M21-1 Manual / Part IV, Subpart i, Chapter 2, Section E

Examinations in Special Situations

M21-1, Part IV, Subpart i, Chapter 2, Section E

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	Aid and Attendance (A&A) and Housebound Examinations
2	Special Issue Claims and Other Types of Examination Requests
3	Pre-Discharge Examinations
4	Examinations of Pregnant Claimants
5	Independent Medical Opinions (IMOs)

1. A&A and Housebound Examinations

Introduction

This topic contains information about A&A and housebound examinations, including

purpose of an A&A and housebound examination
when an A&A and housebound examination may be useful
requesting an A&A and housebound examination, and
locally devised checklists.

Change Date

September 22, 2023

IV.i.2.E.1.a. Purpose of an A&A and Housebound Examination

The aid and attendance (A&A) and housebound examination is designed to

pinpoint findings relevant to A&A determinations under 38 CFR 3.351 and 38 CFR 3.352, and
provide a basis for determining if the housebound benefit may be paid if the need for A&A is not shown.

IV.i.2.E.1.b. When an A&A and Housebound Examination May Be Useful

It may be useful to request an A&A and housebound examination before a final determination is made, especially if the evidence of record demonstrates a reasonable probability of entitlement to A&A or housebound benefits but is not sufficient to allow the benefit. Note: As provided in 38 CFR 3.326, an examination is not required and should not be pursued if the evidentiary record is otherwise sufficient to independently support entitlement to A&A or housebound benefits.

IV.i.2.E.1.c. Requesting an A&A and Housebound Examination

Use the table below when requesting an A&A and housebound examination. Notes:

A disability benefits questionnaire (DBQ) does not exist at this time for A&A and housebound examinations.
A&A examinations do not require condition-specific DBQs unless a claim for an increased rating is received or found to be within scope of the claim for special monthly compensation (SMC) as noted in M21-1, Part II, Subpart iii, 1.A.3.c.

If the examination is being requested through the ...

Then ...

Compensation and Pension Record Interchange (CAPRI)

select AID AND ATTENDANCE OR HOUSEBOUND EXAMINATION from the LIST OF EXAMS menu, and
ensure any relevant information for the examiner is placed in the COMMENTS field.

Veterans Benefits Management System (VBMS)

add the specific service-connected (SC) condition(s) upon which the claim is based to the A&A contention in the RATED ISSUE(S) field under the CONTENTIONS chevron in VBMS
associate the examination scheduling request (ESR) with the A&A contention, ensuring that its classification type is Special Monthly Compensation – Aid and Attendance/Housebound
ensure any other relevant information for the examiner is placed in the ADDITIONAL INFORMATION field, and
ensure the DBQ A&A Worksheet – VA Form 21-2680 is selected.

Note: When the SC condition(s) applicable to the claim for A&A or housebound benefits is/are added to the A&A contention, as described above, standard language will automatically populate in the ESR indicating that the Veteran is claiming A&A or housebound benefits based on the selected SC condition(s).

References: For more information on

developing for A&A and housebound status under 38 CFR 3.351, see M21-1, Part IX, Subpart ii, 1.A.3, and
requesting examinations in
- general, see M21-1, Part IV, Subpart i, 2.A
- CAPRI, see the CAPRI User Manual, and
- VBMS Exam Management System (EMS), see the
  - VBMS Core User Guide, and
  - EMS User Guide.

IV.i.2.E.1.d. Locally Devised Checklists

Regional offices (ROs) are not authorized to create local checklists for A&A and/or housebound examinations. Checklists created and submitted by individual treatment providers should be evaluated as any other item of evidence. However, Yes or No blocks do not provide sufficient descriptive information to assess the extent of a claimant’s incapacitation.

2. Special Issue Claims and Other Types of Examination Requests

Introduction

This topic contains information about other types of examination requests, including

examinations of non-Veteran claimants and beneficiaries
hospital observation
field examinations
examinations of incarcerated Veterans
board examinations
reexaminations by a different examiner
homeless Veterans examination requests, and
examinations in claims involving foreign residence.

