### Section B. Determining Service Connection

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  3            Determining Direct and Presumptive Service     2-B-2
               Connection                                     

  4            Determining Service Incurrence of an Injury    2-B-8

  5            Determining In-Service Aggravation of          2-B-11
               Pre-Service Disability                         

  6            Determining Secondary Service Connection,      2-B-13
               Including by Aggravation                       

  7            Determining Service Connection for Congenital, 2-B-15
               Developmental, or Hereditary Disorders         
  ------------ ---------------------------------------------- ------------

#### 3. Determining Direct and Presumptive Service Connection

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on determining direct |
| troduction | > and presumptive service connection, including         |
|            |                                                         |
|            | -   establishing service connection based on            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   chronicity, and                                     |
|            |                                                         |
|            | -   continuity of symptoms                              |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   direct service connection under 38 CFR 3.303(d)     |
|            |                                                         |
|            | -   the definition of ***presumption of soundness***    |
|            |                                                         |
|            | -   service requirements for presumption of soundness   |
|            |                                                         |
|            | -   the definition of ***active*** ***continuous        |
|            |     service***                                          |
|            |                                                         |
|            | -   service requirements for presumptive service        |
|            |     connection for                                      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   chronic and tropical diseases, and                  |
|            |                                                         |
|            | -   radiogenic diseases                                 |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   active duty for training, and                       |
|            |                                                         |
|            | -   inactive duty training.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > To establish service connection based on the          |
| #### a. Es | > chronicity of a disease shown in service, the         |
| tablishing | > evidence must include                                 |
|  Service C |                                                         |
| onnection  | -   manifestations sufficient to identify the disease   |
| Based on C |     entity, and                                         |
| hronicity  |                                                         |
|            | -   observation sufficient to distinguish chronicity    |
|            |     from merely isolated findings or a diagnosis that   |
|            |     includes the word "chronic."                        |
|            |                                                         |
|            | > When service connection is established for chronic    |
|            | > disease shown in service, or within the presumptive   |
|            | > period of [38 CFR                                     |
|            | > 3.307](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_307.DOC), |
|            | > consider all subsequent manifestations of the same    |
|            | > chronic disease as service connected, unless they are |
|            | > clearly shown to be due to intercurrent causes.       |
|            | >                                                       |
|            | > ***Reference***: For more information on chronicity,  |
|            | > see [38 CFR                                           |
|            | > 3.303(b)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

3\. Determining Direct and Presumptive Service Connection, Continued

+------------+---------------------------------------------------------+
| ##         | > Service connection may be established based on        |
| ### b. Est | > continuity of symptoms when a disease noted in        |
| ablishing  | > service, or within the presumptive period of [38 CFR  |
| Service Co | > 3.307](http://                                        |
| nnection B | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_307.DOC) |
| ased on Co |                                                         |
| ntinuity o | -   is not shown to be chronic, or                      |
| f Symptoms |                                                         |
|            | -   a diagnosis of chronicity is questionable.          |
|            |                                                         |
|            | > ***Note***: When evidence shows that symptoms that    |
|            | > began during service have continued after discharge,  |
|            | > a medical opinion is generally not required to        |
|            | > establish a link between the claimed disability and   |
|            | > the veteran's service.                                |
|            | >                                                       |
|            | > ***Reference***: For more information on continuity   |
|            | > of symptoms, see [38 CFR                              |
|            | > 3.303(b)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

+------------+---------------------------------------------------------+
| #####      | > Consider whether direct service connection may be     |
| c. Direct  | > established under [38 CFR                             |
| Service Co | > 3.303(d)](http://w                                    |
| nnection U | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC), |
| nder 38 CF | > even if service connection is claimed for a disease   |
| R 3.303(d) | > diagnosed *after* service has ended. Service          |
|            | > connection may be granted for a disease diagnosed     |
|            | > after discharge when all the evidence establishes     |
|            | > that the disease was incurred in service.             |
|            | >                                                       |
|            | > Do not attempt to establish presumptive service       |
|            | > connection for chronic or tropical diseases until the |
|            | > possibility of establishing direct service connection |
|            | > has been ruled out.                                   |
|            | >                                                       |
|            | > ***Important***: A veteran who lacks the requisite 90 |
|            | > days or six months of service may be awarded direct   |
|            | > service connection *only*.                            |
|            | >                                                       |
|            | > ***Note***: Award direct service connection *only*    |
|            | > for any disability not included in [38 CFR            |
|            | > 3.309](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > The ***presumption of soundness*** means that veteran |
|  d. Defini | > will be considered to have been in sound condition    |
| tion: Pres | > when examined, accepted, and enrolled for service     |
| umption of | > except                                                |
|  Soundness |                                                         |
|            | -   as to defects, infirmities, or disorders noted at   |
|            |     entrance into service, or                           |
|            |                                                         |
|            | -   where clear and unmistakable (obvious or manifest)  |
|            |     evidence demonstrates that an injury or disease     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   existed prior to service, and                       |
|            |                                                         |
|            | -   was not aggravated by such service.                 |
+------------+---------------------------------------------------------+

