### Section E. Service Connection for Disabilities Incurred as a Prisoner of War (POW) 

#### Overview

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

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

  18           General Information on POW Rating Activities   2-E-2

  19           Deciding Claims Involving Former POWs          2-E-4

  20           Presumption of Service Connection Under 38 CFR 2-E-8
               3.309(c)                                       

  21           Considering Service Connection for Residuals   2-E-12
               of Frostbite, Peptic Ulcer Disease, Peripheral 
               Neuropathy, and Posttraumatic Arthritis        

  22           Preparing a Rating Decision Involving a        2-E-16
               Presumption of Service Connection              

  23           History of Disabilities Subject to a           2-E-20
               Presumption of Service Connection Under 38 CFR 
               3.309(c)                                       
  ------------ ---------------------------------------------- ------------

#### 18. General Information on POW Rating Activities

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains general information on            |
| troduction | > prisoner-of-war (POW) rating activities, including    |
|            | > information on                                        |
|            |                                                         |
|            | -   designating members of the rating activity to       |
|            |     handle POW claims                                   |
|            |                                                         |
|            | -   the purpose of POW rating activities                |
|            |                                                         |
|            | -   the responsibilities of the Veterans Service Center |
|            |     Manager (VSCM)                                      |
|            |                                                         |
|            | -   the members of the POW rating activity, and         |
|            |                                                         |
|            | -   the responsibilities of the POW rating activities.  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Each regional office (RO) must designate at least one |
| ### a. Des | > member of its rating activity to be specifically      |
| ignating M | > responsible for handling claims filed by former       |
| embers of  | > prisoners of war (POW).                               |
| the Rating | >                                                       |
|  Activity  | > ROs with a rating activity composed of 25 or more     |
| to Handle  | > Rating Veterans Service Representatives (RVSRs) must  |
| POW Claims | > designate at least two of its members. ROs with an    |
|            | > insufficient number of RVSRs may make alternate       |
|            | > arrangements consistent with individual               |
|            | > circumstances.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > The purpose of creating special POW rating activities |
| #### b. Pu | > is to ensure POW claims are handled and decided by    |
| rpose of P | > those RVSRs who are                                   |
| OW Rating  |                                                         |
| Activities | -   knowledgeable on issues affecting former POWs, and  |
|            |                                                         |
|            | -   sensitive to the POW experience.                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > The Veterans Service Center Manager (VSCM) must       |
| . Responsi | > select all POW rating activity members.               |
| bilities o |                                                         |
| f the VSCM |                                                         |
+------------+---------------------------------------------------------+

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18\. General Information on POW Rating Activities, Continued

+------------+---------------------------------------------------------+
| ###        | > Each POW rating activity                              |
| ## d. Memb |                                                         |
| ers of the | -   must consist of two regular members and one         |
|  POW Ratin |     alternate, and                                      |
| g Activity |                                                         |
|            | -   should include a medical member, if available.      |
|            |                                                         |
|            | > ***Note***: Except in unusual circumstances, only     |
|            | > designated members or alternate members of the        |
|            | > special rating activity may sign rating decisions     |
|            | > involving former POWs.                                |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > The primary responsibility of the POW rating          |
| ### e. Res | > activities is to ensure that disability claims filed  |
| ponsibilit | > by former POWs are handled properly.                  |
| ies of the | >                                                       |
|  POW Ratin | > All members of the POW rating activity are expected   |
| g Activity | > to be thoroughly familiar with all laws, regulations, |
|            | > and directives concerning former POWs.                |
|            | >                                                       |
|            | > ***Note***: The rating activity must exercise the     |
|            | > utmost care and compassion in deciding former POW     |
|            | > claims.                                               |
+------------+---------------------------------------------------------+

#### 19. Deciding Claims Involving Former POWs

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on deciding claims    |
| troduction | > involving former POWs, including information on       |
|            |                                                         |
|            | -   considering all relevant laws, regulations, and     |
|            |     directives                                          |
|            |                                                         |
|            | -   the liberal application of directives per 38 CFR    |
|            |     3.304(e)                                            |
|            |                                                         |
|            | -   Department of Veterans Affairs (VA)                 |
|            |     responsibilities when adjudicating claims involving |
|            |     former POWs                                         |
|            |                                                         |
|            | -   considering                                         |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   the adequacy of medical evidence, and               |
|            |                                                         |
|            | -   statements from former POWs as evidence of          |
|            |     disability symptoms                                 |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   ensuring complete development                       |
|            |                                                         |
|            | -   finding a reasonable basis for establishing service |
|            |     connection, and                                     |
|            |                                                         |
|            | -   requesting an advisory opinion.                     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a    | > All claims filed by former POWs must be adjudicated   |
| . Consider | > with constant reference to all sections of the laws,  |
| ing All Re | > regulations, and directives concerning such claims.   |
| levant Law | >                                                       |
| s, Regulat | > ***References***: For more information on rating      |
| ions, and  | > claims filed by former POWs, see                      |
| Directives |                                                         |
|            | -   38 U.S.C. 1112                                      |
|            |                                                         |
|            | -   38 CFR 1.18                                         |
|            |                                                         |
|            | -   38 CFR 3.304(e)                                     |
|            |                                                         |
|            | -   38 CFR 3.307(a)(5)                                  |
|            |                                                         |
|            | -   38 CFR 3.309(c)                                     |
|            |                                                         |
|            | -   M21-1MR, Part IV, Subpart ii, 1.G                   |
|            |                                                         |
|            | -   M21-1MR, Part III, Subpart v.1.C (TBD) or M21-1,    |
|            |     Part IV, 11.06                                      |
|            |                                                         |
|            | -   M21-1MR, Part III, Subpart iv, 3.A, and             |
|            |                                                         |
|            | -   M21-1MR, Part IV, Subpart ii, 2.B.5.                |
+------------+---------------------------------------------------------+