Change Date

September 24, 2025

IV.i.2.E.2.a. Examinations of Non-Veteran Claimants and Beneficiaries

As the facts of an individual case demand, the rating activity may schedule examinations of non-Veteran claimants and beneficiaries

only after approval by the Veterans Service Center Manager or Pension Management Center Manager or a designated reviewer, or
to determine if a
- claimant is entitled to A&A or housebound benefits
- Chapter 18 birth defect diagnosis exists
- claimant was insane at the time the claimant caused the death of the Veteran
- dependent child or child claimant is incapable of self-support and/or incompetent, and/or
- beneficiary is competent to handle funds.

References: For more information on
Chapter 18 birth defects eligibility and development, see M21-1, Part VIII, Subpart i, 3.C
determining when an examination is required to resolve the question of permanent incapacity for self-support, see M21-1, Part X, Subpart ii, 6.B.2.b
the facts to be considered in a wrongful and intentional death, see M21-1, Part X, Subpart iv, 2.B.3, and
submitting ESRs in VBMS for non-Veteran claimants/beneficiaries, see the EMS User Guide.

IV.i.2.E.2.b. Hospital Observation

To properly visualize and evaluate complex disability issues, the rating activity may request a period of hospitalization for observation and examination.

IV.i.2.E.2.c. Field Examinations

Request a field examination when it is not possible, through the routine examination process, to

determine the competency of the beneficiary
assess employment and social adjustment, or
substantiate items of evidence regarding the existence of disease or injury prior to enlistment.

Reference: For more information on requests for field examinations, see M21-1, Part X, Subpart v, 1.E.

IV.i.2.E.2.d. Examinations of Incarcerated Veterans

An incarcerated Veteran is entitled to a Department of Veterans Affairs (VA) compensation examination as part of the duty to assist. When examination of an incarcerated Veteran is required, the RO and/or Veterans Benefits Administration (VBA) contract examination provider must confer with prison authorities to determine whether the Veteran should be

escorted to a VA medical facility for examination by Veterans Health Administration (VHA) personnel, or
examined at the prison by
- VBA contract examination providers
- VHA personnel, or
- fee-basis providers contracted by VHA.
Important:
- Because some State laws restrict the movement of and access to prison inmates, the above options may not be possible. In such cases, documentation of substantial efforts to schedule and conduct the examination must be added to the claims folder.
- ROs must include the following information, to the extent that it is known, in examination requests for incarcerated Veterans:
  - name of the correctional facility
  - location of the correctional facility
  - circumstances of confinement (nature/type of conviction, level of institutional security, etc.), and
  - whether the Veteran is considered violent.
- ROs must document all efforts made to schedule an examination, including identifying and requesting the assistance of the appropriate prison officials.
- VHA compensation clinics and VBA contract examination vendors are required to provide documentation that they have
  - made substantial attempts to schedule and conduct the examination, and
  - exhausted all possible avenues for obtaining access to the incarcerated Veteran for the examination.
- If the examination provider has exhausted examination efforts to no avail, treat a Veteran’s inability to attend a necessary examination (claim-related or review) by reason of incarceration as the equivalent of a failure to report, and take appropriate action in accordance with M21-1, Part IV, Subpart i, 2.F. If the evidence shows that failures in scheduling or conducting an examination are associated with the Veteran’s release from incarceration or transfer to another facility, then a showing of good cause should be liberally construed.
Notes:
- When requesting an examination for an incarcerated Veteran, ensure that the Incarceration corporate flash, has been properly applied to the associated corporate record.
- When requesting an examination for an incarcerated Veteran through VBMS, claims processors must select Incarcerated Veteran from the VETERAN PRIORITY ISSUES drop-down menu under the CLAIM INFORMATION tab.
- Request any examination(s) needed in support of an incarcerated Veteran’s claim for individual unemployability (IU) benefits, as discussed in M21-1, Part VIII, Subpart iv, 3.B.2, even though there may be no award of such benefits while the Veteran is incarcerated.
References: For more information on
- requesting examinations in VBMS, see the
  - VBMS Core User Guide, and
  - EMS User Guide
- limitations on payment of compensation for incarcerated Veterans, see
  - M21-1, Part VI, Subpart iv, 1.A.2.a, and
  - 38 U.S.C. 5313
- effect of incarceration on ratings of IU, see
  - M21-1, Part VIII, Subpart iv, 3.C.4.c
- VA’s duty to examine incarcerated Veterans, see
  - Bolton v. Brown, 8 Vet.App. 185 (1995), and
  - Wood v. Derwinski, 1 Vet.App. 190 (1991), and
- VHA policy on incarcerated Veteran examinations, see the DMA C&P Disability Examinations Procedure Manual.