Continued on next page

3\. Determining Direct and Presumptive Service Connection, Continued

+------------+---------------------------------------------------------+
| ##### e.   | > VA must presume the veteran was in sound condition    |
|  Service R | > upon his/her entrance into active service if the      |
| equirement | > veteran meets the service requirements in the table   |
| s for Pres | > below.                                                |
| umption of |                                                         |
|  Soundness |                                                         |
+------------+---------------------------------------------------------+

+---------------------------------+------------------------------------+
| If the veteran served during    | Then the veteran must ...          |
| ...                             |                                    |
+---------------------------------+------------------------------------+
| peacetime before January 1,     | have had active continuous service |
| 1947                            | six months or more, per [38 CFR    |
|                                 | 3.305                              |
|                                 | (b)](http://www.warms.vba.va.gov/r |
|                                 | egs/38CFR/BOOKB/PART3/S3_305.DOC). |
+---------------------------------+------------------------------------+
| -   peacetime on or after       | meet *no* minimum active service   |
|     January 1, 1947, or         | requirements, per [38 CFR          |
|                                 | 3.304                              |
| -   wartime                     | (b)](http://www.warms.vba.va.gov/r |
|                                 | egs/38CFR/BOOKB/PART3/S3_304.DOC). |
+---------------------------------+------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Active continuous service*** excludes lengthy      |
| f. Definit | > periods of extended absence from duty, such as        |
| ion: Activ | > unauthorized absence or other extended non-pay        |
| e Continuo | > status.                                               |
| us Service | >                                                       |
|            | > ***Example***: The following facts and findings are   |
|            | > set forth in *General Counsel (GC) Opinion 4-80*:     |
|            | >                                                       |
|            | > *"The service member was absent from duty for 1,344   |
|            | > days before returning to military control. The        |
|            | > veteran received an honorable discharge nine days     |
|            | > later and developed a chronic disease within one year |
|            | > of discharge. Since the veteran was without active,   |
|            | > continuous service for all but nine days of the 3-3/4 |
|            | > years preceding separation, the continuous service    |
|            | > requirement of 38 CFR 3.307 is not met*."             |
+------------+---------------------------------------------------------+

Continued on next page

3\. Determining Direct and Presumptive Service Connection, Continued

+------------+---------------------------------------------------------+
| ####       | > The table below shows the service requirements the    |
| # g. Presu | > veteran must meet before VA may establish presumptive |
| mptive Ser | > service connection for chronic and tropical diseases. |
| vice Conne |                                                         |
| ction for  |                                                         |
| Chronic an |                                                         |
| d Tropical |                                                         |
|  Diseases  |                                                         |
+------------+---------------------------------------------------------+

