless of any additional traumatic event(s) identified by the Veteran or shown by the evidence. 
References:  For more information on

VIII.iv.1.C.1.b.  Requesting Initial PTSD Examinations Other Than Personal Trauma

  
When evidence of exposure to stressors related to combat, experience as a former prisoner of war (FPOW), fear of hostile military or terrorist activity, or drone aircraft crew member duties is established by a Veteran’s individual decoration(s) or other military records, include a statement to that effect in the REMARKS section of the examination request.  This evidence allows VA (including the examiner) to accept the Veteran’s own description of the specific events without further corroboration.
 
Important:  Evidence of experience as an FPOW, exposure to combat, fear of hostile military or terrorist activity, or drone aircraft crew member duties, in itself, does not satisfy the diagnostic criteria for PTSD.
 
Note:  When requesting a PTSD examination, specify that, if possible, the Veteran’s treating mental health professional should not perform the examination.
 
References:  For more information on

VIII.iv.1.C.1.c.  Requesting Examinations for PTSD Claims Based on Personal Trauma

  
In compliance with 38 CFR 3.159(c)(4), an examination will always be needed for a PTSD claim based on personal trauma (including MST) when a thorough review shows
  • a current medical diagnosis of PTSD or the Veteran’s lay statements describing symptoms of PTSD or symptoms that mirror PTSD (even if another mental diagnosis is shown)
  • credible supporting evidence sufficient to establish that the personal traumatic event(s) occurred during a period of qualifying service or evidence of a marker(s) in the in-service or post-service records
  • indication that the PTSD symptoms may be associated with the claimed personal traumatic event(s) (established by applying a low threshold and liberal approach, which may be satisfied by virtue of a current diagnosis or symptoms and either sufficient documentary evidence of the personal traumatic event(s) or the presence of one or more markers), and
  • medical evidence adequate for rating purposes is not already of record.  
Important:  A medical opinion will not be required in all cases where an examination is warranted based on meeting the elements described above.
  • If there is sufficient documentary evidence, either in service records or alternative sources of evidence, to establish the occurrence of the in-service personal traumatic event(s), then typically only an examination request for the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire would be necessary, as discussed in M21-1, Part IV, Subpart i, 2.A.7.i.  When only an examination is needed, it is not necessary to route the claim to the rating activity for complex medical opinion review. 
  • Scenarios that do and do not require a medical opinion for a PTSD claim based on personal trauma are further discussed in M21-1, Part VIII, Subpart iv, 1.C.1.d and e.
References:  For more information on

VIII.iv.1.C.1.d.  Medical Opinions for PTSD Claims Based on Personal Trauma With Sufficient Documentation of the Event or Treatment in Service

  
In claims for PTSD based on personal trauma (including MST), a separate medical opinion DBQ should not routinely be ordered when either
  • sufficient documentary evidence to establish the personal traumatic event(s) is of record, or
  • in-service treatment of PTSD is shown.
In examination requests for such cases, do not include medical opinion language asking the examiner to interpret evidence of behavioral changes, or markers.  The personal trauma marker-based medical opinion language is necessary only in claims for PTSD where the in-service personal traumatic event(s) cannot be established without clinical interpretation of behavioral changes or marker evidence.
 
Example:  The Veteran submitted a substantially complete claim for PTSD related to MST.  Service treatment records show a medical examination during service documenting that the Veteran had recently experienced a sexual assault.  This is considered sufficient documentary evidence to establish the in-service personal traumatic event.  An examination should be requested using the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire.  The MST marker-based medical opinion language should not be included, and a separate medical opinion DBQ is not necessary.  Accordingly, referral to the rating activity for complex medical opinion review is not required. 
 
Note:  Claims for non-PTSD diagnoses must be adjudicated under the general SC provisions of 38 CFR 3.303, which require sufficient documentary evidence to establish the in-service event.  Therefore, when the evidence of record or an initial PTSD DBQ shows a diagnosis other than PTSD and there is sufficient evidence to establish the occurrence of the in-service event, sympathetically read the claim and consider whether a direct medical opinion is necessary.  A personal trauma marker-based medical opinion is not appropriate in such cases.  Follow applicable guidance in M21-1, Part IV, Subpart i, 1.B to determine whether an examination and/or medical opinion is warranted in a non-PTSD claim.
 