IV.i.2.E.2.e. Board Examinations

There should be at least two physicians, preferably three, on “board examinations,” and at least one (but preferably all) should be a recognized specialist in the particular field involved. The rating activity has the authority to request board examinations to

reconcile differing diagnoses, or
resolve particularly complex issues concerning
- awards of SMC, or
- entitlement to specially adapted housing.

IV.i.2.E.2.f. Reexaminations by a Different Examiner

The rating activity may request that the claimant be reexamined by another medical examiner if compelling reasons exist. To request a reexamination

prepare another examination request
annotate it to show that reexamination is necessary
identify any specific information needed in the examination report, and
include the name and the facility of the medical examiner who conducted the prior examination.

Reference: For more information on preparing examination requests, see M21-1, Part IV, Subpart i, 2.A.

IV.i.2.E.2.g. Homeless Veteran Examination Requests

ROs must expedite the processing of all claims submitted by Veterans who are

homeless, or
at immediate risk of homelessness.

Depending upon the Examination Request Routing Assistant (ERRA) tool's recommendations, use the appropriate system to request these examinations, and ensure that the following comment (or its near equivalent) is included in the body of the examination request: Claim for a homeless or at imminent risk of homelessness Veteran. Expeditious processing is requested. References: For more information on
priority processing of claims from homeless Veterans, see M21-1, Part X, Subpart i, 1
interpreting the ERRA tool’s results, see M21-1, Part IV, Subpart i, 2.A.2.d, and
selecting the appropriate application for requesting examinations, see M21-1, Part IV, Subpart i, 2.A.2.f.

IV.i.2.E.2.h. Examinations in Claims Involving Foreign Residence

Examinations in claims involving foreign residence should only be requested by claims processors at a station with jurisdiction to process the foreign claim.After a designated foreign claims processor has requested an examination for a claimant residing in a foreign country, a contract examination vendor may generate a request for clarification indicating that particular contentions require examination outside of the contract vendor’s network. In such cases, the contract vendor will identify one of the following processes as required to examine the specified contention(s):

Alternative Medical Evidence (AME) Process, or
Single Source Subcontracted Examination (SSSCE) Process.

Following receipt of this communication from the contract vendor, a foreign claims processor will apply the appropriate Foreign Out-of-Network (FOON) special issue indicator to the specified contention(s), either the FOONAME or FOONSSSCE special issue indicator.Important:

The FOONAME and FOONSSSCE special issue indicators should only be applied by designated foreign claims processors at stations with jurisdiction over foreign claims.
If one or more of the FOON special issue indicators is discovered upon review of a claim, verify the location of the claimant’s address. If the claimant has a domestic address, remove the special issue indicator(s) from all contentions.

References: For more information on
jurisdiction of claims involving foreign residence, see
M21-1, Part II, Subpart ii, 3.1.b, and
M21-1, Part X, Subpart i, 3.A.2.a
requests for clarification, see M21-1, Part IV, Subpart i, 2.A.10.c, and
special issue indicators, see M21-4, Appendix E, 2.

