A VA examination report submitted to the rating activity, must be as complete as possible.
Any missing required information on the report makes the examination insufficient for rating purposes. This can include, but is not limited to, the following instances
The examination report is unsigned.
The examination report did not address all disabilities for which an examination was requested.
The required question(s) on the DBQ were left blank.
The required review of the claims folder was not accomplished.
Missing information on the report pertinent to the disability under review, such as failure to discuss the impact of musculoskeletal pain on the functional loss of an affected joint.
A medical opinion is not properly supported by a valid rationale and/or by the evidence of record.
A requested medical opinion was not furnished.
Note: Examinations that are cancelled by VHA or a contractor, without a valid reason, should be returned as insufficient for rating purposes if the rating activity determines that the examination is warranted.
Example: An examination for a requested knee pain claim was not completed because “the claimed condition was not documented and diagnosed in the service treatment records on examiner review”. If the rating activity determines that such examination is needed, return to the examining facility as insufficient for rating purposes.
Exception: There are instances where missing information in an examination report does not make the examination itself insufficient. See M21-1, Part III, Subpart iv, 3.D.3.b c for examples.
References: For more information on
inadequate examinations, see 38 CFR 4.70
when further development may be needed, see M 21-1, Part III, Subpart iv, 5.7
weighing evidence, see M21-1, Part III, Subpart iv, 5.9
resolving inconsistencies, see M21-1, Part III, Subpart iv.3.D.3.cd, and
descriptions of pain affecting functional loss, see Floydv. Brown, 9 Vet. App. 88 (1996).
b. Handling Insufficient Exams Erroneously Requested
In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court held that if VA provides an examination when developing an SC claim, even if not statutorily obligated to do so
the examination must be adequate, or
the Veteran must be notified as to why one will not or cannot be provided.
Exception: If new and material evidence has not been presented and the claim is not considered reopened, then the issue of the adequacy of any new VA medical examination conducted pursuant to 38 U.S.C. 5103A(d) becomes moot, because readjudication of the merits of the claim is barred by statute if VA does not reopen the claim. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007).
bc. Examination Reports for Clarification
An examination report which needs clarification must be discussed or returned to the examiner. Such instances include, but are not limited to, the following.
The same disability is diagnosed differently by different examiners.
Conclusions or findings have been expressed in ambiguous or equivocal terms.
An examination report shows a change in the diagnosis or etiology for a disability previously recognized as service-connectedSC.
cd. Resolving Inconsistencies
Resolve any inconsistency or conflicting findings of various medical examiners by requesting a medical opinion by a different examiner.
References: For more information on requesting
return the examination as insufficient thru CAATS.
Important: When a VBA-contracted exam is found to be insufficient, it should NOT be resolved by VHA examiners. VHA examiners can provide an addendum or clarification that is considered to be supplemental—not to remedy an insufficiency or inadequacy. Additionally, VHA examiners can provide medical opinions not previously requested of the contract examiner.
VHA or a VHA-contracted provider
call or e-mail the examiner or point of contact at the examination facility, to try and resolve the issue(s) expeditiously, or