+-----------------------+----------------------+----------------------+
| If the veteran served | And the disease is a | Then ...             |
| during ...            | ...                  |                      |
+-----------------------+----------------------+----------------------+
| peacetime before      | chronic disease      | there is no          |
| January 1, 1947       | listed in [38 CFR    | provision for        |
|                       | 3.309(a)](ht         | presumptive service  |
|                       | tp://www.warms.vba.v | connection under [38 |
|                       | a.gov/regs/38CFR/BOO | CFR                  |
|                       | KB/PART3/S3_309.DOC) | 3.308(a)](htt        |
|                       |                      | p://www.warms.vba.va |
|                       |                      | .gov/regs/38CFR/BOOK |
|                       |                      | B/PART3/S3_308.DOC). |
+-----------------------+----------------------+----------------------+
|                       | tropical disease     | the veteran must     |
|                       | listed in [38 CFR    | have had active      |
|                       | 3.309(b)](ht         | continuous service   |
|                       | tp://www.warms.vba.v | for six months or    |
|                       | a.gov/regs/38CFR/BOO | more under [38 CFR   |
|                       | KB/PART3/S3_309.DOC) | 3.308(b)](htt        |
|                       |                      | p://www.warms.vba.va |
|                       |                      | .gov/regs/38CFR/BOOK |
|                       |                      | B/PART3/S3_308.DOC). |
+-----------------------+----------------------+----------------------+
| -   peacetime on or   | -   chronic disease  | the veteran must     |
|     after January 1,  |     listed in [38    | have had active,     |
|     1947, or          |     CFR              | continuous service   |
|                       |     3.309(a)](htt    | of 90 days or more   |
| -   wartime           | p://www.warms.vba.va | under [38 CFR        |
|                       | .gov/regs/38CFR/BOOK | 3.307](htt           |
|                       | B/PART3/S3_309.DOC), | p://www.warms.vba.va |
|                       |     or               | .gov/regs/38CFR/BOOK |
|                       |                      | B/PART3/S3_307.DOC). |
|                       | -   tropical disease |                      |
|                       |     listed in [38    |                      |
|                       |     CFR              |                      |
|                       |     3.309(b)](ht     |                      |
|                       | tp://www.warms.vba.v |                      |
|                       | a.gov/regs/38CFR/BOO |                      |
|                       | KB/PART3/S3_309.DOC) |                      |
+-----------------------+----------------------+----------------------+

+-----------------------------------------------------------------------+
| > ***Note***: According to [38 CFR                                    |
| > 3.30                                                                |
| 3(d)](http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC), |
| > ROs should not routinely deny service connection for disabilities   |
| > first diagnosed after service merely because the                    |
|                                                                       |
| -   veteran is not entitled to presumptive service connection, or     |
|                                                                       |
| -   claimed disability is not subject to a presumption of service     |
|     connection.                                                       |
+-----------------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | In order to be eligible for presumptive service         |
| ## h. Pres | connection for radiogenic diseases under [38 CFR        |
| umptive Se | 3.309(d)(3)(i)](http://w                                |
| rvice Conn | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC), |
| ection for | a veteran must have participated in radiation-risk      |
|  Radiogeni | activities during a period of                           |
| c Diseases |                                                         |
|            | -   active duty                                         |
|            |                                                         |
|            | -   active duty for training, or                        |
|            |                                                         |
|            | -   inactive duty training.                             |
|            |                                                         |
|            | > ***Exception***: Service connection may *not* be      |
|            | > established under the provisions of [38 CFR           |
|            | > 3.311](http://                                        |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_311.DOC) |
|            | > or [38 CFR                                            |
|            | > 3.309(d)](http://                                     |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC) |
|            | > for a listed cancer if it developed as a result of    |
|            | > metastasis of a nonradiogenic cancer *not* listed in  |
|            | > either of these regulations.                          |
+------------+---------------------------------------------------------+

Continued on next page

3\. Determining Direct and Presumptive Service Connection, Continued

+------------+---------------------------------------------------------+
| ####       | > Active duty for training is *not* considered active   |
| # i. Activ | > service unless service connection is awarded for a    |
| e Duty for | > disability                                            |
|  Training  |                                                         |
|            | -   incurred in, or aggravated during, the period of    |
|            |     active duty for training, or                        |
|            |                                                         |
|            | -   resulting from one of the following events, if the  |
|            |     event occurred while an individual was proceeding   |
|            |     directly to, or returning directly from, a period   |
|            |     of active duty for training:                        |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   an acute myocardial infarction                      |
|            |                                                         |
|            | -   a cardiac arrest, or                                |
|            |                                                         |
|            | -   a cerebrovascular accident.                         |
|            |                                                         |
|            | > Use the table below to determine whether to apply the |
|            | > presumption of soundness when the only service is     |
|            | > active duty for training.                             |
+------------+---------------------------------------------------------+

  -------------------------- -----------------------------------------------------------------
  If ...                     Then ...

  service connection has     the presumption of soundness does not apply.
  *not* been established for 
  any disability             

  service connection has     the presumption of soundness applies for other disabilities
  been established for a     alleged to have occurred during that period of active duty for
  disability incurred during training under [*Paulson v.
  active duty for training   Brown*](http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmp), 7
                             Vet. App. 466 (1995).
  -------------------------- -----------------------------------------------------------------