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19\. Deciding Claims Involving Former POWs, Continued

+------------+---------------------------------------------------------+
| ##         | > The provisions of 38 CFR 3.304(e) give regulatory     |
| ### b. Lib | > authority to the Department of Veterans Affairs' (VA) |
| eral Appli | > consistent policy of applying liberally the           |
| cation of  | > directives involving awards of service connection in  |
| Directives | > claims filed by former POWs.                          |
|  Per 38 CF | >                                                       |
| R 3.304(e) | > This policy takes into account the following two      |
|            | > important factors:                                    |
|            |                                                         |
|            | -   the deficiencies or complete absence of many former |
|            |     POWs' service medical records (SMRs) showing        |
|            |     evidence of diseases or injuries suffered during or |
|            |     immediately prior to confinement, and               |
|            |                                                         |
|            | -   the extreme hardships and deprivation suffered by   |
|            |     former POWs during confinement from which physical  |
|            |     or mental impairment may not arise until many years |
|            |     later.                                              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c. V | > Assume all disabilities claimed by the veteran        |
| A Responsi | > resulted from his/her POW experiences unless the      |
| bilities W | > veteran specifically has stated otherwise.            |
| hen Adjudi | >                                                       |
| cating Cla | > Even though the veteran has not alleged a specific    |
| ims From F | > disability, symptoms presented by the veteran may be  |
| ormer POWs | > the result of                                         |
|            |                                                         |
|            | -   the POW experience, or                              |
|            |                                                         |
|            | -   diseases subject to presumptive service connection. |
|            |                                                         |
|            | > In addition, give careful consideration to the        |
|            | > veteran's POW experiences, particularly in reviewing  |
|            | > disabilities that are claimed or diagnosed for the    |
|            | > first time several years after service. Proper        |
|            | > adjudication of a claim demands a close scrutiny of   |
|            | > the duration and circumstances of confinement.        |
+------------+---------------------------------------------------------+

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19\. Deciding Claims Involving Former POWs, Continued

+------------+---------------------------------------------------------+
| ###        | > Recent medical evidence that is accurate and complete |
| ## d. Cons | > is paramount. Examine medical evidence thoroughly to  |
| idering th | > determine whether it is adequate to evaluate the      |
| e Adequacy | > disabilities under consideration and request a        |
|  of Medica | > physical examination to supplement the evidence when  |
| l Evidence | > necessary.                                            |
|            | >                                                       |
|            | > Ensure that a determination is not made on the basis  |
|            | > of medical evidence that is old or that is incomplete |
|            | > with regard to the disabilities under consideration.  |
|            | >                                                       |
|            | > ***Note***: Evidence that is more than one year old   |
|            | > must be supplemented by a request for a physical      |
|            | > examination                                           |
|            | >                                                       |
|            | > ***Reference***: For more information on protocol     |
|            | > examinations for former POW, see M21-1MR, Part III,   |
|            | > Subpart iv, 3.A.6.                                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Accept the statements of former POWs about the        |
| ## e. Cons | > disabilities or diseases incurred during or           |
| idering St | > immediately prior to confinement as proof of service  |
| atements f | > incurrence, as long as residual disability exists     |
| rom Former | > that can be attributed to the alleged service         |
|  POWs as E | > incident.                                             |
| vidence of | >                                                       |
|  Disabilit | > In addition, carefully consider the statements of     |
| y Symptoms | > former camp comrades, if offered in support.          |
|            | >                                                       |
|            | > ***Note***: If these statements are inconsistent with |
|            | > other evidence of record, develop for clarification   |
|            | > of any discrepancies with the veteran.                |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f.   | > Since certain disorders, such as the chronic          |
|  Ensuring  | > residuals of nutritional deficiency, may manifest     |
| Complete D | > themselves through a variety of symptoms,             |
| evelopment |                                                         |
|            | -   ensure that examinations are complete and           |
|            |     comprehensive, and                                  |
|            |                                                         |
|            | -   afford the veteran every opportunity to present a   |
|            |     complete and accurate picture of his POW-related    |
|            |     disabilities.                                       |
+------------+---------------------------------------------------------+

