Important: Before determining that an examination is not necessary because the evidence is adequate to substantiate the claim, ensure that the evidence is fullysufficient to rate, including assignment of a disability evaluation.
38 CFR 3.159(c) provides that the duty to assist applies only when evidence is necessary to substantiate the claim.
38 CFR 3.159(c)(4) provides that an examination or opinion is necessary only if the information and evidence of record is not sufficient to decide the claim.
38 CFR 3.326(a) provides that an examination is authorized when there is a claim for disability compensation but the medical evidence accompanying the claim is not adequate for rating purposes.
Facts: A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2). The claims folder contains a competent medical assessment of chronic fatigue syndrome. The evidence shows that this developed to a compensable degree after service but before December 31, 2016. The evidence of record contains enough information to assign an evaluation for chronic fatigue syndrome.
Result: Do not request an examination. The claim is substantiated under 38 CFR 3.317. The evidence shows a claimant with service qualifying for consideration of 38 CFR 3.317 has a medically unexplained chronic multi-symptom illness listed in the regulation that developed in the period specified in the regulation. The evidence is sufficient to award SC and assign an evaluation.
f. Example 2: Examination is Unnecessary Because Claim is Substantiated
Facts: A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2). The claims folder shows chronic bilateral knee pain developing during Southwest Asia service without a specific injury. The assessments in service were bilateral knee strain, rule out arthritis, and bilateral knee pain. X-rays were negative. The current medical evidence shows a complaint of bilateral knee pain and a diagnosis by a private doctor of bilateral knee strain. The doctor has offered the opinion that the strain had its onset in service. There is no superseding post-service injury. The record contains enough information to assign an evaluation.
Result: Do not request an examination. Although there is a question as to whether this is truly a disability with a clear and specific etiology (a bilateral knee strain) or whether there is an undiagnosed illness manifested by multiple joint pain, the claim for SC is substantiated on a direct basis under 38 CFR 3.303. The evidence is sufficient to award SC for bilateral knee strain and to assign an evaluation.
g. Gulf War Examination Unnecessary – No Potential 38 CFR 3.317 Entitlement
A Gulf War examination is not necessary in a limited variety of cases where there is no potential entitlement under 38 CFR 3.317.
Do not order a Gulf War examination when a Southwest Asia Veteran claims neurological symptoms manifesting within the period specified in 38 CFR 3.317 but there is a competent medical diagnosis of multiple sclerosis (MS). MS is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained. Also, the condition is typically diagnosed only after a neurological examination and hallmark tests such as magnetic resonance imaging (MRI) and cerebrospinal fluid testing.
Do not order a Gulf War examination when a Southwest Asia Veteran claims fatigue, neurological, skin or other listed symptoms manifesting within the period specified in 38 CFR 3.317 but there is a competent medical diagnosis of diabetes. Diabetes is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained. Also, the condition is typically diagnosed only after clinical evaluation and hallmark testing such as blood glucose testing or hemoglobin A1C tests.
Do not request a Gulf War examination when the claim is for a single joint injury – not an undiagnosed illness or medically explained multi-symptom illness – and the evidence shows