Report to the Ranking Democratic 

Member, Committee on Veterans’ 

Affairs, House of Representatives 

United States Government Accountability Office

GAO

October 2005 VETERANS’ 

DISABILITY 

BENEFITS 

VA Could Enhance Its 

Progress in Complying 

with Court Decision 

on Disability Criteria 

GAO-06-46 
Page i GAO-06-46 Veterans' Disability Benefits 

Letter 1

Appendix I: Briefing Section 

 4 

Appendix II: Comments from the Department of Veterans Affairs 31

Contents 

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Page 1 GAO-06-46 Veterans' Disability Benefits 

October 12, 2005 

The Honorable Lane Evans 

Ranking Democratic Member 

Committee on Veterans’ Affairs 

House of Representatives 

Dear Mr. Evans: 

To properly decide veterans’ disability claims, the regional offices of the 

Department of Veterans Affairs (VA) must obtain all medical evidence 

required by law and federal regulations. To do so, in fiscal year 2004, the 

regional offices asked VA’s medical centers to examine about 500,000 

claimants and provide examination reports containing the necessary 

medical information. Exams for joint and spine impairments are among 

the exams that regional offices most frequently request, and in 2002, VA 

found that 61 percent of the exam reports for such impairments did not 

provide sufficient information for regional offices to make decisions 

complying with disability criteria mandated by the U.S. Court of Appeals 

for Veterans Claims in DeLuca v. Brown, 8 Vet. App. 202 (1995). 

In DeLuca, the court held that when federal regulations define joint and 

spine impairment severity in terms of limits on range of motion, VA claims 

adjudicators must consider whether range of motion is further limited by 

factors such as pain and fatigue during “flare-ups” or following repetitive 

use of the impaired joint or spine. Whenever VA regional offices ask VA 

medical centers to conduct joint and spine disability exams, the medical 

centers should prepare exam reports containing the information mandated 

in DeLuca. You asked that we determine VA’s progress since 2002 in 

ensuring that its medical centers consistently prepare joint and spine exam 

reports containing the information required by DeLuca. 

In conducting our research, we obtained pertinent information from and 

interviewed officials of the Veterans Benefits Administration (VBA), which 

manages VA’s 57 regional offices; the Veterans Health Administration 

(VHA), which has 21 health care networks that oversee the operations of 

VA’s 157 medical centers; and the Compensation and Pension Examination 

Project (CPEP) Office, a national office jointly established by VHA and 

VBA in 2001 to improve the disability examination process. We assessed 

and determined that data from the CPEP Office’s quality reviews of 

medical center exam reports for the 10 most frequently requested exams 

United States Government Accountability Office

Washington, DC 20548 
Page 2 GAO-06-46 Veterans' Disability Benefits 

were reliable for the purposes of our work, and we attended a December 

2004 VA training conference aimed at improving the ability of medical 

center clinicians to conduct and report high-quality disability 

examinations. In addition, we interviewed officials of Disabled American 

Veterans, The American Legion, Paralyzed Veterans of America, and 

National Veterans Legal Services Program. We conducted our review from 

November 2004 through September 2005 in accordance with generally 

accepted government auditing standards. After discussing our initial 

findings on DeLuca with your office, your office asked that we furnish 

briefing slides containing the information discussed. This letter conveys 

the requested briefing slides. 

In summary, since 2002, VA has made progress in ensuring that its medical 

centers’ exam reports adequately address the DeLuca criteria, but more 

improvements are needed. As of May 2005, the percentage of joint and 

spine exam reports not meeting the DeLuca criteria had declined 

substantially from 61 percent to 22 percent. Much of this progress appears 

attributable to a performance measure for exam report quality that VHA 

established in fiscal year 2004. However, a 22 percent deficiency rate 

indicates that many joint and spine exam reports still did not comply with 

DeLuca, and moreover, the percentage of exam reports satisfying the 

DeLuca criteria varied widely—from a low of 57 percent to a high of 92 

percent among VHA’s 21 health care networks. Further, VA’s CPEP Office 

has found deficiencies in a substantial portion of the requests that VBA’s 

regional offices send to VHA’s medical centers, asking them to perform 

disability exams. For example, the CPEP Office found in early 2005 that 

nearly one-third of the regional office requests for spine exams contained 

errors such as not identifying the pertinent medical condition or not 

requesting the appropriate exam. However, VBA has not yet established a 

performance measure for the quality of the exam requests that regional 

offices submit to medical centers. 

