Department of Veterans Affairs M21-1, Part III, Subpart IV



Download 118.17 Kb.
Page3/4
Date conversion16.05.2016
Size118.17 Kb.
1   2   3   4

3. Handling Examinations Insufficient for Rating Purposes

Introduction

This topic contains information about returning insufficient examinations, including




Change Date

July 22, 2015September 24, 2015




a. Insufficient Examination Reports

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 Floyd v. 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

  • medical opinions on conflicting medical evidence and independent medical opinions, see M21-1 Part III, Subpart iv,3.A.7.



de. Returning Examination Reports

Return an examination report as insufficient for rating purposes to the health care provider or appropriate contractor through


  • CAPRI - if the examination was requested through a VHA facility, or

  • Centralized Administration Accounting Transaction System (CAATS) – if the examination was requested from a VBA contractor.


Important:

  • Avoid using language that can be construed as adversarial when returning reports for clarification. Use the term “insufficient for rating purposes” rather than “inadequate examination.”

  • Describe clearly the issue(s) needing clarification or resolution.

Refer to the table below for returning examination reports to the provider.






If the examination report…

and the examiner is from a…

Then …

is insufficient

VHA or a VHA-contracted provider

return the examination as insufficient thru CAPRI

VBA-contracted provider

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.

needs clarification

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

  • input a medical opinion DBQ request in CAPRI, if the issue(s) is complex or cannot be resolved by phone or e-mail.

VBA-contracted provider

return the examination as insufficient thru CAATS.

needs resolution of a conflicting opinion or diagnosis

VHA, a VHA-contracted provider, or a VBA-contracted provider

input a medical opinion DBQ request in either CAPRI or CAATS, whichever is applicable.




Notes:

  • For VHA examinations, try to resolve any questions or clarifications with the RO resident clinician as much as possible, before calling the examination as insufficient.

  • For VBA-contracted examinations, the contractor has seven days to clarify any insufficiency, to avoid an insufficiency call.

  • When the best interest of the Veteran will be advanced by a personal conference or e-mail with the examiner, such venues should always be considered.


1   2   3   4


The database is protected by copyright ©essaydocs.org 2016
send message

    Main page