Continued on next page

19\. Deciding Claims Involving Former POWs, Continued

+------------+---------------------------------------------------------+
| #          | > A reasonable basis for establishing service           |
| #### g. Fi | > connection must be found upon review of the veteran's |
| nding a Re | > POW experiences. The evidence of record must          |
| asonable B | > establish a reasonable connection between the         |
| asis for E | > veteran's current disabilities and his/her            |
| stablishin | > experiences while a POW.                              |
| g Service  | >                                                       |
| Connection | > ***Notes***:                                          |
|            |                                                         |
|            | -   Intercurrent diseases or injuries, shown to be the  |
|            |     cause of the disabilities under consideration, may  |
|            |     preclude the establishment of service connection.   |
|            |                                                         |
|            | -   Evidence of treatment or observation of the claimed |
|            |     disability during service is not required.          |
|            |                                                         |
|            | -   A lack of a history showing continuity or           |
|            |     chronicity of the claimed disabilities since        |
|            |     separation from service, although an important      |
|            |     factor generally, is not by itself sufficient to    |
|            |     justify denying service connection.                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### h.   | > If it is unclear whether a condition is a residual of |
| Requesting | > the POW experience, submit the claim to Compensation  |
|  an Adviso | > and Pension (C&P) Service (211B) for an advisory      |
| ry Opinion | > opinion.                                              |
|            | >                                                       |
|            | > ***Reference***: For more information on C&P Service  |
|            | > guidance and advisory opinions, see M21-1MR, Part     |
|            | > III, Subpart vi, 1 (TBD) or M21-1, Part IV, Chapter   |
|            | > 7.                                                    |
+------------+---------------------------------------------------------+

#### 20. Presumption of Service Connection Under 38 CFR 3.309(c)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on presumptive        |
| troduction | > service connection under 38 CFR 3.309(c), including   |
|            | > information on                                        |
|            |                                                         |
|            | -   disabilities presumed to be SC under 38 CFR         |
|            |     3.309(c)                                            |
|            |                                                         |
|            | -   establishing presumptive service connection under   |
|            |     38 CFR 3.309(c)                                     |
|            |                                                         |
|            | -   minimum length of confinement as a POW              |
|            |                                                         |
|            | -   absence of evidence in service records or           |
|            |     presumptive disabilities                            |
|            |                                                         |
|            | -   noncompensable evaluations, and                     |
|            |                                                         |
|            | -   denying service connection.                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

20\. Presumption of Service Connection Under 38 CFR 3.309(c), Continued

+------------+---------------------------------------------------------+
| ##         | > The following disabilities are presumed to be SC      |
| ### a. Dis | > under 38 CFR 3.309(c):                                |
| abilities  |                                                         |
| Presumed t | -   atherosclerotic heart disease or hypertensive       |
| o be SC Un |     vascular disease (including hypertensive heart      |
| der 38 CFR |     disease) and their complications (including         |
|  3.3.09(c) |     myocardial infarction, congestive heart failure,    |
|            |     arrhythmia)                                         |
|            |                                                         |
|            | -   avitaminosis                                        |
|            |                                                         |
|            | -   beriberi, including beriberi heart disease          |
|            |                                                         |
|            | -   chronic dysentery                                   |
|            |                                                         |
|            | -   cirrhosis of the liver                              |
|            |                                                         |
|            | -   dysthymic disorder, or depressive neurosis          |
|            |                                                         |
|            | -   helminthiasis                                       |
|            |                                                         |
|            | -   irritable bowel syndrome                            |
|            |                                                         |
|            | -   malnutrition, including optic atrophy associated    |
|            |     with malnutrition                                   |
|            |                                                         |
|            | -   organic residuals of frostbite                      |
|            |                                                         |
|            | -   pellagra                                            |
|            |                                                         |
|            | -   peptic ulcer disease                                |
|            |                                                         |
|            | -   peripheral neuropathy, except where directly        |
|            |     related to infectious causes                        |
|            |                                                         |
|            | -   post-traumatic osteoarthritis                       |
|            |                                                         |
|            | -   psychosis                                           |
|            |                                                         |
|            | -   stroke and its complications, and                   |
|            |                                                         |
|            | -   any                                                 |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   of the anxiety states, and                          |
|            |                                                         |
|            | -   other nutritional deficiency.                       |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   "Beriberi heart disease" includes ischemic heart    |
|            |     disease in a former prisoner of war who had         |
|            |     experienced localized edema during captivity.       |
|            |                                                         |
|            | -   Irritable bowel syndrome normally includes the      |
|            |     symptoms noted under diagnostic code 7319,          |
|            |     irritable colon syndrome.                           |
|            |                                                         |
|            | > ***Reference***: For more information on diseases and |
|            | > disabilities subject to a presumption of service      |
|            | > connection, see 38 U.S.C. 1112.                       |
+------------+---------------------------------------------------------+