To help ensure continued progress in satisfying the DeLuca criteria, we 

recommend that the Secretary of Veterans Affairs direct the Under 

Secretary for Health to develop a strategy for improving the consistency of 

VHA’s networks across the nation in meeting the DeLuca criteria. We also 

recommend that the Secretary direct the Under Secretary for Benefits to 

develop a performance measure for the quality of the exam requests that 

regional offices submit to medical centers. 

In written comments on a draft of this report, VA agreed with our 

conclusions and concurred with our recommendations. 
Page 3 GAO-06-46 Veterans' Disability Benefits 

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

issue date. At that time, we will send copies of this report to the 

Chairman, House Committee on Veterans’ Affairs; the Chairman and 

Ranking Democratic Member, Senate Committee on Veterans’ Affairs; and 

the Secretary of Veterans Affairs. We will also make copies available upon 

request. In addition, the report will be available at no charge on GAO’s 

Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

on (202) 512-7215 or bascettac@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Irene Chu, Assistant Director; Ira Spears, Analyst-In-Charge; 

Joseph Natalicchio; and Walter Vance also made key contributions to this 

report. 

Sincerely yours, 

Cynthia A. Bascetta 

Director, Education, Workforce, 

 and Income Security Issues 
Appendix I: Briefing Section 

Page 4 GAO-06-46 Veterans' Disability Benefits 

Appendix I: Briefing Section 

1

VA Could Enhance Its Progress in

Complying with Court Decision on Disability Criteria

Briefing for Staff of

Representative Lane Evans

Ranking Democratic Member

House Committee on Veterans’ Affairs
Appendix I: Briefing Section 

Page 5 GAO-06-46 Veterans' Disability Benefits 

2

• Objective

• Background

• Scope and Methodology

• Key Findings

• Conclusions

• Recommendations
Appendix I: Briefing Section 

Page 6 GAO-06-46 Veterans' Disability Benefits 

3

Objective

• In 2002, the Department of Veterans Affairs (VA) found that 

about 61 percent of the joint and spine disability 

examination reports prepared by VA medical centers did not 

provide the information required for VA’s joint and spine 

disability decisions to comply with DeLuca v. Brown, 8 Vet. 

App. 202 (1995). GAO was asked to determine the 

progress VA has made since 2002 in ensuring that joint and 

spine exam reports prepared by VA medical centers provide 

VA regional office claims adjudicators with the medical 

information that DeLuca requires for disability decisions.
Appendix I: Briefing Section 

Page 7 GAO-06-46 Veterans' Disability Benefits 

4

Background

• To determine disability severity, VA claims adjudicators 

must use medical criteria published in federal regulations. 

For certain musculoskeletal disabilities, such as joint and 

spine impairments, the regulations specify range-of-motion 

limitations that adjudicators must use to determine severity.

• However, the U.S. Court of Appeals for Veterans Claims 

held in DeLuca that, in addition to the range-of-motion 

limitations specified in VA’s regulations, adjudicators also 

must consider any additional functional limitations that may 

occur during “flare-ups” or following “repetitive use” because 

of painful motion, weakened movement, excess fatigability 

(or lack of endurance), or incoordination.
Appendix I: Briefing Section 

Page 8 GAO-06-46 Veterans' Disability Benefits 

5

Background, cont’d

• Ensuring that joint and spine exam reports meet the DeLuca

requirements is important. Otherwise, a claims adjudicator 

may not assign an appropriate severity rating for a veteran’s 

condition.