Continued on next page

3\. Determining Direct and Presumptive Service Connection, Continued

+------------+---------------------------------------------------------+
| #          | > Inactive duty training is *not* considered active     |
| #### j. In | > service unless service connection is awarded for      |
| active Dut | > disability or death resulting from                    |
| y Training |                                                         |
|            | -   an injury directly incurred or aggravated during    |
|            |     the period of inactive duty training, or            |
|            |                                                         |
|            | -   an injury or one of the following events if the     |
|            |     injury or event occurred during inactive duty       |
|            |     training or while an individual was proceeding      |
|            |     directly to, or returning directly from, a period   |
|            |     of such training:                                   |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   an acute myocardial infarction                      |
|            |                                                         |
|            | -   a cardiac arrest, or                                |
|            |                                                         |
|            | -   a cerebrovascular accident.                         |
|            |                                                         |
|            | > ***Note***: If evidence establishes that an           |
|            | > individual suffers from a disabling condition as a    |
|            | > result of the administration of an anthrax vaccine    |
|            | > during inactive duty training, the individual may be  |
|            | > considered disabled by an "injury" incurred during    |
|            | > such training.                                        |
|            | >                                                       |
|            | > ***References***: For more information on             |
|            |                                                         |
|            | -   determining duty periods, see [38 CFR               |
|            |     3.6](http:/                                         |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_6.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   injuries that occurred                              |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   while an individual was proceeding directly to, or  |
|            |     returning directly from, a period of inactive duty  |
|            |     training, see [38 CFR                               |
|            |     3.6(e)](http:/                                      |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_6.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   as a result of administration of an anthrax vaccine |
|            |     during inactive duty training, see [VAOPGCPREC      |
|            |                                                         |
|            |   4-2002](http://www1.va.gov/OGC/docs/PREC_4-2002.doc). |
+------------+---------------------------------------------------------+

#### 4. Determining Service Incurrence of an Injury

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on determining        |
| troduction | > service incurrence of an injury, including            |
|            |                                                         |
|            | -   substantiating the circumstances of injuries        |
|            |                                                         |
|            | -   evaluating evidence of scars                        |
|            |                                                         |
|            | -   handling examination reports of scars               |
|            |                                                         |
|            | -   considering evidence for combat-related             |
|            |     disabilities, and                                   |
|            |                                                         |
|            | -   the definition of ***satisfactory evidence***.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > ROs must review the evidence of record, to include    |
| ## a. Subs | > personnel and service treatment records, to ensure    |
| tantiating | > the injury occurred during service and in the line of |
|  the Circu | > duty.                                                 |
| mstances o | >                                                       |
| f Injuries | > ***Rationale***: The results of injuries, including   |
|            | > gunshot wounds acquired before or after service, are  |
|            | > frequently encountered.                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b    | > When considering evidence of scars, keep in mind that |
| . Evaluati | > a claimant may have                                   |
| ng Evidenc |                                                         |
| e of Scars | -   been accepted into service with a notation of one   |
|            |     or more scars existing at the time of entrance      |
|            |                                                         |
|            | -   sustained a wound, with a resulting scar, during    |
|            |     service, or                                         |
|            |                                                         |
|            | -   received an injury following separation from        |
|            |     service that resulted in a scar that would be       |
|            |     present at subsequent physical examinations.        |
|            |                                                         |
|            | > Because the veteran could have incurred a scar before |
|            | > or after service, exercise caution in characterizing  |
|            | > a scar as the residual of a wound or injury incurred  |
|            | > in service.                                           |
|            | >                                                       |
|            | > If there is any doubt as to whether the scar is a     |
|            | > residual of a wound or injury incurred in service,    |
|            | > simply describe the scar, without ascribing it to a   |
|            | > "gunshot wound," "shrapnel wound," and so forth.      |
+------------+---------------------------------------------------------+