3. Pre-Discharge Examinations

Introduction

This topic contains information about pre-discharge examinations, including

who is eligible for pre-discharge examination
what the Separation Health Assessment (SHA) covers and its usage, and
general medical examinations and the SHA.

Change Date

September 24, 2025

IV.i.2.E.3.a. Who Is Eligible for Pre-Discharge Examination

Pre-discharge claim submission is available to service members with no more than 180 days remaining until discharge. References: For more information on
who may file a pre-discharge claim, see M21-1, Part X, Subpart i, 6.A.1.b, and
claims that are not processed prior to discharge, see M21-1, Part X, Subpart i, 6.B.1.b.

IV.i.2.E.3.b. What the SHA Examination Covers and Its Usage

The Separation Health Assessment (SHA) is a single examination that supports transitioning service members seeking VA disability compensation under the Benefits Delivery at Discharge (BDD) or Integrated Disability Evaluation System (IDES) programs. The SHA also

satisfies Department of War (DOW) requirements for separation/retirement, and
provides service members with an improved general medical examination, to include an audiogram and a full laboratory analysis via VA examination protocols.

To reduce duplication of agency efforts, VA will provide DOW an electronic copy of the SHA for BDD and IDES participants. For those not participating in the BDD or IDES programs, DOW will conduct its Separation History Physical Examination and include the assessment in the service member’s service treatment records (STRs). Prior to VA conducting the SHA, the service member must submit a Separation Health Assessment – Part A Self Assessment (SHA, Part A). Pre-discharge claims processors must ensure an SHA, Part A, is in the service member’s electronic claims folder prior to requesting the SHA in VBMS. Notes:
All claimed and reported issues at the SHA examination must be addressed by VA completing the appropriate DBQ for each issue.
However, in order to add any conditions to a pending claim, the claimant is required to file a claim on the appropriate form.
A separate DBQ, including for a specialist examination, is generally not warranted or necessary for conditions that are legally ineligible for service connection (SC) for compensation purposes.
All unclaimed but reported or suspected issues at the examination must be addressed in the General Medical – Separation Health Assessment Disability Benefits Questionnaire, along with any abnormal findings identified and any appropriate additional DBQ(s). There is no requirement, however, for the examiner to complete additional DBQs in conjunction with the General Medical – Separation Health Assessment Disability Benefits Questionnaire for subjective complaints rendered at the time of examination without objective findings noted at that time.
If a service member complains of ringing in the ears or tinnitus during the examination, a Hearing Loss And Tinnitus Disability Benefits Questionnaire must be completed by the examiner. A specific claim for tinnitus is not necessary in order for the audio examination to be required, or for the audio examiner to be required to address tinnitus.
References: For more information on
conditions that are legally ineligible for SC, see
38 CFR 4.9
38 CFR 3.303(c), and
38 CFR 3.381(b)
when a specialist examination is not warranted for conditions that are not subject to SC, see M21-1, Part IV, Subpart i, 2.A.6.a
hearing loss and tinnitus medical opinions, see M21-1, Part IV, Subpart i, 2.A.7.h, and
special claims-handling procedures for BDD claims, see M21-1, Part X, Subpart i, 6.C.1.b.

IV.i.2.E.3.c. General Medical Examinations and the SHA

Effective October 2013, all eligible BDD claimants receive an SHA in lieu of a general medical examination. Those claimants who file pre-discharge claims that are excluded from the BDD program, however, will continue to require a general medical examination and should not be examined under the SHA protocol. When ordering an examination for a BDD claim, select the General Medical - Separation Health Assessment Disability Benefits Questionnaire and add the following comment: BDDclaim. References: For more information on

