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

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4. Reviewing Examination Reports for Rating Criteria


This topic contains information about

  • bruxism examination report review

  • eye examination report review

  • headache examination report review

  • hearing loss and tinnitus examination report review

  • mental health examination report review

  • metabolic equivalents of task (METS) for heart conditions examination report review

  • musculoskeletal report review for functional loss, ROM, and X-rays

  • nerves examination report review

  • pulmonary function test (PFT) examination report review

  • post traumatic stress disorder (PTSD) examination review

  • skin and scars examination report review

  • sleep disorders examination report review

  • temporomandibular joint (TMJ) disorder examination report review, and

  • traumatic brain injury (TBI) examination report review.

Change Date

August 5, 2015

a. Bruxism Examination Report Review

Bruxism is defined as excessive grinding of the teeth and/or excessive clenching of the jaw.
Bruxism may not be rated as a stand-alone service-connectedSC disability. However, it may be considered on a secondary basis as a symptom of a service-connectedSC disability, such as an anxiety disorder, TMJ dysfunction, or another disability for rating purposes.
If an examination report diagnoses bruxism, then the examiner has to provide the etiology of bruxism.
Reference: For information on processing dental claims, see M21-1, Part III, Subpart v, 7.C.

b. Eye Examination Report Review

Examiners must perform visual field testing using either

  • Goldmann kinetic perimetry

  • automated perimetry using Humphrey Model 750, Octopus Model 101, or

  • later versions of these perimetric devices with simulated kinetic Goldmann testing capability.

If the examination was not performed using the proper testing method or the results are not properly recorded on a standard Goldmann chart as specified in the regulation, then the exam should be returned as insufficient.

Reference: For more information about eye conditions, see

  • 38 CFR 4.76(b)(3)

  • 38 CFR 4.77

  • 38 CFR 4.79 , and

  • M21-1, Part III, Subpart iv, 4.B.1.

c. Headache Examination Report Review

A neurological headache examination report will be considered insufficient if the frequency of prostrating headaches and whether the headaches are migraine-type or non-migraine type are not adequately addressed. These examination reports require clear indication of the frequency of prostrating headaches and whether the headaches are migraine or non-migraine.
Reference: For more information on rating migraines, see 38 CFR 4.124a.

d. Hearing Loss and Tinnitus Examination Report Review

A hearing loss and tinnitus examination may be considered insufficient if an opinion was requested by the RO and it is not provided in the report.
Unusual circumstances may arise during the examination where the examiner will have to

  • state if there are one or more frequency(ies) that could not be tested (CNT) and enter CNT in the box for frequency(ies) that could not be tested. Then explain why testing could not be done

  • provide an explanation of why the use of the speech discrimination score is not appropriate or not performed for the Veteran, and

  • state the functional impact of tinnitus.

Reference: For more information on requesting audiometric examinations and medical opinions, see M21-1, Part III, Subpart iv, 4.B.3.d.

e. Mental Health Examination Report Review

Mental health examinations can be complex when there are psychological symptoms existing simultaneously with and usually independently of another medical condition, such as PTSD and TBI symptoms of memory loss.
An examination may be insufficient if

  • there is more than one mental disorder diagnosed and the examiner does not address the criteria for all the diagnoses

  • there is a diagnosis of a mental disorder and TBI, and the examiner did not

  • differentiate and list which symptom(s) is/are attributable to each diagnosis, or

  • provide a reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis, or

  • the occupational and social impairment field is not completed.

Reference: For more information on considering a change in the diagnosis of a psychiatric disorder, see M21-1, Part III, Subpart iv, 4.H.1.c.

f. METS for Heart Conditions Examination Report Review

The metabolic equivalents of task (METS) score for heart conditions can be provided as an estimate as indicated on the DBQs. If the Veteran has co-morbid conditions that prevents the examiner from estimating the METS, then the

  • examiner must indicate why a METS could not be performed, and

  • the RVSR or DRO will evaluate the condition based on the examination results.