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20\. Presumption of Service Connection Under 38 CFR 3.309(c), Continued

+------------+---------------------------------------------------------+
| ####       | > The diseases specified in 38 CFR 3.309(c) *must* be   |
| # b. Estab | > presumed to be SC if they become 10 percent or more   |
| lishing Pr | > disabling at any time after service.                  |
| esumptive  | >                                                       |
| Service Co | > Any disability that develops secondary to one of      |
| nnection U | > those listed in 38 CFR 3.309(c) are also subject to   |
| nder 38 CF | > presumptive service connection.                       |
| R 3.309(c) | >                                                       |
|            | > ***Reference***: For more information on establishing |
|            | > presumptive service connection for disabilities that  |
|            | > are 10 percent or more disabling, see 38 CFR          |
|            | > 3.307(a)(5).                                          |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### c    | > Use the table below to determine whether internment   |
| . Minimum  | > as a POW for a minimum of 30 days is a prerequisite   |
| Length of  | > to establishing service connection on a presumptive   |
| Confinemen | > basis for the disabilities listed.                    |
| t as a POW |                                                         |
+------------+---------------------------------------------------------+

  ----------------------------------- -----------------------------------
  Confinement of 30 days or longer    No minimum confinement

  avitaminosis                        psychosis

  beriberi                            any of the anxiety states

  malnutrition                        dysthymic disorder (or depressive
                                      disorder)

  pellagra                            atherosclerotic heart disease and
                                      its complications

  any other nutritional deficiency    hypertensive vascular disease and
                                      its complications

  cirrhosis of the liver              organic residuals of frostbite

  helminthiasis                       post-traumatic arthritis

  irritable bowel syndrome            stroke and its complications

  peptic ulcer disease                
  ----------------------------------- -----------------------------------

Continued on next page

20\. Presumption of Service Connection Under 38 CFR 3.309(c), Continued

+------------+---------------------------------------------------------+
| #####      | > Since the disabilities listed in 38 CFR 3.309(c) are  |
|  d. Absenc | > presumed to be SC, a record of their treatment or     |
| e of Evide | > existence during service is not required.             |
| nce in Ser | >                                                       |
| vice Recor | > Do not deny service connection for one of these       |
| ds of Pres | > conditions predicated solely upon a deficiency in the |
| umptive Di | > veteran's service medical records.                    |
| sabilities | >                                                       |
|            | > ***Exception***: The absence of evidence in service   |
|            | > medical records showing treatment or observation of a |
|            | > disability may be used to deny direct service         |
|            | > connection.                                           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Consider the possibility that the disability at issue |
|  e. Noncom | > was more severely disabling in the past, if residuals |
| pensable E | > currently exist but not to a degree warranting the    |
| valuations | > assignment of a compensable evaluation.               |
|            | >                                                       |
|            | > If this is the case, the establishment of service     |
|            | > connection with a noncompensable evaluation may be in |
|            | > order.                                                |
|            | >                                                       |
|            | > ***Note***: The law and regulations do not require a  |
|            | > current finding of disability warranting the          |
|            | > assignment of a compensable evaluation at the time    |
|            | > the claim for service connection is filed.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f    | > Before denying presumptive service connection, at     |
| . Denying  | > least one of the following two conclusions must be    |
| Presumptiv | > reached based on a thorough review of the evidence of |
| e Service  | > record:                                               |
| Connection |                                                         |
|            | -   the disability in question cannot be associated     |
|            |     with the veteran's POW experiences (for example,    |
|            |     the claimed condition was the result of an          |
|            |     intercurrent disease or injury per 38 CFR           |
|            |     3.307(d)), or                                       |
|            |                                                         |
|            | -   the veteran was never diagnosed with the disability |
|            |     in question.                                        |
+------------+---------------------------------------------------------+

#### 21. Considering Service Connection for Residuals of Frostbite, Peptic Ulcer Disease, Peripheral Neuropathy, and Posttraumatic Arthritis