Continued on next page

4\. Determining Service Incurrence of an Injury, Continued

+------------+---------------------------------------------------------+
| #####      | > If the presence of a scar or scars is recorded in a   |
| c. Handlin | > physical examination report, review official records  |
| g Examinat | > to ensure that the scar or scars are in fact a        |
| ion Report | > residual of wounds in service.                        |
| s of Scars |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Accept satisfactory lay or other evidence that an     |
| ### d. Con | > injury or disease was incurred or aggravated in       |
| sidering E | > combat if the evidence is consistent with the         |
| vidence fo | > circumstances, conditions, or hardships of such       |
| r Combat-R | > service even though there is no official record of    |
| elated Dis | > such incurrence or aggravation.                       |
| abilities  | >                                                       |
|            | > In order for evidence submitted by the veteran to     |
|            | > support a factual presumption that the claimed        |
|            | > disease or injury was incurred or aggravated in       |
|            | > service, the evidence must                            |
|            |                                                         |
|            | -   be satisfactory when considered alone               |
|            |                                                         |
|            | -   be consistent with the circumstances, condition or  |
|            |     hardships of such service, and                      |
|            |                                                         |
|            | -   not be refuted by clear and convincing evidence to  |
|            |     the contrary.                                       |
|            |                                                         |
|            | > ***References***:                                     |
|            |                                                         |
|            | -   For a definition of satisfactory evidence, see      |
|            |     [M21-1MR, Part IV, Subpart ii,                      |
|            |     2.B.4.e](../pt04_sp02_ch02_secB.xml#IV.ii.2.B.4.e). |
|            |                                                         |
|            | -   For more information on satisfactory proof of       |
|            |     combat-related disability, see                      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   [38 CFR                                             |
|            |     3.304(d)](http://                                   |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC) |
|            |                                                         |
|            | -   [38 U.S.C.                                          |
|            |     1154(b)](http://straylight.law.cornell.edu/         |
|            | uscode/html/uscode38/usc_sec_38_00001154----000-.html), |
|            |     and                                                 |
|            |                                                         |
|            | -   [*Collette v.                                       |
|            |     Brown*](                                            |
|            | http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bmc), |
|            |     82F.3d.389 (Fed. Cir. 1996).                        |
|            |                                                         |
|            | > ***Note***: [38 CFR                                   |
|            | > 3.304(d)](http://                                     |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC) |
|            | > is derived from [38 U.S.C.                            |
|            | > 1154(b)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001154----000-.html), |
|            | > and lightens the evidentiary burden with respect to   |
|            | > disabilities alleged to be the result of combat       |
|            | > service.                                              |
+------------+---------------------------------------------------------+

Continued on next page

4\. Determining Service Incurrence of an Injury, Continued

+------------+---------------------------------------------------------+
| ##         | > ***Satisfactory evidence*** generally means evidence  |
| ### e. Def | > that is credible.                                     |
| inition: S | >                                                       |
| atisfactor | > It is proper to                                       |
| y Evidence |                                                         |
|            | -   consider internal consistency and plausibility in   |
|            |     determining whether evidence is credible, and       |
|            |                                                         |
|            | -   regard statements that contradict other evidence of |
|            |     record as unsatisfactory.                           |
+------------+---------------------------------------------------------+

#### 5. Determining In-Service Aggravation of Pre-Service Disability

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on determining        |
| troduction | > aggravation of pre-service disability, including      |
|            |                                                         |
|            | -   considering the presumption of soundness at entry   |
|            |     into service                                        |
|            |                                                         |
|            | -   the records needed to determine baseline level of   |
|            |     disability                                          |
|            |                                                         |
|            | -   determining whether a preexisting disability was    |
|            |     aggravated by service                               |
|            |                                                         |
|            | -   considering flare-ups of preexisting injury or      |
|            |     disease                                             |
|            |                                                         |
|            | -   considering the usual effects of medical or         |
|            |     surgical treatment, and                             |
|            |                                                         |
|            | -   additional considerations under *Splane v. West.*   |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Presume the veteran was in sound condition when       |
| ### a. Con | > examined, accepted, and enrolled for service, except  |
| sidering t | > when defects, infirmities, or disorders are noted at  |
| he Presump | > entrance into service.                                |
| tion of So | >                                                       |
| undness at | > When no preexisting condition is noted at entrance    |
|  Entry Int | > into service, the burden falls on the VA to rebut the |
| o Service  | > presumption of soundness by clear and unmistakable    |
|            | > evidence showing that the disease or injury           |
|            |                                                         |
|            | -   existed prior to service, and                       |
|            |                                                         |
|            | -   was not aggravated by service.                      |
|            |                                                         |
|            | > ***Reference***: For more information on the          |
|            | > presumption of soundness, see                         |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.304(b)](http://w                                  |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [M21-1MR, Part IV, Subpart ii,                      |
|            |     2.B.3.d](http://vbaw.vba.va.gov/bl/21/M21-1MR       |
|            | /pt04/sp02/ch02/pt04_sp02_ch02_secB.xml#IV.ii.2.B.3.d). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > The baseline for determining whether a preexisting    |
|  b. Record | > disability was aggravated by service is in *all* of a |
| s Needed t | > veteran\'s medical records for that condition, not    |
| o Determin | > just those covering the period of enlistment and      |
| e Baseline | > entry on active duty.                                 |
|  Level of  |                                                         |
| Disability |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