• Under VA’s quality review standards, a joint or spine exam 

report satisfies the DeLuca “repetitive use” criteria if the 

exam report indicates the extent, if any, and the number of 

degrees, if possible, to which range of motion is additionally 

limited by pain, fatigue, weakness, or lack of endurance 

following repetitive use. The additional functional loss may 

be stated in terms of either degrees of loss of motion or the 

additional percentage of loss of motion.
Appendix I: Briefing Section 

Page 9 GAO-06-46 Veterans' Disability Benefits 

6

Background, cont’d

• Under VA’s quality review standards, a joint or spine exam 

report satisfies the DeLuca “flare-up” criteria if the report 

either states the claimant does not experience any flare-ups 

or provides a description of the flare-ups.

• The Veterans Benefits Administration (VBA) operates 57 

regional offices whose claims adjudicators develop required 

evidence and decide disability claims.

• The Veterans Health Administration (VHA) operates VA’s 

157 medical centers. VHA has organized these medical 

centers into 21 geographic areas known as Veterans 

Integrated Service Networks (VISN). Each VISN oversees 

the operations of the medical centers within its assigned 

geographic area.
Appendix I: Briefing Section 

Page 10 GAO-06-46 Veterans' Disability Benefits 

7

Background, cont’d

• To obtain the medical evidence required to make disability 

decisions, VBA regional offices asked VHA’s medical 

centers to perform about 500,000 disability examinations in 

fiscal year 2004.1

• In 2001, the VA Claims Processing Task Force reported 

ongoing concerns about the quality of the VBA-VHA 

disability examination process.

• In 2001, VBA and VHA jointly chartered the Compensation 

and Pension Examination Project (CPEP) Office to improve 

the disability examination process.

1Because of workload issues at certain medical centers, 10 regional offices use the

services of a contractor to obtain disability examinations.
Appendix I: Briefing Section 

Page 11 GAO-06-46 Veterans' Disability Benefits 

8

Background, cont’d

• In 2002, after VA developed exam-specific quality indicators 

for the 10 most frequently requested disability exams, the 

CPEP Office did its initial (baseline) review of VHA medical 

centers’ disability examination reports, including joint and 

spine exam reports.2

• To assess quality, the CPEP Office uses 10 exam-specific 

indicators to assess joint exam report quality and 11 

indicators for spine exam report quality. In both cases, two 

of the quality indicators address DeLuca’s repetitive use and 

flare-up criteria.

2The 10 exams that regional offices most frequently request are audio (hearing), eye,

feet, general medical, initial post-traumatic stress disorder (PTSD), joints, mental 

disorders other than initial PTSD and eating disorders, subsequent review of PTSD,

skin (not scars), and spine. 
Appendix I: Briefing Section 

Page 12 GAO-06-46 Veterans' Disability Benefits 

9

Scope and Methodology

• We interviewed or obtained information from officials of:

• VBA central office

• VHA central office

• CPEP Office, Nashville, Tenn.

• VHA VISN offices in Duluth, Ga; and Linthicum, Md.

• VHA medical centers in Baltimore, Md; and Birmingham, 

Ala.

• VBA regional offices in Atlanta, Ga; and Baltimore, Md.
Appendix I: Briefing Section 

Page 13 GAO-06-46 Veterans' Disability Benefits 

10

Scope and Methodology, cont’d

• We also interviewed officials of:

• Disabled American Veterans

• The American Legion

• Paralyzed Veterans of America

• National Veterans Legal Services Program.

• We attended a VA training conference for improving the ability of VHA 

clinicians to conduct and report high-quality disability examinations.

• We assessed the CPEP Office’s quality review data for the 10 most 

frequently requested exams and found these data were reliable for the 

purposes of our work.

• We conducted our review from November 2004 through September 

2005 in accordance with generally accepted government auditing 

standards.
Appendix I: Briefing Section 

Page 14 GAO-06-46 Veterans' Disability Benefits 

11

Key Findings

• VA has made progress since 2002 in ensuring that medical 

centers prepare joint and spine exam reports satisfying the 

DeLuca criteria. Much of this progress appears to be due to 

an overall performance measure that VHA established for 

exam reports for the 10 most frequently requested exams.