References:  For more information on

VIII.iv.1.C.1.e.  Medical Opinions for PTSD Claims Based on Personal Trauma When Clinical Interpretation of Behavioral Changes Is Necessary

  
In cases where the only evidence of the personal traumatic event(s) are behavioral changes that may be markers of the claimed traumatic event, an examination with a medical opinion is almost always needed.  A marker(s) itself does not establish the occurrence of the personal traumatic event(s), but the opinion of a qualified examiner can provide credible and probative evidence to concede that the traumatic event(s) occurred, as provided in 38 CFR 3.304(f)(5). 
 
A medical opinion is needed specifically to determine
  • whether the examiner’s clinical interpretation of behavioral changes can provide evidence to support the occurrence of the claimed in-service personal traumatic event(s) based on marker evidence and the Veteran’s lay statement, and
  • whether that claimed personal traumatic event(s) is related to current PTSD symptoms. 
Important: 
  • Medical opinions for clinical interpretation of behavioral changes are considered complex and should be prepared and entered by the rating activity, as discussed in M21-1, Part IV, Subpart i, 2.A.7.a and b.  The rating activity should ensure that the Veteran’s description of the personal traumatic event(s) and all marker evidence is clearly identified in the medical opinion request and annotated or bookmarked for the examiner’s review.
  • In order to ensure the medical opinion request language is adequate, use the existing examination request tools to generate the necessary PTSD MST or PTSD personal trauma (non-MST) medical opinion based on the nature of the claimed personal traumatic event(s).
Example:  The Veteran submitted a substantially complete claim for PTSD related to MST.  All necessary development is completed, and review of the Veteran’s service records and all other available evidence fails to show sufficient documentary evidence to establish the occurrence of the personal traumatic event(s).  Behavioral changes following the MST event are both reported by the Veteran and shown in service records and post-service evidence.  An examination should be requested using the Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire and a separate medical opinion DBQ with the MST marker-based medical opinion language.
 
References:  For more information on

2.  Handling PTSD Examination and Medical Opinion Reports

 
 

Introduction

  
This topic contains information about handling examination and medical opinion reports in claims for SC for PTSD, including

Change Date

   January 23, 2025

VIII.iv.1.C.2.a.  Handling Insufficient PTSD Examination  or Medical Opinion Reports

  
When a PTSD examination or medical opinion report is insufficient for rating purposes, follow procedures in M21-1, Part IV, Subpart i, 3.C.
  
Reasons that a PTSD examination or medical opinion report may be insufficient for VA purposes include
  • the assessment does not conform to current Diagnostic and Statistical Manual of Mental Disorders (DSM) standards
  • it does not identify or adequately describe the claimed stressor(s)
  • it does not sufficiently describe symptomatology, social and occupational functional impairment, or other facts required by the regulatory diagnostic criteria
  • the examiner did not discuss the significance of, and reconcile, any differential diagnoses or changes in diagnosis
  • the claims folder was not provided or the examiner did not review provided claims folder material
  • the examiner did not provide a requested comment or opinion
  • the examiner was not sufficiently qualified to conduct a psychological examination as specified in M21-1, Part IV, Subpart i, 3.A.1.i
  • the examiner did not justify a conclusion that an opinion could not be provided without resorting to mere speculation, or
  • a provided medical opinion is not properly supported by a valid rationale and/or by the evidence of record.
Notes: 
  • The diagnosis of PTSD must be made by a competent (properly qualified) medical professional and should be unequivocal.
  • The examining psychiatrist or psychologist should comment on whether the Veteran has experienced other traumatic events and, if so, indicate the relevance of these events to the current symptoms.
Important:  The Federal Circuit held in AZ and AY v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013), that the absence of a service record documenting an unreported sexual assault or a Veteran’s failure to report a claimed assault in service may not be treated as pertinent evidence that the assault did not occur.  Accordingly, if an examiner provides a negative medical opinion in response to a request for clinical interpretation of behavioral changes and the examiner uses the absence of a report or documentation of the event in the service records to support the negative opinion, then the medical opinion should be returned as insufficient.  A VA examiner cannot use the absence of in-service documentation as evidence that the personal traumatic event did not occur.
  
References:  For more information on

VIII.iv.1.C.2.b.  PTSD Examination Reports and DSM Criteria

  
Based on the May 2013 publication of DSM-5, 38 CFR 4.125 was updated to specifically refer to DSM-5 effective August 4, 2014.
  
Important:  Mental health examinations conducted after August 2014, to include PTSD examinations, must comply with DSM-5 standards.  
  
References:  For more information on