the General Medical - Separation Health Assessment Disability Benefits Questionnaire, see DMA Fact Sheet 24-001, Pre-Discharge Examinations and Referral of Service Members for Mental Health Services During Transition
pre-discharge claims, eligibility requirements, and exclusion from BDD processing, see M21-1, Part X, Subpart i, 6.A and B
the responsibility of BDD coordinators in ensuring that appropriate examinations are conducted, see M21-1, Part X, Subpart i, 6.B.3.b
handling when an initial examination for a pre-discharge claim is requested after discharge, see M21-1, Part X, Subpart i, 6.B.3.f
claims-handling procedures for BDD claims, including entering examination requests, see M21-1, Part X, Subpart i, 6.C.1.b
follow-up requirements for BDD examinations, see M21-1, Part X, Subpart i, 6.C.1.e
special considerations on requesting examinations for BDD-excluded claimants, see M21-1, Part X, Subpart i, 6.C.2.e
responsibilities in the SHA exchange with the service department, see M21-1, Part X, Subpart i, 6.C.3.c, and
requesting examinations for pre-discharge claims involving an undiagnosed illness or a medically unexplained chronic multi-symptom illness due to exposures during Gulf War era service, see M21-1, Part VIII, Subpart ii, 1.B.2.o.

4. Examinations of Pregnant Claimants

Introduction

This topic contains information about examinations for pregnant claimants, including

general information on examinations for pregnant claimants
ancillary conditions of pregnancy
tests not recommended for pregnant claimants
how pregnancy affects participation in pre-discharge programs, and
options for processing claims for pregnant claimants.

Change Date

May 11, 2023

IV.i.2.E.4.a. General Information on Examinations for Pregnant Claimants

Many pregnant claimants submit claims for conditions that are either

directly related to pregnancy, or
acute and transitory and expected to resolve upon delivery.

Some physical examinations and routine tests required to accurately evaluate the disabilities identified in claims are complicated and not recommended for or normally performed on pregnant women since they may pose a significant health risk to the woman or baby. Note: To the extent permissible and/or possible, utilize the Acceptable Clinical Evidence (ACE) Process to examine pregnant claimants.

IV.i.2.E.4.b. Ancillary Conditions of Pregnancy

Some ancillary conditions common to pregnancy are

anemia
back pain
edema in the legs
gestational diabetes
hypertension
shortness of breath, and
urinary tract infections.

IV.i.2.E.4.c. Tests Not Recommended for Pregnant Claimants

The prevention of unnecessary risks or negative outcomes is a priority for both the mother and unborn child. Examination validity during pregnancy is also a concern due to mechanical, hormonal, and metabolic changes in the mother during pregnancy. Tests and procedures that are not recommended for pregnant claimants include

x-rays
pulmonary function tests (PFTs)
range of motion examinations
gait testing
laboratory testing, and
any other examination or procedure that may place the mother and/or unborn child at risk.

Note: When pregnancy is known, include in the examination request a comment indicating that the claimant is pregnant.

IV.i.2.E.4.d. How Pregnancy Affects Participation in Pre-Discharge Programs

Pregnant service members may file pre-discharge claims up to 180 days prior to separation/retirement. Since pregnancy prohibits certain diagnostic tests and procedures, the examiner may be unable to accurately assess the claimant’s medical condition. This may preclude completion of an examination and the rating process for certain issues until conclusion of the pregnancy. Claims processors must include the following remarks in any examination request for a pregnant pre-discharge claimant: Please be advised that this individual has indicated a current pregnancy. If the examining physician determines that this examination (or any part of this examination) is medically contraindicated, please clearly indicate which parts of the examination were not completed due to the pregnancy.Further, the examiner should indicate the earliest date that the examination may be safely completed.For pre-discharge claims, the receiving RO will rate any claimed conditions that may be awarded based on the existing STRs, evidence of record, and examination findings, and defer consideration of any additional disabilities that could not be examined until conclusion of the pregnancy. Note: For examination purposes, conclusion of the pregnancy is generally considered to be three months following delivery. References: For more information on
partial rating decisions and deferrals, see M21-1, Part V, Subpart ii, 3.B, and
handling cases involving pregnant
BDD claimants, see M21-1, Part X, Subpart i, 6.D.5, and
IDES participants, see M21-1, Part X, Subpart i, 6.K.3.