Reference: For information on rating heart conditions, see M21-1, Part III, Subpart iv, 4.E.1.

g. Musculoskeletal Report Review for Functional Loss, ROM, and X-rays

Musculoskeletal joint examinations must address range of motion (ROM) criteria for repetitive motion and flare-ups.
Following the initial assessment of ROM, the examiner must perform repetitive use testing. After the initial measurement, the examiner must reassess ROM after 3 repetitions and report the post-test measurements. The examination is insufficient if the examiner does not repeat ROM testing during the exam and fails to report additional functional loss.
The examiner must address additional functional limitation or limitation of motion (LOM) during flares-ups or repeated use over time, based on the Veteran’s history and the examiner’s clinical judgment.
The examination report must address whether functional ability of a joint is significantly limited during flare-ups (to address the Court’s interpretation of VA’s regulation in DeLuca) or when the joint is used repeatedly over a period of time (to address the Court’s interpretation of VA’s regulation in Mitchell) because of

  • pain

  • weakness

  • fatigability

  • incoordination

If such opinion is not feasible, then the examiner must state so and provide an explanation as to why the opinion cannot be rendered.

Example: John Smith reports severe knee pain with repeated use over time when walking back and forth to the store several times a day.  During those flare ups, the ability to flex the knee is demonstrated/reported to be 0-110 degrees.
If the clinician is unable to opine based on the claimant’s reported history and knowledge gained by the examination, then an explanation as to why functional loss cannot be determined must be given on the examination report. 
The following terms in an examination report may lead to an insufficient examination request

  • unaffected gait but walks with a cane

  • surgery to joint but scar not addressed

  • no arthritis but x-ray states degenerative joint disease (DJD)

  • limited ROM but no diagnosis provided.

  • If the ROM is decreased for the affected joint but the ROM is the same on the unaffected joint then this is now the Veteran’s new “Normal” and must be documented as such. Otherwise there is no explanation for decreased ROM.

  • pain of joint with exam or movement but diagnosis is “normal joint”.

  • inconsistent statement and the examiner must provide an explanation in remarks section.

  • stress fractures: resolved, and

  • stress fractures with residual limited ROM, pain.

During review of musculoskeletal exam reports, check to ensure that x-rays were obtained when necessary.

A diagnosis of arthritis must be confirmed by x-ray or other radiographic testing before service connectionSC may be established.
Where there is a claim of non-specific joint pain in a joint or multiple joints, x-rays will not be provided prior to the Veteran being seen by the examiner. The examiner will determine if x-rays are needed in order to provide a diagnosis consistent with the history and symptomatology. If there is a diagnosis other than arthritis or a diagnosis of no disability, do not return the examination as insufficient merely because x-rays were not provided.
However, if arthritis is claimed or diagnosed, the examination did not include x-rays and there are no x-rays of the joint at issue, then return the examination as insufficient.
Note: Once arthritic changes are shown in a joint, no further x-rays will ever be required for that joint to support a diagnosis of arthritis.
Reference: For more information on musculoskeletal conditions, see M21-1, Part III, Subpart iv, 4.A.

h. Nerves Examination Report Review

Examiners must identify the nerve that best correlates to the area affected even though the condition is a spinal cord nerve condition.
This information will allow the rating decision to address the functional impairment of the area affected.
Reference: For more information on diseases of the peripheral nerves, see

  • 38 CFR 4.120, and

  • M21-1, Part III, Subpart iv, 4.G.4.

i. PFT Examination Report Review

Pulmonary function tests (PFTs) are required for most pulmonary conditions unless

  • there is a recent study in the Veteran’s records that accurately reflects the Veteran’s current condition, or

  • the examiner provides an explanation on the special exceptions listed in 38 CFR 4.96(d)(i) through (iv).

Obtaining and reporting the PFT is only half of the requirement. The other half of the requirement is for the examiner to interpret the PFT in relation to the claimed condition.