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on                    |
| troduction |                                                         |
|            | -   considering service connection for                  |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   residuals of frostbite                              |
|            |                                                         |
|            | -   peptic ulcer disease                                |
|            |                                                         |
|            | -   peripheral neuropathy, and                          |
|            |                                                         |
|            | -   posttraumatic arthritis                             |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   weighing evidence related to arthritis              |
|            |                                                         |
|            | -   distingushing between posttraumatic arthritis and   |
|            |     degenerative arthritis                              |
|            |                                                         |
|            | -   requesting opinions from the physician designated   |
|            |     to conduct POW examinations, and                    |
|            |                                                         |
|            | -   final responsibility for determining service        |
|            |     connection for posttraumatic osteoarthritis.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Internment as a POW in climatic conditions consistent |
| a. Conside | > with the occurrence of frostbite is a prerequisite to |
| ring Servi | > establishing service connection on a presumptive      |
| ce Connect | > basis for organic residuals of frostbite.             |
| ion for Re | >                                                       |
| siduals of | > ***Notes***:                                          |
|  Frostbite |                                                         |
|            | -   Frostbite injury may occur at different             |
|            |     temperatures and after different lengths of         |
|            |     exposure, depending on the individual.              |
|            |                                                         |
|            | -   If a veteran was a POW during seasons other than    |
|            |     winter, the possibility of exposure to climatic     |
|            |     conditions consistent with permanent frostbite      |
|            |     injury must not be eliminated without careful       |
|            |     consideration.                                      |
|            |                                                         |
|            | > ***Reference***: For more information on rating       |
|            | > residuals of cold injury, see M21-1MR, Part III,      |
|            | > Subpart iv, 4.E.21.                                   |
+------------+---------------------------------------------------------+

Continued on next page

21\. Considering Service Connection for Residuals of Frostbite, Peptic
Ulcer Disease, Peripheral Neuropathy, and Posttraumatic Arthritis,
Continued

+------------+---------------------------------------------------------+
| ####       | > A proper diagnosis of gastric or duodenal ulcer       |
| # b. Consi | > (peptic ulcer) is to be considered established for    |
| dering Ser | > rating purposes if it                                 |
| vice Conne |                                                         |
| ction for  | -   represents a medically sound interpretation of      |
| Peptic Ulc |     sufficient clinical findings warranting such        |
| er Disease |     diagnosis, and                                      |
|            |                                                         |
|            | -   provides an adequate basis for a differential       |
|            |     diagnosis from other conditions with like           |
|            |     symptomatology.                                     |
|            |                                                         |
|            | > ***Reference***: For more information on rating       |
|            | > peptic ulcer disease, see the Schedule for Rating     |
|            | > Disabilities, 38 CFR 4.110.                           |
+------------+---------------------------------------------------------+

Continued on next page

+------------+---------------------------------------------------------+
| #####      | > Peripheral neuropathy is subject to a presumption of  |
|  c. Consid | > service connection, *except* for peripheral           |
| ering Serv | > neuropathy that is related directly to infectious     |
| ice Connec | > causes.                                               |
| tion for P | >                                                       |
| eripheral  | > The law does not require a denial of presumptive      |
| Neuropathy | > service connection for peripheral neuropathy due to   |
|            | > infectious causes *unless*                            |
|            |                                                         |
|            | -   the evidence establishes that the infectious agent  |
|            |     was an intercurrent cause of peripheral neuropathy, |
|            |     or                                                  |
|            |                                                         |
|            | -   a review of the circumstances of internment         |
|            |     definitely rules out exposure to the infectious     |
|            |     agent during confinement.                           |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The possibility of nutritional deficiency during    |
|            |     internment and resultant lowering of the body's     |
|            |     resistance to infection must be considered.         |
|            |                                                         |
|            | -   Medical evidence must also establish a current      |
|            |     diagnosis of peripheral neuropathy.                 |
+------------+---------------------------------------------------------+

Continued on next page

21\. Considering Service Connection for Residuals of Frostbite, Peptic
Ulcer Disease, Peripheral Neuropathy, and Posttraumatic Arthritis,
Continued

+------------+---------------------------------------------------------+
| ##### d    | > Give due weight to both the veteran's                 |
| . Weighing |                                                         |
|  Evidence  | -   statements of trauma resulting in arthritis, and    |
| Related to |                                                         |
|  Arthritis | -   medical history so far as it is available.          |
|            |                                                         |
|            | > ***Note***: Do not hesitate to develop for            |
|            | > clarification of the traumatic incident if it cannot  |
|            | > be determined satisfactorily from the evidence at     |
|            | > hand that arthritis due to trauma is actually the     |
|            | > issue.                                                |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > If a veteran of advanced age with multiple joint      |
| ### e. Dis | > arthritis alleges trauma as the cause of arthritis at |
| tinguishin | > all or some of the disease sites, it is important to  |
| g Between  | > distinguish between posttraumatic arthritis and       |
| Posttrauma | > degenerative arthritis, the latter being a common     |
| tic Arthri | > development as a person ages.                         |
| tis and De | >                                                       |
| generative | > In such situations, obtain the most complete account  |
|  Arthritis | > possible of the traumatic incident. Information that  |
|            | > should be available for consideration includes        |
|            |                                                         |
|            | -   the nature of the trauma                            |
|            |                                                         |
|            | -   a statement of the type and severity of the         |
|            |     injuries received, and                              |
|            |                                                         |
|            | -   the frequency of traumatic injury, such as how      |
|            |     often a former POW might have been beaten by his    |
|            |     captors.                                            |
|            |                                                         |
|            | > ***Note***: A reasonable basis for an award of        |
|            | > service connection might include                      |
|            |                                                         |
|            | -   the appearance of arthritis at an earlier age than  |
|            |     would be expected normally, or                      |
|            |                                                         |
|            | -   confinement of arthritis to the location of the     |
|            |     alleged trauma, regardless of the age at which it   |
|            |     appears.                                            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > POW rating activities must consider the value of      |
| f. Request | > requesting an opinion from the physician designated   |
| ing Opinio | > by the medical facility to conduct POW examinations   |
| ns From th | > as to whether or not a diagnosis of arthritis         |
| e Physicia | > resulting from trauma would be consistent with the    |
| n Designat | > injuries received in the traumatic incident mentioned |
| ed to Cond | > by the former POW.                                    |
| uct POW Ex | >                                                       |
| aminations | > The physician is not required to give an opinion, but |
|            | > if one is made, it merits serious consideration and   |
|            | > cannot be ignored.                                    |
+------------+---------------------------------------------------------+