• However, many joint and spine exam reports still do not 

comply with the DeLuca criteria, and VHA’s 21 VISNs vary 

widely in the percentage of exams that satisfy the DeLuca

criteria.

• The CPEP Office has found that a substantial portion of 

regional office requests for exams are inaccurate or 

incomplete.
Appendix I: Briefing Section 

Page 15 GAO-06-46 Veterans' Disability Benefits 

12

VA Has Made Progress in Satisfying 

DeLuca Criteria

• In its 2002 baseline review of disability exam report quality, 

CPEP found that about 61 percent of VHA’s joint and spine 

exam reports did not contain the information required by 

DeLuca.

• However, by May 2005, the percentage of joint and spine 

exam reports not containing the information required by 

DeLuca had declined substantially from 61 percent to 22 

percent. (See table 1.)
Appendix I: Briefing Section 

Page 16 GAO-06-46 Veterans' Disability Benefits 

13

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

Table 1: VHA’s Performance in Satisfying the DeLuca Criteria

March-May 2005 27 27 17 17 22.0

June-August 2004 49 52 32 26 40.0

60 64 64 58 61.5

July-September 2001 

(2002 baseline study)

Spine 

exams

Joint 

exams

Spine 

exams

Joint 

exams

Overall percentage 

of joint and spine 

reports not 

satisfying the 

DeLuca criteria

Flare-up

criteria

Repetitive use 

criteria

Percentage of joint and spine exam reports

that did not satisfy the DeLuca criteria

Time frame of exam 

reports reviewed by 

CPEP

Source: CPEP.
Appendix I: Briefing Section 

Page 17 GAO-06-46 Veterans' Disability Benefits 

14

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• To improve disability exam report quality, including satisfying the 

DeLuca criteria, VA has done the following .

• VHA required medical centers in 2002 to develop quality 

improvement plans for exams and exam reports for the 10 most 

requested exams, including joint and spine exams.

• CPEP distributed musculoskeletal exam training videos and other 

resource materials in 2002 and 2004.

• CPEP sponsored national training conferences in 2003 and 2004 

that included training on the DeLuca criteria.

• Via satellite broadcasts, VHA conducted training on DeLuca for its 

medical centers in 2004, and VBA, for its regional offices in 2005.
Appendix I: Briefing Section 

Page 18 GAO-06-46 Veterans' Disability Benefits 

15

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• VA also did the following to improve joint and spine disability 

exam report quality.

• To focus attention on the DeLuca criteria, CPEP has 

published monthly DeLuca performance statistics for 

each of VHA’s 21 VISNs since October 2003.

• VBA instructed regional offices in 2004 to send back to 

the medical centers any musculoskeletal exam reports 

not adequately addressing the DeLuca criteria.
Appendix I: Briefing Section 

Page 19 GAO-06-46 Veterans' Disability Benefits 

16

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• In addition, CPEP and VA’s Office of Information developed and 

distributed software during 2004 and 2005 that provides medical centers 

with automated templates for clinicians to use in conducting and

reporting disability exams, including joint and spine exams.

• The templates provide a guided and structured approach for 

conducting exams and entering the results at a computer 

workstation. Using the templates is optional.

• CPEP believes the templates can help ensure that clinicians do not 

omit necessary exam information, such as for the DeLuca criteria.

• CPEP is conducting a study in which medical center clinicians use a 

selected template routinely in order to gather data on the costs and 

benefits of using the templates.
Appendix I: Briefing Section 

Page 20 GAO-06-46 Veterans' Disability Benefits 

17

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• Finally, in fiscal year 2004, VHA established a performance 

measure for the quality of exam reports for its VISN 

directors. This performance measure for exam report 

quality takes into account a VISN’s combined performance 

on all of the 10 most frequently requested exams. For fiscal 

years 2004 and 2005, VHA defined fully successful 

performance as when 64 percent of the exam reports 

prepared by a VISN’s medical centers satisfy at least 90 

percent of the CPEP quality indicators.