5\. Determining In-Service Aggravation of Pre-Service Disability,
Continued

+------------+---------------------------------------------------------+
| ##### c. D | > Under [38 CFR                                         |
| etermining | > 3.306](http://w                                       |
|  Whether a | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_306.DOC), |
|  Preexisti | > consider a preexisting injury or disease to have been |
| ng Disabil | > aggravated by active military service where there is  |
| ity Was Ag | > an increase in disability during active military      |
| gravated b | > service, *unless* there is a specific finding that    |
| y Service  | > the increase in disability is due to the natural      |
|            | > progress of the injury or disease.                    |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Always address the issue of aggravation when        |
|            |     service connection for a preexisting disability is  |
|            |     claimed.                                            |
|            |                                                         |
|            | -   If service connection is *not* found, indicate in   |
|            |     the *Reasons for Decision* part of the rating       |
|            |     decision the relevant findings from the medical     |
|            |     records before, during, and after service that      |
|            |     demonstrate that the condition which existed prior  |
|            |     to service had not increased in severity.           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Temporary or intermittent flare-ups of a preexisting  |
| ## d. Cons | > injury or disease are not sufficient to be considered |
| idering Fl | > aggravation in service unless the underlying          |
| are-ups of | > condition, as contrasted to symptoms, is worsened.    |
|  Preexisti | >                                                       |
| ng Injury  | > Do *not* concede aggravation merely because a         |
| or Disease | > veteran's condition was in remission at the time of   |
|            | > entry on active duty.                                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > As required under [38 CFR                             |
| #### e. Co | > 3.306(b)(1)](http://w                                 |
| nsidering  | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_306.DOC), |
| the Usual  | > unless a disease or injury that was incurred prior to |
| Effects of | > service is otherwise aggravated by service, do *not*  |
|  Medical o | > establish service connection for the usual effect of  |
| r Surgical | > medical or surgical treatment in service to correct   |
|  Treatment | > or improve the condition, such as postoperative scars |
|            | > and/or absent or poorly functioning parts or organs.  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > In *Splane v. West*, 216 F.-3d 1058 (Fed. Cir. 2000), |
|  f. Additi | > the U.S. Court of Appeals for the Federal Circuit     |
| onal Consi | > held that [38 U.S.C.                                  |
| derations  | > 11                                                    |
| Under Spla | 12(a)](http://www4.law.cornell.edu/uscode/38/1112.html) |
| ne v. West | > establishes a presumption of aggravation for chronic  |
|            | > diseases that existed prior to service but first      |
|            | > manifested to a degree of disability of 10 percent or |
|            | > more within the presumptive period after service.     |
|            | >                                                       |
|            | > Under [38 CFR                                         |
|            | > 3.307](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_307.DOC), |
|            | > this presumption may be rebutted by affirmative       |
|            | > evidence to the contrary or evidence to establish     |
|            | > that such disability is due to an intercurrent        |
|            | > disease or injury suffered after separation from      |
|            | > service.                                              |
+------------+---------------------------------------------------------+