Continued on next page

21\. Considering Service Connection for Residuals of Frostbite, Peptic
Ulcer Disease, Peripheral Neuropathy, and Posttraumatic Arthritis,
Continued

+------------+---------------------------------------------------------+
| ##### g    | > The rating activity has the final responsibility for  |
| . Final Re | > determining whether a relationship exists between the |
| sponsibili | > development of arthritis and the veteran's            |
| ty for Det | > experiences as a POW.                                 |
| ermining S | >                                                       |
| ervice Con | > ***Note***: Any reasonable doubt arising after review |
| nection fo | > of the evidence *must* be resolved in favor of the    |
| r Posttrau | > veteran.                                              |
| matic Oste |                                                         |
| oarthritis |                                                         |
+------------+---------------------------------------------------------+

#### 22. Preparing a Rating Decision Involving a Presumption of Service Connection

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on preparing a rating |
| troduction | > decision involving a presumption of service           |
|            | > connection, including information on                  |
|            |                                                         |
|            | -   the information required in the rating decision     |
|            |                                                         |
|            | -   citing disabilities                                 |
|            |                                                         |
|            | -   providing the *Reasons for Decision*                |
|            |                                                         |
|            | -   considering results of the POW protocol examination |
|            |                                                         |
|            | -   coding specific disabilities                        |
|            |                                                         |
|            | -   reviewing POW rating decisions prior to             |
|            |     promulgation, and                                   |
|            |                                                         |
|            | -   distributing copies of the rating decision.         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Rating decisions must contain a summary of all        |
| ### a. Inf | > available information about the veteran's confinement |
| ormation R | > as a POW, such as the                                 |
| equired in |                                                         |
|  the Ratin | -   dates of confinement, and                           |
| g Decision |                                                         |
|            | -   name(s) of specific camp(s) or sector(s) in which   |
|            |     the veteran was confined.                           |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > Cite the disabilities alleged to have been incurred   |
|  Citing Di | > or aggravated during the veteran's period of          |
| sabilities | > confinement as a POW apart from other claimed         |
|            | > disabilities.                                         |
|            | >                                                       |
|            | > If the veteran claims all disabilities were incurred  |
|            | > or aggravated as a result of the POW experience,      |
|            | > state the issue as "*Disabilities Incurred or         |
|            | > Aggravated as a Result of Confinement as a Former     |
|            | > POW*," with the specific disabilities listed by       |
|            | > number.                                               |
+------------+---------------------------------------------------------+

Continued on next page

22\. Preparing a Rating Decision Involving a Presumption of Service
Connection, Continued

+------------+---------------------------------------------------------+
| ##### c    | > The *Reasons for Decision* section of the rating      |
| . Providin | > decision must                                         |
| g the Reas |                                                         |
| ons for th | -   contain a statement as to                           |
| e Decision |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   whether or not the claimant was examined under the  |
|            |     former POW protocol, and                            |
|            |                                                         |
|            | -   the availability and adequacy of SMRs               |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   indicate that available secondary evidence, such as |
|            |     statements of the veteran's camp comrades during    |
|            |     internment, has been considered thoroughly, and     |
|            |                                                         |
|            | -   explain fully the reasons for awarding or denying   |
|            |     service connection and the rationale for any        |
|            |     disability evaluations assigned.                    |
|            |                                                         |
|            | > The explanations must be phrased clearly and must     |
|            | > cite the appropriate authority upon which the         |
|            | > decision is based.                                    |
|            | >                                                       |
|            | > ***Reference***: For more information on examinations |
|            | > under the former POW protocol, see                    |
|            |                                                         |
|            | -   M21-1MR, Part III, Subpart iv, 3.A.6, and           |
|            |                                                         |
|            | -   M21-1MR, Part III, Subpart iv, 3.A.7.               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > If the results of the POW protocol examination were   |
| # d. Consi | > considered as evidence, dispose of the following      |
| dering the | > under the appropriate rating codes:                   |
|  Results o |                                                         |
| f the POW  | -   all disabilities identified by the medical          |
| Protocol E |     examiner, and                                       |
| xamination |                                                         |
|            | -   all complaints mentioned by the veteran that are    |
|            |     indicative of a specific, ratable disorder.         |
+------------+---------------------------------------------------------+

