What Is a VA ACE Exam (Acceptable Clinical Evidence Review)

Section 1: What ACE Actually Is

ACE stands for Acceptable Clinical Evidence. It is a process VA uses to complete a Compensation and Pension exam without bringing the veteran in for a physical or telehealth visit. The examiner reviews the medical records already in the file (service treatment records, VA medical center notes, private treatment records, prior DBQs, lay statements, test results) and fills out the appropriate DBQ entirely from that paper trail. If the records leave a question open, the examiner may add a brief telephone interview to confirm subjective symptoms.

VA's plain-English explanation on the claim-exam page reads: "if you have sufficient medical documentation supporting your claim, we'll follow the Acceptable Clinical Evidence (ACE) process. This means we'll review your medical records and ask you to submit more evidence if needed, instead of asking you to have an exam."

An ACE-completed DBQ carries the same legal weight as a DBQ filled out in a clinic. The rater treats it as a C&P examination for all purposes under 38 CFR § 3.326 and 38 CFR § 4.2.

Section 2: The Legal and Procedural Authority

• M21-1, Part IV, Subpart i, Chapter 2, Section A: Examination Requests Overview. Defines the ACE process and tells raters and contractors when ACE may substitute for an in-person request. Last updated 2026-05-27 with an HLR / BVA-remand exception for aggravation opinions, see the HLR guide for the substantive impact.
• 38 CFR § 3.326: Examinations. Says VA may accept a private examination or an existing report "in lieu of" a VA exam when the report is adequate for rating purposes. ACE is the in-house version of the same principle, the existing records are themselves the report.
• 38 CFR § 4.2: Interpretation of examination reports. Requires the rater to ensure each report contains sufficient detail to apply the rating schedule. An ACE-completed DBQ must meet this same standard.
• 38 CFR § 4.6: Evaluation of evidence. Caselaw-anchored requirement that VA weigh, not count, the evidence, including evidence used in an ACE review.

The process is purely administrative. There is no statute that creates "ACE" as a special category of examination, it is an efficiency mechanism VA built so that veterans with thoroughly documented conditions are not forced to repeat exams that the records already answer.

Section 3: When VA Uses ACE

VA's contract examination vendors (Optum Serve, VES, QTC) are trained to identify ACE-eligible claims at the request-intake stage. The trigger is straightforward: are the existing records detailed enough to answer every question on the relevant DBQ? If yes, the case is routed to ACE. If no, it is scheduled for an in-person or telehealth exam.

Conditions where ACE is most commonly used:

• Tinnitus (38 CFR DC 6260). Diagnosis is subjective; an audiogram and lay statements are usually enough.
• Hearing loss (DC 6100). An audiogram with Maryland CNC speech recognition score and pure-tone thresholds is the entire evidentiary requirement; if a recent qualifying audiogram is in the file, no exam is needed.
• Migraine headaches (DC 8100). Neurology records documenting attack frequency, prostrating-attack history, and the medications tried are usually sufficient.
• Sleep apnea (DC 6847). A sleep study report establishes diagnosis; CPAP compliance reports and follow-up notes establish severity.
• Cardiac conditions (DCs 7000-7019). A stress-test report with documented METs, an echocardiogram, and treatment notes can carry the entire rating analysis.
• Increase claims on stable conditions where treatment records show consistent symptoms or rating-level changes, e.g., a long-held knee or back rating with recent imaging.
• ALS, terminal conditions, and other circumstances where travel imposes hardship on the veteran. ACE protects the veteran from a futile clinic visit.
• Pre-discharge BDD claims with complete service treatment records.

Conditions where ACE is generally not used:

• Mental health (PTSD, MDD, anxiety, bipolar, schizophrenia). The diagnosis and severity assessment require a clinical interaction (interview, mental-status exam, observation of affect). See Mental Health Rating Formula.
• Traumatic Brain Injury (TBI). The ten-facet 38 CFR § 4.124a evaluation requires cognitive testing and observation. See Rating TBI.
• General medical exams (initial overall comp claims). These typically involve multiple body systems and benefit from in-person assessment.
• New, undiagnosed, or symptom-only conditions where the file has no anchoring diagnostic test.
• Cases where the electronic medical record cannot be accessed by the contract examiner.
• Telehealth is not ACE. If you are asked to log into a video appointment, that is a regular C&P exam delivered remotely. ACE has no live component beyond the optional phone call.