####  

#### 6. Determining Secondary Service Connection, Including by Aggravation

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on determining        |
| troduction | > secondary service connection, including by            |
|            | > aggravation, including                                |
|            |                                                         |
|            | -   the provisions for service connection under 38 CFR  |
|            |     3.310(a) and (b)                                    |
|            |                                                         |
|            | -   the medical evidence requirements in claims based   |
|            |     on aggravation of a nonservice-connected (NSC)      |
|            |     disability by an SC disability                      |
|            |                                                         |
|            | -   requesting examinations and opinions in claims      |
|            |     based on aggravation of an NSC disability by an SC  |
|            |     disability                                          |
|            |                                                         |
|            | -   information that must be included in the examiner's |
|            |     report, and                                         |
|            |                                                         |
|            | -   determining the extent to which an NSC disability   |
|            |     was aggravated by an SC disability.                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Grant service connection for the following under the  |
| ### a. Pro | > provisions of [38 CFR 3.310(a) and                    |
| visions fo | > (b)](http://w                                         |
| r Service  | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_310.DOC): |
| Connection |                                                         |
|  Under 38  | -   disabilities that are proximately due to, or the    |
| CFR 3.310( |     result of, a SC condition, or                       |
| a) and (b) |                                                         |
|            | -   the increase in severity of a nonservice-connected  |
|            |     (NSC) disability that is attributable to            |
|            |     aggravation by an SC disability, and not to the     |
|            |     natural progress of the NSC disability.             |
|            |                                                         |
|            | > ***Reference***: For more information on service      |
|            | > connection for aggravation of NSC disabilities by SC  |
|            | > disabilities, see                                     |
|            |                                                         |
|            | -   [38 CFR                                             |
|            |     3.310(b)](http://w                                  |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_310.DOC), |
|            |     and                                                 |
|            |                                                         |
|            | -   [*Allen v.                                          |
|            |     Brown*](                                            |
|            | http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm#bma), |
|            |     7 Vet. App. 439 (1995).                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Do not concede an NSC disability was aggravated by an |
|  b. Medica | > SC disability unless the baseline level of severity   |
| l Evidence | > of the NSC disease or injury was established by       |
|  Required  |                                                         |
| to Show an | -   medical evidence created before the onset of        |
|  NSC Disab |     aggravation, or                                     |
| ility Was  |                                                         |
| Aggravated | -   the earliest medical evidence created between the   |
|  by an SC  |                                                         |
| Disability | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   onset of aggravation, and                           |
|            |                                                         |
|            | -   receipt of medical evidence establishing the        |
|            |     current level of severity of the NSC disability.    |
+------------+---------------------------------------------------------+

Continued on next page

6\. Determining Secondary Service Connection, Including by Aggravation,
Continued

+------------+---------------------------------------------------------+
| #####      | > In order to adjudicate a claim for secondary service  |
| c. Request | > connection based on aggravation of an otherwise NSC   |
| ing Examin | > disability, request a medical examination and         |
| ations and | > opinion, to include a review of the claims folder by  |
|  Opinions  | > the examiner, to establish whether increased          |
| in Claims  | > manifestations of an NSC disability are proximately   |
|            | > due to an SC disability.                              |
| ##### B    | >                                                       |
| ased on Ag | > ***Notes***:                                          |
| gravation  |                                                         |
| of an NSC  | -   Do not order the examination until                  |
| Disability |                                                         |
|  by an SC  | ```{=html}                                              |
| Disability | <!-- -->                                                |
|            | ```                                                     |
|            | -   all potentially relevant records have been          |
|            |     obtained, or                                        |
|            |                                                         |
|            | -   it is determined that no further evidence can be    |
|            |     obtained.                                           |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   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.                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d    | > The examiner's report must separately address all of  |
| . Informat | > the following medical issues in order to be           |
| ion That M | > considered adequate for rating a claim for secondary  |
| ust Be Inc | > service connection based on aggravation:              |
| luded in t |                                                         |
| he Examine | -   the current level of severity of the NSC disease or |
| r's Report |     injury                                              |
|            |                                                         |
|            | -   which manifestations, if any, of the NSC disease or |
|            |     injury are proximately due to an SC disability, as  |
|            |     opposed to the natural progress of the NSC disease  |
|            |     or injury, and                                      |
|            |                                                         |
|            | -   the medical considerations supporting an opinion    |
|            |     that these manifestations of the NSC disease or     |
|            |     injury are proximately due to an SC disability.     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > To determine the extent to which, if any, an NSC      |
| # e. Deter | > disability was aggravated by an SC disability         |
| mining the |                                                         |
|  Extent to | -   determine the baseline and current levels of        |
|  Which an  |     severity of the NSC disability under [38 CFR Part   |
| NSC Disabi |     4](http://www.warms.vba.va.gov/bookc.html),         |
| lity Was A |     *Schedule for Rating Disabilities*, and             |
| ggravated  |                                                         |
| by an SC D | -   deduct the baseline level of severity of the NSC    |
| isability  |     disability, as well as any increase of the          |
|            |     disability due to natural progression, from the     |
|            |     current level.                                      |
+------------+---------------------------------------------------------+

