C&P Exam for Residuals of traumatic brain injury (DC 8045)

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Diagnostic code: 8045Condition: Residuals of traumatic brain injury (TBI)Regulation: 38 CFR § 4.124aDBQ: DBQ NEURO Initial Evaluation of TBI

Which form the examiner uses

For residuals of traumatic brain injury (DC 8045), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What to expect at your C&P exam

A TBI exam looks at the lasting effects of a head injury across thinking, physical, and behavioral areas. The examiner scores ten specific facets, and the single highest facet level sets the rating under 38 CFR 4.124a, DC 8045.

1Initial interview (history)

  • How and when the head injury happened, and whether you lost consciousness.
  • Current symptoms: memory and concentration problems, headaches, dizziness, sensitivity to light or noise, irritability, mood changes, and sleep problems.
  • How symptoms affect work, relationships, and daily tasks.
  • Other conditions that overlap (PTSD, headaches), and current treatment.

2Physical examination

  • A neurological exam: strength, sensation, coordination, balance, reflexes, vision, and speech.
  • A check of memory, attention, and orientation.

3Diagnostic tests the examiner may rely on

Used to document the injury and its cognitive effects.

CT or MRI what's this?
Brain imaging to show structural injury.
Neuropsychological (cognitive) testing what's this?
Detailed testing of memory, attention, and problem-solving.

4Functional assessment

  • The exam scores ten facets, including memory and attention, judgment, social interaction, orientation, motor activity, visual-spatial skills, subjective symptoms, neurobehavioral effects, communication, and consciousness.
  • The single highest facet level sets the rating.
  • Symptoms that belong to a separately diagnosed condition (such as migraines or PTSD) are rated under that condition instead.
  • Findings map to 38 CFR 4.124a, DC 8045.

Test explainers open MedlinePlus (NIH National Library of Medicine), or Wikipedia where MedlinePlus has no matching page. This describes what happens and what is measured, not how to influence a result.

Rating Levels for DC 8045

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

Evidence cited in published BVA decisions for DC 8045

The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code, among issues the Board granted or denied (remanded issues are not included). Each row reports how often a given evidence type was discussed in the decision text, broken down by outcome. This is a factual aggregate of the public record, not a prediction or recommendation about any specific claim.

  • VA examination: appeared in 2901 granted decisions (6565 denied; 9466 decided total)
  • Service treatment records: appeared in 2196 granted decisions (5580 denied; 7776 decided total)
  • Buddy / lay statements: appeared in 1807 granted decisions (3886 denied; 5693 decided total)
  • Private medical opinion: appeared in 901 granted decisions (2065 denied; 2966 decided total)
  • Nexus letter: appeared in 828 granted decisions (816 denied; 1644 decided total)
  • Medical literature: appeared in 139 granted decisions (251 denied; 390 decided total)

What the Board discussed in granted decisions for DC 8045

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

  1. 19% Benefit of the doubt doctrine cited as inapplicable
    The Board noted that because the preponderance of the evidence weighed against the claim, the benefit of the doubt doctrine was found inapplicable and the claim was denied.
    97 of 500 sample sentences
  2. 18% Benefit of the doubt resolved in veteran's favor
    The Board recorded that because the evidence was in approximate balance or relative equipoise, the benefit of the doubt was resolved in the veteran's favor and the claim was granted.
    89 of 500 sample sentences
  3. 14% Positive nexus opinion noted for TBI or TBI residuals
    A VA or private examiner recorded an opinion that the veteran's TBI, or its residuals such as headaches, cognitive impairment, or other symptoms, was at least as likely as not incurred in or caused by active military service.
    72 of 500 sample sentences
  4. 12% Benefit of the doubt legal standard recited
    The Board cited the statutory or regulatory rule that when there is an approximate balance of positive and negative evidence on a material issue, the benefit of the doubt shall be given to the claimant.
    62 of 500 sample sentences
  5. 11% Evidence found in equipoise on service connection
    The Board found that the lay and medical evidence was at least in relative equipoise on the question of whether the veteran's disability was related to or incurred during active service.
    57 of 500 sample sentences
  6. 8% Positive nexus opinion noted for secondary or aggravation claims
    A VA or private examiner recorded an opinion that the veteran's disability was at least as likely as not proximately due to, caused by, or aggravated beyond its natural progression by a service-connected condition.
    41 of 500 sample sentences
  7. 7% Examiner opinion requested on TBI nexus or residuals
    The Board directed a VA examiner to provide an opinion with rationale as to whether the veteran's TBI or its residuals were at least as likely as not incurred in or related to service.
    33 of 500 sample sentences
  8. 3% Negative nexus or non-service-connection opinion noted
    A VA examiner recorded an opinion that the veteran's claimed condition was not at least as likely as not related to service or a service-connected disability, contributing to denial of the claim.
    17 of 500 sample sentences
  9. 3% TDIU or unemployability found supported by evidence
    The Board recorded that the evidence, including medical opinions and lay statements, supported a finding that the veteran's service-connected disabilities rendered him unable to secure or follow substantially gainful employment.
    16 of 500 sample sentences
  10. 3% Evidence in equipoise on disability rating level
    The Board found that the evidence was at least in equipoise as to whether the veteran's service-connected disability more nearly approximated the criteria for a higher disability rating.
    16 of 500 sample sentences

Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.