Section 4: What an ACE Review Includes

1. Records review. The examiner reads the relevant slice of your claims file: service treatment records, prior C&P reports, VA medical center notes, private treatment records you submitted, any imaging or test reports, and lay statements.
2. DBQ completion. The examiner fills out the standardized Disability Benefits Questionnaire for the claimed condition, exactly the same form a clinic examiner would use.
3. Functional Impact section. Required on every DBQ. The examiner answers the question "Does the Veteran's [condition] impact his or her ability to work?" using what the records show. This is the section that drives TDIU and occupational-impact analysis.
4. Optional telephone interview. The examiner may call you to fill specific gaps, for example, current symptom frequency, current medications, current employment status. The call typically lasts 5 to 20 minutes. The examiner must verify that the person on the line is the veteran (or an authorized representative). If you receive a call asking for sensitive medical detail and the caller cannot identify themselves as a VA contract examiner, treat it as suspicious and ask for a callback number tied to the contractor.
5. ACE certification on the DBQ. The examiner checks a box on the form indicating ACE was used, then lists the specific records relied on. This audit trail lets the rater (and, later, the Board) confirm the basis.

Section 5: What ACE Does NOT Include

• No physical examination, no range-of-motion measurement, no goniometer, no audiometric booth, no blood pressure check.
• No telehealth video appointment.
• No new diagnostic testing. The examiner can only use evidence already in the file or obtainable through the optional phone call.
• No mental-status exam.
• No observation of pain on motion, gait abnormalities, scar appearance, or other in-person findings.

This list matters because it is the source of most ACE inadequacy challenges. If the rating schedule for your condition requires something that can only be observed in person (painful motion under 38 CFR § 4.59, flare-up analysis under Sharp v. Shulkin, 29 Vet. App. 26 (2017), or any other observable physical finding), an ACE-completed DBQ that does not address it is potentially inadequate.

Section 6: Worked Examples

All three examples are fictional. Facts are illustrative and resemble patterns from real claims, but no real veteran is described.

Section 7: Is an ACE Exam Good or Bad for You?

It depends on whether your records understate, accurately state, or overstate your current condition.

Practical tactic. Before any claim where ACE is realistic (tinnitus, hearing, migraine, sleep apnea, cardiac, stable orthopedic), update your treatment records. A current visit to your primary or specialist where you describe your symptoms at their worst before the C&P request is sent gives the ACE examiner the right baseline. See C&P Exam Preparation for the symptom-diary template that works the same way for ACE as for in-person.

Section 8: What the Examiner Must Document on the DBQ

Per M21-1 IV.i.2.A and per the ACE-process training materials VA distributes to contract examiners, an ACE-completed DBQ must:

• Check the ACE box. A specific checkbox on the DBQ indicates the exam was completed without an in-person component.
• List the source of every clinical finding. Each rating-relevant answer must be tied to a specific record (service treatment note, prior DBQ, VA medical center visit, private record, imaging report). Vague references like "claims file reviewed" are inadequate under Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).
• Document any phone interview. If a call took place, the DBQ must record the date, duration, the questions asked, and the answers received. The examiner verifies the veteran's identity at the start of the call.
• Address every required DBQ question. An ACE write-up that skips the Functional Impact section or a required diagnostic finding is incomplete on its face.
• Provide rationale where the records conflict. If the file contains contradictory evidence, the examiner must explain which records were given weight and why. Conclusory write-ups are challengeable under Stefl v. Nicholson.

If any of these elements is missing, the rater is supposed to return the report as insufficient under 38 CFR § 4.2 and order a new exam. In practice, raters sometimes accept thin ACE reports. That is the most common ground for a Higher-Level Review challenge of an ACE-based decision.

Section 9: Can You Demand an In-Person Exam Instead?

Short answer: no, not as a matter of right. ACE eligibility is VA's call, based on whether the records are adequate.