IV.i.2.E.4.e. Options for Processing Claims for Pregnant Claimants

There are three options for processing claims for pregnant claimants. The receiving RO should determine, on an individual basis, which of the following actions is appropriate based on the claimed contentions:

defer the entire examination until conclusion of the pregnancy
rate the entire claim based on existing STRs and evidence of record, or
rate any claimed conditions that may be awarded based on existing STRs and evidence of record, and defer consideration of any additional disabilities that may not be examined until conclusion of the pregnancy.

Example: SC for an amputated finger can be awarded based on STRs, but the other claimed issues require specific tests that are prohibited due to pregnancy and must be deferred until the pregnancy concludes and a full examination can be conducted. Exception: If the pregnant claimant is a participant in a pre-discharge program, refer to guidance in M21-1, Part IV, Subpart i, 2.E.4.d. Reference: For more information on partial rating decisions and deferred issues, see M21-1, Part V, Subpart ii, 3.B.

5. IMOs

Introduction

This topic contains information about IMOs, including

definition of an IMO
who may initiate a request for an IMO
submitting a request for an IMO, and
processing requests for an IMO.

Change Date

August 22, 2024

IV.i.2.E.5.a. Definition: IMO

An independent medical opinion (IMO), as discussed in 38 CFR 3.328, is
a type of advisory medical opinion that may be obtained from one or more recognized medical experts who are not VA employees, and
only warranted in connection with
claims of significant medical complexity and/or controversy, and/or
fulfillment of instructions contained in a remand order from the Board of Veterans' Appeals (BVA).
Note: As discussed in M21-1, Part IV, Subpart i, 2.E.5.d, VA Central Office has the responsibility for deciding if the IMO is warranted.

IV.i.2.E.5.b. Who May Initiate a Request for an IMO

A request for an IMO under 38 CFR 3.328, in conjunction with a pending claim, may be initiated by the

RO
claimant
claimant’s representative, or
BVA.

IV.i.2.E.5.c. Submitting a Request for an IMO

Submit a request for an IMO

in writing
through a designated reviewer, and
by stating, in detail,
- the reasons why the opinion is necessary, and
- the specific information or opinion required.

IV.i.2.E.5.d. Processing Requests for an IMO

The table below describes how to process a request for an IMO under 38 CFR 3.328 and identifies the responsible parties.

Stage	Who Is Responsible	Description
1	rating activity, or service organization representative	Brings the request for an IMO to the attention of the designated reviewer.
2	designated reviewer	Decides whether the request has merit.
3	designated reviewer	Does the request have merit? If yes, refers the compensation claim request to Compensation Service following procedures outlined in M21-1, Part X, Subpart v, 1.A.1.g, or pension/survivor’s request to Pension and Fiduciary (P&F) Service for review containing all required information outlined in M21-1, Part X, Subpart v, 1.A.1.e including a block for P&F Service Director or designee signature to satisfy 38 CFR 3.328, and following procedures outlined in M21-1, Part X, Subpart v, 1.A.1.f. If no, denies the request without the need for referral to Compensation Service or P&F Service. *Important*: This determination may only be contested as part of a legacy appeal or notice of disagreement (NOD) to BVA on the primary issue under consideration.
4	Compensation Service, or P&F Service	Decides whether the request has merit and notifies the designated reviewer as to the appropriate action to take.
5	designated reviewer	Does the request have merit? If yes, notifies the claimant that the request has been approved obtains the opinion from the appropriate medical expert, and sends a copy of the opinion to the claimant when it is available. If no, notifies the claimant, if initiated by the claimant or duly appointed representative. *Important*: This determination may only be contested as part of a legacy appeal or NOD to BVA on the primary issue under consideration.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part IV, Subpart i, Chapter 2, Section E (U.S. government work, reproduced for reference). Browse all sections →