• The two VISNs we visited told us they had included this 

performance measure in the performance plans of the 

directors for the medical centers in their VISN.
Appendix I: Briefing Section 

Page 21 GAO-06-46 Veterans' Disability Benefits 

18

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• Since VHA instituted the exam report quality performance 

measure, the combined quality of exam reports for the 10 

most frequently requested exams has improved broadly, 

indicating that the performance measure may have been a 

catalyst for improvement. (See table 2.)

• Still, it should be noted that because the performance 

measure applies to a VISN’s combined performance on all 

10 types of exam reports, poor performance on one exam 

type could be masked in the overall average performance 

statistic if performance on another exam type is sufficiently 

high to allow the VISN to still meet the fully successful 

definition of performance.
Appendix I: Briefing Section 

Page 22 GAO-06-46 Veterans' Disability Benefits 

19

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

Table 2: Number of VISNs Meeting the Fully Successful Definition

for the Combined Exam Report Quality of the 10 Most Frequently

Requested Exams

3 21 rd quarter-fiscal year 2005

4 15 th quarter-fiscal year 2004

1 0 st quarter-fiscal year 2004

Number of VISNs that achieved 

Time period the fully successful standard

Source: CPEP.
Appendix I: Briefing Section 

Page 23 GAO-06-46 Veterans' Disability Benefits 

20

VA Has Made Progress in Satisfying 

DeLuca Criteria, cont’d

• If a joint or spine exam report fails on both of the DeLuca

criteria (flare-ups and repetitive use), the exam report 

automatically fails the quality review—that is, it does not 

pass at least 90 percent of the exam-specific quality 

indicators.

• As a result, the exam report quality performance measure 

provides an incentive for VISNs and their medical centers to 

focus on satisfying the DeLuca criteria because, to optimize 

the chance to be rated as fully successful on combined 

performance for all 10 of the most frequently requested 

exams, VISNs and their medical centers must pay attention 

to the quality of all 10 exam types, including the joint and 

spine exams that are subject to the DeLuca criteria.
Appendix I: Briefing Section 

Page 24 GAO-06-46 Veterans' Disability Benefits 

21

More Improvement Needed in 

Satisfying DeLuca Criteria

• As of May 2005, 22 percent of joint and spine exams still did 

not satisfy the DeLuca criteria. Also, as of May 2005, VA 

found a large degree of inconsistency in the extent that the 

21 VISNs satisfied the DeLuca criteria. Among the 21 

VISNs, the percentage of joint and spine exam reports 

satisfying the DeLuca criteria ranged from a low of 57 

percent to a high of 92 percent. (See table 3.)

• It should be noted that within a given VISN, an individual 

medical center’s performance in meeting the DeLuca criteria 

may be lower than the combined average DeLuca

performance for all the medical centers in that VISN. 

Therefore, in the VISN that had 57 percent of its joint and 

spine exams meeting DeLuca criteria, an individual medical 

center within that VISN may have had less than 57 percent 

meeting the DeLuca criteria.
Appendix I: Briefing Section 

Page 25 GAO-06-46 Veterans' Disability Benefits 

22

More Improvement Needed in 

Satisfying DeLuca Criteria, cont’d

Table 3: Percentage of Each VISN’s Joint and Spine Exams Satisfying

the DeLuca Criteria as of May 2005

10 76

9 67

8 86

7 83

6 92

5 86

4 80

3 78

2 84

1 57

Percentage meeting

DeLuca criteria

VISN

number

Note: Table 3 continues on the 

next slide.

Source: CPEP.
Appendix I: Briefing Section 

Page 26 GAO-06-46 Veterans' Disability Benefits 

23

More Improvement Needed in 

Satisfying DeLuca Criteria, cont’d

Table 3: Percentage of Each VISN’s Joint and Spine Exams Satisfying the

DeLuca Criteria as of May 2005, cont’d

23 71

22 64

21 73

20 69

19 81

18 87

17 85

16 92

15 79

12 75

11 72

Percentage meeting

DeLuca criteria

VISN

number

Note: VA had 22 networks until January 

2002, when it merged Networks 13 and 

14 to form a new network, Network 23.