Continued on next page

22\. Preparing a Rating Decision Involving a Presumption of Service
Connection, Continued

+------------+---------------------------------------------------------+
| ##### e    | > Use the information below to code specific            |
| . Coding S | > conditions.                                           |
| pecific Di |                                                         |
| sabilities |                                                         |
+------------+---------------------------------------------------------+

+----------------------+-----------------------------------------------+
| If the disability is | Then ...                                      |
| ...                  |                                               |
+----------------------+-----------------------------------------------+
| peripheral           | ensure that the                               |
| neuropathy           |                                               |
|                      | -   last two digits of the diagnostic codes   |
|                      |     (DCs) used, DCs 8510 through 8730,        |
|                      |     correspond to the actual nerve involved,  |
|                      |     and                                       |
|                      |                                               |
|                      | -   second digit of the DC (5, 6 or 7)        |
|                      |     accurately reflects the symptomatology    |
|                      |     shown, such as paralysis, sensory         |
|                      |     deficits, or pain.                        |
+----------------------+-----------------------------------------------+
| peptic ulcer disease | > award service connection for those          |
|                      | > disorders independently ratable under DCs   |
|                      |                                               |
|                      | -   7304                                      |
|                      |                                               |
|                      | -   7305                                      |
|                      |                                               |
|                      | -   7306                                      |
|                      |                                               |
|                      | -   7308, or                                  |
|                      |                                               |
|                      | -   7348\.                                    |
|                      |                                               |
|                      | > ***Note***: The appropriate DC must be used |
|                      | > to identify the location of the ulcer or    |
|                      | > residual disability.                        |
|                      | >                                             |
|                      | > ***Reference***: For more information on    |
|                      | > rating peptic ulcer disease, see the        |
|                      | > Schedule for Rating Disabilities, 38 CFR    |
|                      | > 4.110.                                      |
+----------------------+-----------------------------------------------+

Continued on next page

22\. Preparing a Rating Decision Involving a Presumption of Service
Connection, Continued

+------------+---------------------------------------------------------+
| #          | > The VSCM must review all rating decisions involving   |
| #### f. Re | > former POWs prior to promulgation.                    |
| viewing PO | >                                                       |
| W Rating D | > The review must ensure compliance with all laws,      |
| ecisions P | > regulations, and directives affecting claims from     |
| rior to Pr | > former POWs.                                          |
| omulgation | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Authority for reviewing these ratings may not be    |
|            |     delegated to a designee lower than a coach, and     |
|            |                                                         |
|            | -   the reviewer must annotate the rating "*POW rating  |
|            |     reviewed.* **\[signature and title\]\[date\]**."    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### g.   | > A copy of the rating decision must be provided to the |
|  Distribut | > POW coordinator (if different than the                |
| ing Copies | > VSCM-designated reviewer) for his/her records.        |
|  of Rating | >                                                       |
|  Decisions | > ROs must maintain copies of all rating decisions      |
|            | > involving a former POW for a period of two years.     |
|            | > Thereafter, the decisions may be destroyed in         |
|            | > accordance with *RCS VB-l*, Part 1, Item 13-052.300.  |
+------------+---------------------------------------------------------+

#### 23. History of Disabilities Subject to a Presumption of Service Connection Under 38 CFR 3.309(c)

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on the history behind |
| troduction | > the presumption of service for disabilities listed in |
|            | > 38 CFR 3.309(c), including the                        |
|            |                                                         |
|            | -   history behind the length of confinement            |
|            |     requirement, and                                    |
|            |                                                         |
|            | -   history of *Public Laws (PLs)* and Federal Register |
|            |     citations authorizing a presumption of service      |
|            |     connection.                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Effective December 16, 2003, the Veterans Benefits    |
| #### a. Hi | > Act of 2003 eliminated the length of confinement      |
| story Behi | > requirement of 30 days or longer for the following    |
| nd the Len | > disabilities:                                         |
| gth of Con |                                                         |
| finement R | -   psychosis                                           |
| equirement |                                                         |
|            | -   any of the anxiety states                           |
|            |                                                         |
|            | -   dysthymic disorder (or depressive neurosis)         |
|            |                                                         |
|            | -   organic residuals of frostbite, and                 |
|            |                                                         |
|            | -   post-traumatic arthritis.                           |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   From October 1, 1981, through December 15, 2003, a  |
|            |     former POW must have been confined for 30 days or   |
|            |     longer to be eligible for a presumption of service  |
|            |     connection for any of the disabilities listed in 39 |
|            |     CFR 3.309(c).                                       |
|            |                                                         |
|            | -   Prior to October 1, 1981, six months of confinement |
|            |     were required.                                      |
|            |                                                         |
|            | -   There is no length of confinement requirement for   |
|            |     the following disabilities, which were added to 38  |
|            |     CFR 3.309(c) on October 7, 2004:                    |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   atherosclerotic heart disease                       |
|            |                                                         |
|            | -   hypertensive heart disease, and                     |
|            |                                                         |
|            | -   stroke.                                             |
+------------+---------------------------------------------------------+