References: For more information on

  • when PFTs are required, see M21-1, Part III, Subpart iv, 4.D.1.i, and

  • assigning disability evaluations based on the results of PFTs, see M21-1, Part III, Subpart iv, 4.D.1.j.

j. PTSD Examination Review

Reasons that a PTSD examination report may be insufficient for VA purposes are detailed in M21-1, Part III, Subpart iv, 4.H.5.c.

k. Skin and Scars Examination Report Review

To ensure a skin or scar examination is not considered insufficient, the sections regarding body surface areas on the skin DBQ would need to be completed. Specifically, the affected areas need

  • to be measured to include the length and width of the affected area

  • a description of the quality of the skin condition or scar, and

  • a description of the percentage of total body surface and exposed body surface affected.

Note: Do not return the skin or scar examination as insufficient to request color photographs if they are not included with the examination report. However, if photographs are included then consider the evidence when evaluating the criteria.
Reference: For more information on rating skin and scars, see

  • 38 CFR 4.118, and

  • M21-1, Part III, Subpart iv, 4.J.

l. Sleep Disorders Examination Review

Sleep apnea must be diagnosed with a sleep study. Review the sleep study to ensure the condition is interpreted in relationship to the claimed condition.
If there is a co-morbid service-connectedSC condition to the sleep apnea which requires a PFT, like asthma, ensure that such testing was completed.
Sleep disturbances including insomnia may be claimed as a secondary condition, but not inclusively to,

  • mental health disorders

  • pain experienced from a service-connectedSC disability, and/or

  • signs or symptoms of undiagnosed illness and medically unexplained chronic multisymptom illnesses.

Note: When the sleep apnea DBQ is negative for a diagnosis of sleep apnea, but the examiner provides information about sleep disturbances, then review the report to determine if an additional secondary medical opinion DBQ is required.
References: For more information on

  • sleep apnea and sleep studies, see M21-1, Part III, Subpart iv, 4.D.1.l m

  • signs or symptoms of undiagnosed illness and medically unexplained chronic multisymptom illnesses, see 38 CFR 3.317(b)(9)

  • sleep apnea schedule of ratings, see 38 CFR 4.97, diagnostic code 6847

  • when PFTs are required, see M21-1, Part III, Subpart iv, 4.D.1.iPFT examination review, see M21-1, Part III, Subpart iv, 3.D.3.l, and

  • examination DBQ, see VA Form 21-0960L-2 Sleep Apnea Disability Benefits Questionnaire.

m. TMJ Examination Report Review

There is no need to return a TMJ examination to VHA simply because a dentist did not perform the examination. TMJ is musculoskeletal in nature.
Important: As part of the musculoskeletal requirements, the TMJ DBQ requires the examiner to address

  • flare-ups that impact the function of the temporomandibular joint

  • initial ROM measurements

  • ROM measurement after repetitive use testing

  • functional loss and additional limitation in ROM, and

  • pain (pain on palpation) and crepitus.

References: For more information about

  • rating TMJ, see 38 CFR 4.150, and

  • the TMJ DBQ, see VA Form 21-0960M-15, Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire.

n. TBI Examination Report Review

Ensure the initial TBI diagnosis is conducted by a qualified examiner.
The examiner must address

  • all the of facets of the TBI diagnosis, and

  • if any facets are left blank, it must be indicated in the remarks section of the DBQ that the symptoms are related to a non-TBI condition, and

  • provide an explanation

  • any additional residuals, other findings, diagnostic testing, and functional impact of the diagnosis, and an explanation regarding conflicting diagnoses from medical vs. mental health clinicians must be provided

  • other pertinent physical findings, scars, complications, conditions, signs and/or symptoms such as mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere’s disease), and

  • the functional impact on the Veteran’s ability to work.

A mental health evaluation alone is not sufficient in addressing TBI. TBI examination completed by a medical clinician with input from a mental health examiner need to be completed when attributable signs and symptoms co-exist.

Objective evidence and neuropsychiatric testing may be required when cognitive impairment symptoms are identified. Some examples of cognitive impairment symptomology include

  • memory loss, and

  • reduced attention, concentration, and executive functioning.

References: For more information on

  • TBI examiner qualifications, see M21-1, Part III, Subpart iv, 3.D.2.h, and

  • evaluating TBI, see

  • 38 CFR 4.124a, and

  • M21-1, Part III, Subpart iv, 4.G.2.

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