d. Requesting VHA Examinations in the Geographic Jurisdiction of Another RO Use the Exam Request Routing Assistant (ERRA) tool when requesting examinations that are in the geographic jurisdiction of another RO for a Veteran living within the geographic jurisdiction of another RO, or an employee-Veteran who must be examined elsewhere. ROs authorized to request examinations in another RO’s jurisdiction include, but are not limited to those receiving brokered claims from another RO with jurisdiction over special processing claims such as exposure to radiation, mustard gas or lewisite, or Camp Lejeune contaminated water Veteran employee claims, and pre-discharge claims. Note: Requests for non-VHA examinations scheduled through a designated contractor are limited to the geographic area specified by the contractual agreement. Reference: For more information about the ERRA tool, see M21-1, Part III, Subpart iv, 3.A.2.b. e. When an Examination or Opinion is Necessary Reference: For more information on when a medical examination or opinion is necessary, see M21-1, Part I, 1.C.3 , and . f. Definition: General Medical Examination The main purpose of a general medical examination is to screen all body systems and either document normal findings, or identify disabilities that are found or suspected. Note: The examiner must fully evaluate any disability that is found or suspected according to the applicable Disability Benefit Questionnaires (DBQ). Opinions addressing etiology and relationship to service are not typically provided by general medical examinations. References: For more information on general medical examinations, see M21-1, Part III, Subpart iv, 3.A.5, and general medical examination DBQs, see VA’s .
g. Definition: Specialty Examination A specialty examination focuses on the disabilities that are specifically at issue in the Veteran’s claim. For example, if a Veteran claims that (SC) hypertension has worsened, an examination using the hypertension DBQ should be requested. Notes: Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination. Specialty examinations may be (and usually are) performed by non-specialist clinicians, but in unusual cases, or as requested by a Board of Veterans’ Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a specialist. h. Definition: Specialist Examination A specialist examination is any examination that is conducted by a clinician who specializes in a particular field. Notes: All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist. In unusual cases, or as requested by a BVA remand, it may be necessary to request a specialist examination for other types of disabilities. Reference: For more information on specialist examinations, see M21-1, Part III, Subpart iv, 3.A.6. i. Veteran’s Legal Rights at an Examination A Veteran has no legal right to be accompanied by counsel during an examination, or record an examination. j. Contract Examination Exclusions Examinations must not be requested from contract examiners under certain circumstances. Use discretion based on RO expertise and consultation with VHA and/or contract exam providers when determining whether a contract examination is warranted. Circumstances under which contract examinations must not be requested include, but are not limited to, the following: Former Prisoner of War (FPOW) Protocol Exam is required claim for disability based on exposure to environmental hazards such as Gulf War exposure, Camp Lejeune water contamination, and chemical and biological warfare agents (includes new claims, review exams, and claims for increase in disability) claim for undiagnosed illness Veteran requires overnight stay, (for example, a sleep study)
examinations are adequate before inputting the exam requests. Note: Report any corrected information needed by e-mail to . Reference: For more information on ERB functionality and training, see the . e. Requesting Examinations in CAPRI Use CAPRI to request examinations from VHA. Note: CAPRI may also be used to request observation and examination or social surveys. References: For additional information on exam requests in CAPRI, see M21-1, Part III, Subpart v, 6.G, and completing medical opinion requests in CAPRI, see M21-1, Part III, Subpart iv, 3.A.7.c steps to inputting exam requests, see M21-1, Part III, Subpart iv, 3.A.16.a, and VHA’s C&P Clinic points of contact, see the . f. Requesting Examinations in CAATS Use the Centralized Administrative Accounting Transaction System (CAATS) to request examinations from contract examiners. Note: The contract exam sub-module of CAATS replaced the Veterans Examination Request Information System (VERIS). References: For more information about steps to inputting exam requests, see M21-1, Part III, Subpart iv, 3.A.16.a completing medical opinion requests in CAATS, see M21-1, Part III, Subpart iv, 3.A.7.b, and CAATS, see the , and . 3. DBQs Introduction This topic contains information about DBQs, including the definition of DBQs use and acceptance of DBQs for VA examinations and opinions, and DBQs and exam cancellations.