#### 7. Determining Service Connection for Congenital, Developmental, or Hereditary Disorders

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on determining        |
| troduction | > service connection for congenital, developmental, or  |
|            | > hereditary disorders, including                       |
|            |                                                         |
|            | -   the definition of congenital or developmental       |
|            |     defects                                             |
|            |                                                         |
|            | -   establishing service connection                     |
|            |                                                         |
|            | -   considering the                                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   development of symptoms of hereditary disease in    |
|            |     service, and                                        |
|            |                                                         |
|            | -   aggravation of a hereditary disease in service.     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > September 5, 2008                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Congenital*** or ***developmental defects*** are   |
| a. Definit | > normally static conditions that are incapable of      |
| ion: Conge | > improvement or deterioration.                         |
| nital or D | >                                                       |
| evelopment | > ***Note***: A disease, even one that is hereditary in |
| al Defects | > origin, such as retinitis pigmentosa, polycystic      |
|            | > kidney disease, sickle cell disease, or Huntington's  |
|            | > chorea, is usually capable of improvement or          |
|            | > deterioration.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b. E | > Establish service connection, if warranted, for       |
| stablishin |                                                         |
| g Service  | -   diseases of congenital, developmental, or familial, |
| Connection |     hereditary origin that                              |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   first manifest themselves during service, or        |
|            |                                                         |
|            | -   preexist service and progress at an abnormally high |
|            |     rate during service, and                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   a hereditary or familial disease that first became  |
|            |     manifest to a compensable degree within the         |
|            |     presumptive period following discharge from service |
|            |     pursuant to [38 CFR                                 |
|            |     3.309(a)](http://w                                  |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC), |
|            |     provided the rebuttable presumption provisions of   |
|            |     [38 CFR                                             |
|            |     3.307](http://                                      |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_307.DOC) |
|            |     are satisfied.                                      |
|            |                                                         |
|            | > ***Reference***: For more information on awarding     |
|            | > service connection for diseases of familial or        |
|            | > hereditary origin, see *Opinions of the General       |
|            | > Counsel, Precedent Opinion* *1-90* ([VAOPGCPREC       |
|            | > 1-90](http://www1.va.gov/ogc/docs/PREC_1-90.doc)),    |
|            | > March 16, 1990.                                       |
+------------+---------------------------------------------------------+

Continued on next page

7\. Determining Service Connection for Congenital, Developmental, or
Hereditary Disorders, Continued

+------------+---------------------------------------------------------+
| #          | > Consider diseases of hereditary origin to be incurred |
| #### c. Co | > in service if the pathological sign or symptoms were  |
| nsidering  | > manifested after entry on duty.                       |
| the Develo | >                                                       |
| pment of S | > Even if the individual is almost certain to           |
| ymptoms of | > eventually develop a disease, a genetic or other      |
|  Hereditar | > familial predisposition does not constitute having    |
| y Disease  | > the disease.                                          |
| in Service | >                                                       |
|            | > Only when actual symptomatology or signs of pathology |
|            | > are manifest may he/she be said to have developed the |
|            | > disease.                                              |
|            | >                                                       |
|            | > ***Note***: At what point the individual starts to    |
|            | > manifest signs or symptoms is a factual, medical      |
|            | > determination that *must* be based upon               |
|            |                                                         |
|            | -   the medical evidence of record in each case, and    |
|            |                                                         |
|            | -   sound medical judgment.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d    | > A hereditary disease that manifests some symptoms     |
| . Consider | > before entry on duty may be found to have been        |
| ing Aggrav | > aggravated during service if it progresses during     |
| ation of a | > service at a rate greater than normally expected      |
|  Hereditar | > according to accepted medical authority.              |
| y Disease  | >                                                       |
| in Service | > ***Note***: This is a factual, medical determination  |
|            | > that must be based upon the evidence of record and    |
|            | > sound medical judgment.                               |
+------------+---------------------------------------------------------+