Continued on next page

23\. History of Disabilities Subject to a Presumption of Service
Connection Under 38 CFR 3.309(c), Continued

+------------+---------------------------------------------------------+
| ####       | > The table below contains the history of the *Public   |
| # b. Histo | > Laws (PLs)* and *Federal Register* citations that     |
| ry of PLs  | > have authorized a presumption of service connection   |
| and Federa | > for the disabilities listed in 38 CFR 3.309(c).       |
| l Register |                                                         |
|  Citations |                                                         |
+------------+---------------------------------------------------------+

+--------------------+-------------------------------------------------+
| Public Law or      | Disease(s)                                      |
| Federal Register   |                                                 |
| Citation           |                                                 |
+--------------------+-------------------------------------------------+
| *PL 91-376*,       | -   Avitaminosis                                |
| effective August   |                                                 |
| 12, 1970           | -   beriberi, including beriberi heart disease  |
|                    |                                                 |
|                    | -   chronic dysentery                           |
|                    |                                                 |
|                    | -   helminthiasis                               |
|                    |                                                 |
|                    | -   malnutrition, including optic atrophy       |
|                    |     associated with malnutrition and any other  |
|                    |     nutritional deficiency                      |
|                    |                                                 |
|                    | -   pellagra, and                               |
|                    |                                                 |
|                    | -   psychosis.                                  |
|                    |                                                 |
|                    | ***Notes***:                                    |
|                    |                                                 |
|                    | -   No listed disease, other than psychosis,    |
|                    |     has ever been subject to any time limit for |
|                    |     compensable manifestations.                 |
|                    |                                                 |
|                    | -   Effective                                   |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   August 12, 1970, compensable manifestations |
|                    |     of psychosis were required within 2 years   |
|                    |     of separation from service, and             |
|                    |                                                 |
|                    | -   October 1, 1981, the time limit for         |
|                    |     compensable manifestations of psychosis was |
|                    |     removed.                                    |
|                    |                                                 |
|                    | ```{=html}                                      |
|                    | <!-- -->                                        |
|                    | ```                                             |
|                    | -   *PL 91-376* was amended effective August    |
|                    |     24, 1993, to include ischemic heart disease |
|                    |     in former POWs who experienced localized    |
|                    |     edema during captivity.                     |
+--------------------+-------------------------------------------------+
| *PL 97-37*,        | Any of the anxiety states.                      |
| effective October  |                                                 |
| 1, 1981            |                                                 |
+--------------------+-------------------------------------------------+
| *PL 98-223*,       | Dysthymic disorder or depressive neurosis.      |
| effective October  |                                                 |
| 1, 1983            |                                                 |
+--------------------+-------------------------------------------------+

Continued on next page

23\. History of Disabilities Subject to a Presumption of Service
Connection Under 38 CFR 3.309(c), Continued

  -----------------------------------------------------------------------
  b\. History of PLs and Federal Register Citations (continued)

  -----------------------------------------------------------------------

+--------------------+-------------------------------------------------+
| Public Law or      | Disease(s)                                      |
| Federal Register   |                                                 |
| Citation           |                                                 |
+--------------------+-------------------------------------------------+
| *PL 99-576*,       | -   Organic residuals of frostbite, if it is    |
| effective October  |     determined that the veteran was interned in |
| 1, 1986            |     climatic conditions consistent with the     |
|                    |     occurrence of frostbite, and                |
|                    |                                                 |
|                    | -   post-traumatic osteoarthritis.              |
+--------------------+-------------------------------------------------+
| *PL 100-322*,      | -   Irritable bowel syndrome                    |
| effective May 20,  |                                                 |
| 1988               | -   peptic ulcer disease, and                   |
|                    |                                                 |
|                    | -   peripheral neuropathy, except where         |
|                    |     directly related to infectious causes.      |
+--------------------+-------------------------------------------------+
| *PL 108-183*,      | Cirrhosis of the liver                          |
| effective July 18, |                                                 |
| 2003               |                                                 |
+--------------------+-------------------------------------------------+
| *69 FR 60083*,     | -   Atherosclerotic heart disease               |
| effective October  |                                                 |
| 7, 2004            | -   hypertensive vascular disease, and          |
|                    |                                                 |
|                    | -   stroke.                                     |
+--------------------+-------------------------------------------------+