Longer answer: you can make ACE inadequate by ensuring the file contains what an in-person exam would have added. If your records do not document a key piece of evidence the rating turns on, VA should default to an in-person exam. Practical steps if you want to nudge VA toward an in-person:

• Submit a current lay statement describing flares, frequency, severity, and the symptoms you only have on bad days.
• Submit recent treatment records that document a worsening trend.
• Submit a private DBQ from your own provider that documents the in-person findings (range of motion, painful motion, gait, scar measurements). A private DBQ also gives the rater a competing report that strengthens any later challenge if the ACE write-up is thin. See How VA Raters Weigh Medical Opinions.
• If you receive notice that ACE is being used and you believe the records cannot answer the rating questions, write to the regional office (VA Form 21-4138) before the DBQ is completed and ask for an in-person exam, citing the specific findings the records do not contain. This is not a right, but it puts the issue on the record for any future appeal.

Section 10: What to Do If the ACE Write-Up Got It Wrong

An ACE-completed DBQ is challengeable on exactly the same grounds as any other C&P report:

• Inadequate report. If the examiner skipped the Functional Impact section, did not address flares, or did not cite specific records, raise an inadequate-exam argument under Stefl v. Nicholson and request a new exam under 38 CFR § 4.2.
• Factually inaccurate premise. If the examiner relied on a specific record that contains a factual error (misread date, wrong diagnostic code), the report has no probative value under Reonal v. Brown, 5 Vet. App. 458 (1993).
• Failure to address competing evidence. If you submitted a private DBQ or lay statements the ACE examiner ignored, that is reversible under Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), for lay evidence, and Nieves-Rodriguez v. Peake for the medical-opinion-weighing test.
• Missing in-person finding the rating schedule requires. A painful-motion rating under 38 CFR § 4.59 needs an examiner observation. A flare-up analysis under Sharp v. Shulkin needs an examiner discussion of flares. If the ACE write-up does not have it, the rating decision is appealable.

The right appeal lane depends on what the rating decision did with the ACE report:

• Rating decision relied on a thin ACE write-up but the evidence already in your file contradicts it: Higher-Level Review arguing the rater misweighed the existing record.
• You can produce new evidence the ACE examiner did not have (private DBQ, new specialist note, current symptom diary): Supplemental Claim with the new and relevant evidence.
• The ACE examiner missed an in-person finding the rating schedule requires: Supplemental Claim with a private DBQ that supplies the missing finding, paired with a request for a new VA exam.

See also the Letter Interpreter to decode the specific rating decision language and the 10 Most Common Claim Mistakes for the broader appeal-lane decision tree.

Related on this site

• C&P Exam Preparation: how to prepare even when the exam is records-only, the symptom diary still matters.
• C&P Exam Reference: the master reference page for all C&P exam types and required examiner credentials by condition.
• Bad C&P Examiner: how to challenge an inadequate exam, including an ACE write-up that misses required findings.
• How VA Raters Weigh Medical Opinions: the five-factor probative-value test applies to ACE reports too.
• Nexus Letters Guide: a private nexus letter is the strongest counter to a thin ACE write-up.
• TDIU Guide: how the Functional Impact section of an ACE-completed DBQ feeds the TDIU analysis.
• Painful Motion Rule: an in-person finding ACE cannot capture.
• Supplemental Claim Guide: the right appeal lane when you have new evidence the ACE examiner did not see.
• Higher-Level Review Guide: the right appeal lane when the rater misweighed the ACE report against the existing record.

Sources

1. VA.gov: VA claim exam (C&P exam), the public-facing explanation of the ACE process and when it is used.
2. M21-1, Part IV, Subpart i, Chapter 2, Section A: Examination Requests Overview, including the ACE process subsection.
3. 38 CFR § 3.326: Examinations.
4. 38 CFR § 4.2: Interpretation of examination reports.
5. 38 CFR § 4.6: Evaluation of evidence.
6. 38 CFR § 4.59: Painful motion (the in-person finding ACE cannot capture).
7. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008): the five-factor probative-value test applied to medical opinions, including ACE reports.
8. Stefl v. Nicholson, 21 Vet. App. 120 (2007): conclusory exam reports are inadequate.
9. Sharp v. Shulkin, 29 Vet. App. 26 (2017): flare-up analysis required even when the exam is not during a flare.
10. Reonal v. Brown, 5 Vet. App. 458 (1993): factually inaccurate premise has no probative value.
11. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006): lay testimony is competent evidence of observable symptoms.
12. NAVAO Fact Sheet 16-005, Acceptable Clinical Evidence (ACE) to Support the Disability Compensation Examination Process (December 2016).