inception in service. All pertinent or relevant medical and lay evidence must be considered, including the service records (which may show the places, types, and circumstances of service and the official history of the organization in which the Veteran served). References: For more information on principles relating to SC, see guidance on the current disability requirement, see M21-1, Part IV, Subpart ii, 2.B.1.b evaluating evidence, see M21-1, Part III, Subpart iv, 5 requesting evidence from the claimant, see M21-1, Part III, Subpart iii, 1.B.1, and the benefit of the doubt rule, see , and M21-1, Part III, Subpart iv, 5.1.k. b. Establishing Direct SC Based on Chronicity Chronicity is a key concept for establishing direct SC. Department of Veterans Affairs (VA) disability compensation is based on current chronic (ongoing, lasting) disability. Direct SC requires that the current disability must have begun during active duty service either by manifestation of the disease entity or by the occurrence of an injury or traumatic event during service resulting in the current, chronic, ongoing disability. To establish SC under based on the chronicity of a disease shown in service, the evidence must include manifestations sufficient to identify the disease entity onset of the condition and/or evidence of injury or trauma during active duty service, and evidence sufficient to establish chronicity from merely isolated findings or a diagnosis that includes the word “chronic,” so long as the evidence does not show a superseding post-service disability. When a chronic disease listed under is shown in service, consider all subsequent manifestations of the same chronic disease as service-connected (SC), unless they are clearly shown to be due to inter-current causes. Notes: A careful review of the evidence may reveal that chronic disability from a condition had its onset during active duty service and has chronically persisted from active service to the present, even when service medical providers did not conclude that there were residuals or continuation of a disease or injury. Application of the chronicity provisions of is limited to the chronic diseases listed under . For any disability not listed under SC must be established under by associating a current disability to service by a nexus consisting of
examination with medical opinion requested in accordance with may provide the required nexus. e. Establishing Direct SC Under 38 CFR 3.303(d) Consider whether direct SC may be established under , even if SC is claimed for a disease diagnosed after service has ended. SC may be awarded for a disease diagnosed after discharge when all the evidence establishes that the disease was incurred in service. f. Definition: Presumption of Soundness The presumption of soundness means that a Veteran will be considered to have been in sound condition (the claimed disability did not exist) when examined, accepted, and enrolled for service. Exceptions: The presumption of soundness does not apply when the evidence shows defects, infirmities, or disorders noted at entrance into service (such as conditions noted on the entrance examination), or the injury or disease clearly and unmistakably existed prior to service and was not aggravated by service. Notes: The presumption of soundness applies only when the Veteran underwent a physical examination at the time of entry into service on which the claim is based. Only the conditions that are recorded in the enlistment examination report are to be considered as noted. A history of pre-service conditions recorded at the time of the entrance examination is not a notation of the condition. It is just one factor that must be considered on the question of presumption of soundness. The presumption of soundness is also applicable when the Veteran underwent a physical examination upon entrance into service, but the report of examination is unavailable. In such a situation, the presumption of soundness will stand. Once the presumption of soundness arises it is only overcome when the record contains clear and unmistakable evidence showing that the disease or injury existed prior to service and was not aggravated by service. Reference: For more information on the presumption of soundness and aggravation, see M21-1, Part IV, Subpart ii, 2.B.4.a , 370 F.3d 1089, 1096 (Fed. Cir. 2004) , 25 Vet.App. 231 (2012), and , 26 Vet.App. 48 (2012).
diseases based on full-body exposure to mustard gas or Lewisite. diseases associated with service in the Southwest Asia theater of operations including undiagnosed illnesses medically unexplained chronic multi-symptom illnesses, and certain infectious diseases. amyotrophic lateral sclerosis (ALS) with at least 90 days of continuous active service. References: For more information on principles related to presumptive SC, see diseases subject to presumptive SC, see , and SC for qualifying disabilities associated with service in Southwest Asia, see M21-1, Part IV, Subpart ii, 2.D. b. Definition: Other Organic Diseases of the Nervous System Other organic diseases of the nervous system under include any commonly recognized neurological disease (such as may be found in a valid, contemporary medical treatise), which is not otherwise specifically listed under ) subject to the rebuttable presumption provisions under . This would include any disease of the central nervous system, as well as cranial and peripheral nerve conditions. Compensation Service has determined that certain diseases constitute an organic disease of the nervous system (however, this does not represent an exclusive list). They include carpal tunnel syndrome peripheral neuropathy migraine headaches sensorineural hearing loss, and glaucoma. Important: The Court of Appeals for Veterans Claims (CAVC) held in , 27 Vet.App. 258 (2015), that organic diseases of the nervous system includes tinnitus, if there is evidence of acoustic trauma. Note: In the event there is uncertainty as to whether or not a disability for which a Veteran seeks compensation constitutes an organic disease of the nervous system, the case should be sent to Compensation Service’s Advisory Review Staff (211B) for guidance. Reference: For more information on requesting CS guidance, see M21-1, Part III, Subpart vi, 1.A.
availability of medical records nature and course of the disease or disability, and amount of time that elapsed since military service. Important: Do not merely dismiss the presence of disability because there is an absence of accompanying medical treatment records. The absence of treatment records does not necessarily mean the absence of disability. Moreover the absence of medical records during combat conditions does not necessarily establish the absence of disability. Reference: For more information on aggravation of a pre-existing disability during combat conditions, see , 230 F.3d 1330 (Fed. Cir. 2000), and , 19 F.3d 1413 (Fed. Cir. 1994). 5. Determining Secondary SC, Including by Aggravation Introduction This topic contains information on determining secondary SC, including by aggravation, including provisions for SC under 38 CFR 3.310(a) and (b) medical evidence required to show a non-service-connected (NSC) disability was aggravated by an SC disability developing claims based on aggravation of an NSC disability by an SC disability information that must be included in the examiner’s report for secondary SC based on aggravation, and determining the extent to which an NSC disability was aggravated by an SC disability. Change Date January 20, 2016