c. When to Request a Specialist Examination Request a specialist examination only if it is considered essential for rating purposes. Example: A specialist examination may be requested if an issue is unusually complex if there are conflicting opinions or diagnoses that must be reconciled, or based on a BVA remand. d. Who Determines the Choice of Examiner The choice of examiners is up to the VA medical facility conducting the examination, unless the BVA remand specifies that the examination must be conducted by a “Board-certified specialist in …,” or “specialist who is Board qualified.” Some DBQs require a specialist to complete the examination. The DBQ will identify specialist requirements in one of the first paragraphs on the form. Note: In the absence of a BVA remand, ROs may not designate qualification requirements for a specialist examination. e. DSM- 5 and Mental Disorders Specialty Examinations Effective August 4, 2014, was amended to reflect that a diagnosis of a mental disorder must conform to the standards set in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Before that date, the regulation required diagnoses to conform to the DSM-IV. For new examination requests on or after August 27, 2014, VHA examinations must be performed using DSM-5 criteria. No comment to that effect is required on requests for mental disorders or PTSD DBQs. Refer to the following table for guidance on whether to request a new examination under the DSM-5 in a claim for SC or Veteran’s Pension where the record contains a mental health DBQ based on historic DSM-IV criteria. If ... Then ... the DSM-IV exam on the issue of SC or Veteran’s Pension is otherwise adequate for rating purposes renders an Axis I diagnosis of a mental disorder, and supports an award of the benefit sought in view of the evidence of record do not request a new examination. the DSM-IV exam on the issue of SC or Veteran’s Pension does not satisfy all of the criteria above request a new examination. the DSM-IV exam on the issue of do not request a new
reevaluation is otherwise adequate for rating purposes examination. Note: The regulation changes do not affect VA’s evaluation criteria for mental disorders. the DSM-IV exam on the issue of reevaluation is not otherwise adequate for rating purposes. request a new examination. 7. Medical Opinions Introduction This topic contains information about medical opinions, including who may request a medical opinion completing the medical opinion request in CAATS in CAPRI procedure for identifying the evidence in a medical opinion request in ERB maintaining objectivity in medical opinion requests medical opinions required for remands instructions for providing medical opinions – claims under 38 U.S.C. 1151 medical opinions in the hearing loss and tinnitus DBQ avoiding asking for legal conclusions in medical opinion requests when to obtain an independent medical opinion initiating a request for an independent medical opinion submitting a request for an independent medical opinion, and processing requests for an independent medical opinion. Change Date January 15, 2016 a. Who May Request a Medical Opinion Journey-level VSRs who have completed training specified by Central Office (CO) may prepare basic or straightforward medical opinion requests without RVSR or DRO review. Subject to the exception below, the VSCM will designate categories of opinions that are sufficiently basic or straightforward. Exception: Only RVSRs or DROs may prepare complex medical opinion requests. These include issues involving: compensation under aggravation (including Allen aggravation)
diagnostic variation or conflicting medical evidence questions of credibility of evidence presented to the examiner, or any other matters specified by the VSCM such as rare disorders/rare etiologies, or sensitive or high priority claims. Notes: A VSCM may authorize a medical opinion in any case in which he/she believes it is warranted. A medical opinion request must be signed by the person who prepared it. Generally any VSR may order an examination using the Hearing Loss and Tinnitus DBQ, which includes certain routine etiology opinions. However, in cases where a separate Medical Opinion DBQ is required to solicit an opinion not included on the DBQ, the opinion request should be prepared by an RVSR or DRO. References: For more information on independent medical opinions under , see M21-1 Part III, Subpart iv, 3.A.7.m, and medical opinions and the Hearing Loss and Tinnitus DBQ, see M21-1 Part III, Subpart iv, 3.A.7.h. b. Completing Medical Opinion Requests in CAATS If requesting a medical opinion from a contract examination facility, ROs must use the CAATS application. Use the table below to determine how to generate the language for the medical opinion request(s). If requesting a medical opinion based on ... Then generate the medical opinion language using ... combat experiences MST, or SC death the . Reference: For more information on the procedure for using the ERB tool to generate medical opinion language, see M21-1, Part III, Subpart iv, 3.A.7.c and d, and . all other types of claims the embedded templates within CAATS. Important: ROs must create all required tracked items in the appropriate claims-processing system for the requested exam(s). References: For more information on requesting exams in CAATS, see the , and creating a tracked item, see the Veterans Benefits Management System (, or Modern Award Processing- Development (.
was conducted within the one year period before receipt of the claim do not request another social survey unless there is an indication that the social/employment situation has changed. is needed prior to other appellate procedures in cases where a notice of disagreement (NOD) has been filed the issue on appeal is either SC or evaluation of a psychiatric disability, and upon review of the claims folder, prior to pre-certification of the appeal, it is found that a social survey was not considered in the denial request a social survey. 13. Pre-Discharge Examinations Introduction This topic contains information about Pre-Discharge examinations, including who is eligible for Pre-Discharge examination what the Separation Health Assessment (SHA) covers, and general medical examinations and the SHA. Change Date July 30, 2015 a. Who Is Eligible for Pre-Discharge Examination The Pre-Discharge program is available to service members with no more than 180 days remaining until discharge at select military installations that contain VA intake sites. References: For more information on who may file a Pre-Discharge claim, see M21-1, Part III, Subpart i, 2.A.1.b, and claims that are not processed in the Pre-Discharge program, see M21-1, Part III, Subpart i, 2.A.1.e. b. What the SHA Examination Covers The Separation Health Assessment (SHA) is a single separation examination which supports the VA disability compensation process and the Department of Defense (DoD) separation/retirement process. It includes the Separation History and Physical Examination Program (SHPE).
Service members who do not file claims with VA will receive an SHA/ SHPE at their local military treatment facility (MTF) in connection with their transition processing. The SHA/SHPE captures the service member’s current health information in a way that is easily accessible by both DoD and VA. The SHA process provides service members with an improved general medical examination, which includes an audiogram, any specialty exams deemed necessary, and a full lab analysis, using VA’s examination protocols. The service member completes and provides the DD Form 2807-1, Report of Medical History, to the examiner. The examiners will complete their designated section of the DD Form 2807-1, and the completed form will be added to the service member’s service treatment records (STRs). Note: The service member may elect to upload the completed DD Form 2807-1 into eBenefits with the Pre-Discharge claim(s) application instead of bringing the form to the SHA examination. c. General Medical Examinations and the SHA Effective October 2013, all eligible Pre-Discharge claimants receive an SHA, which replaced the General Medical (GEN MED) examination. The SHA DBQ is being added to CAPRI/CAATS and is an available selection at most facilities. Select the SHA DBQ if it is available at the requesting examination facility and add the comment: BDD (or Quick Start) claim. If the SHA DBQ is not available in CAPRI or CAATS, select the GEN MED DBQ and add the following statement to the comments: BDD (or Quick Start) claim: SHA DBQ is requested. Reference: For more information about the SHA DBQ, see the Disability and Medical Assessment Fact Sheet . 14. Examinations of Pregnant Claimants Introduction This topic contains information about examinations for pregnant claimants including general information on examinations for pregnant claimants ancillary conditions of pregnancy tests not recommended for pregnant claimants how pregnancy affects participation in the Pre-Discharge program, and options for processing claims for pregnant claimants. Change Date July 30, 2015