Source: CPEP.
Appendix I: Briefing Section 

Page 27 GAO-06-46 Veterans' Disability Benefits 

24

Many Regional Office Exam 

Requests Are Deficient

• Since early 2004, CPEP has done monthly reviews of exam 

requests that regional offices submit to medical centers, and 

CPEP has found that many requests are inaccurate or 

incomplete. For example, of the spine exams requested 

during the second quarter of fiscal year 2005, 32 percent of 

the exam requests had at least one error such as:

• not identifying the pertinent condition,

• not requesting the appropriate exam,

• not providing clear or useful information in the remarks section of the request,

• not identifying the specific joint or part to be examined, 

or

• not explaining instances in which the exam request contained no telephone number for the veteran who was 

to be examined.
Appendix I: Briefing Section 

Page 28 GAO-06-46 Veterans' Disability Benefits 

25

Many Regional Office Exam 

Requests Are Deficient, cont’d

• VBA told GAO it may consider establishing a performance 

measure for the quality of exam requests after CPEP 

modifies its software so that when CPEP finds an error in an 

exam request, the regional office would be able to obtain via 

VA’s intranet the identity of the case involved, study the 

error, and learn from the mistake.

• In July 2005, CPEP said it would soon complete software 

modifications that will make case-specific exam request 

error information available to regional offices via VA’s 

intranet.
Appendix I: Briefing Section 

Page 29 GAO-06-46 Veterans' Disability Benefits 

26

Conclusions

• Although the percentage of joint and spine exam reports that do not 

satisfy the DeLuca criteria declined substantially from 61 percent in 2002 

to 22 percent at the end of May 2005, more improvement is needed to 

further reduce the more than one-fifth of these exam reports not meeting 

the DeLuca criteria. Also, more improvement is needed to reduce wide 

variations in performance on the DeLuca criteria; among the 21 VISNs, 

the percentage of deficient exam reports ranged from a low of 8 percent 

to a high of 43 percent.

• The ability of medical centers to provide exam reports containing the 

information that regional offices need in order to make accurate disability 

decisions is negatively affected when regional offices submit inaccurate 

or incomplete exam requests. Although CPEP has found that many 

exam requests are deficient, the lack of a performance measure for 

exam request quality means regional offices do not have the same

incentive for improvement that medical centers have had since VHA 

instituted the performance measure for exam report quality.
Appendix I: Briefing Section 

DRAFT 

Page 30 GAO-06-46 Veterans' Disability Benefits 

27

Recommendations

• To help ensure continued progress in satisfying the DeLuca criteria, we 

recommend that the Secretary of Veterans Affairs direct the Under 

Secretary for Health to develop a strategy for improving consistency 

among the VHA VISNs in meeting the DeLuca criteria. For example, if 

performance in satisfying the DeLuca criteria continues to vary widely 

among the VISNs during fiscal year 2006, VHA may want to consider 

establishing a new performance measure specifically for joint and spine 

exams. Also, if the CPEP Office’s study of the costs and benefits of the 

automated exam templates supports their use, VHA could require that 

its medical centers use the automated templates for joint and spine 

exams.

• We also recommend that the Secretary direct the Under Secretary for 

Benefits to develop a performance measure for the quality of exam 

requests that regional offices send to medical centers. This measure 

could be implemented as soon as the CPEP Office is able provide 

regional offices with case-specific exam request deficiency data via VA’s 

intranet.
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 31 GAO-06-46 Veterans' Disability Benefits 

Appendix II: Comments from the Department 

of Veterans Affairs 
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 32 GAO-06-46 Veterans' Disability Benefits 
Appendix II: Comments from the Department 

of Veterans Affairs 

Page 33 GAO-06-46 Veterans' Disability Benefits (130483) 
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