M21-1 Manual  /  Part V, Subpart ii, Chapter 3, Section C

Reviewing Diagnoses

M21-1, Part V, Subpart ii, Chapter 3, Section C

Overview

In This Section

This section contains the following topics:
TopicTopic Name
1General Principles for Review of Diagnoses
2Disability Associated With Functional Impairment of Earning Capacity
3Diagnoses Associated With Obesity
4Claims Involving Contentions of Infertility

1. General Principles for Review of Diagnoses

Introduction

This topic contains information on the general principles for review of diagnoses in claims for disability compensation, including
  • requirement for a disability
  • subthreshold diagnoses
  • elective procedures, and
  • abnormal laboratory findings.

Change Date

October 1, 2020

V.ii.3.C.1.a. Requirement for a Disability

In a determination of service connection (SC), the evidence must show that a disability exists as is described in 38 U.S.C. 1110 and 38 U.S.C. 1131. In some situations, regulations prescribe the criteria that must be met to establish a disability diagnosis for Department of Veterans Affairs (VA) purposes, such as forIn other situations, there are no statutory or regulatory criteria for diagnosis of a given disability. Reviewing the probative value and weight of a disability diagnosis is a key aspect of evidentiary review. Reference: For more information on reviewing and weighing evidence, see M21-1, Part V, Subpart ii, 1.A.

V.ii.3.C.1.b. Subthreshold Diagnoses

When specific medical diagnostic criteria exist for a disability, a treating physician may utilize a subthreshold diagnosis for the purpose of treating the symptoms when not all symptoms required for the diagnosis are present. Subthreshold diagnoses, such as pre-hypertension, pre-diabetes, Parkinson-like tremor, and others, are not adequate for use as a confirmed diagnosis for rating purposes. When a subthreshold diagnosis is made and the known diagnostic criteria are clearly not met, do not return a medical examination to clarify the diagnosis. Although a subthreshold diagnosis is acceptable for medical treatment purposes, it is not considered a ratable disability for compensation purposes. Reference: For more information on considering a diagnosis of pre-hypertension, see M21-1, Part V, Subpart iii, 5.3.d.

V.ii.3.C.1.c. Elective Procedures

Elective procedures, such as vasectomy, cosmetic breast reduction, or kidney donation, are not congruent with the disability requirement for the purpose of SC for a disease or injury incurred coincident with a Veteran’s active service. However, unusual or unanticipated outcomes resulting in an actually disabling condition that arise as a result of an in-service elective procedure may be subject to SC. References: For more information on considering SC for

V.ii.3.C.1.d. Abnormal Laboratory Findings

Abnormal laboratory findings, even if diagnosed, are not themselves disabilities subject to compensation for VA purposes. Such findings include, but are not limited to,
  • elevated blood sugar
  • hyperlipidemia
  • elevated triglycerides, or
  • elevated cholesterol.
Notes:
  • Although an abnormal laboratory finding is not a disability subject to compensation, a claim for SC for an abnormal laboratory finding meets the criteria for a complete claim as defined in 38 CFR 3.160(a)(4). Provided that all other criteria for a complete claim have been satisfied, the claim for SC for an abnormal laboratory finding requires full adjudication by rating decision.
  • Clarification may be necessary when there is a claim for a benefit based upon laboratory findings.
  • Do not solicit a claim based merely on abnormal laboratory findings discovered in the service treatment records.
Example: A claim for SC for “blood sugar” or “high blood sugar” may have been intended as a claim for diabetes. Development could substantiate that elevated blood sugar readings in service represented the onset of diabetes first diagnosed after service or that diabetes may have been diagnosed in a presumptive period.

2. Disability Associated With Functional Impairment of Earning Capacity

Introduction

This topic contains information on determining if pain or another condition may be accepted as a disability based on whether there is associated functional impairment of earning capacity, including
  • conditions resulting in functional impairment of earning capacity
  • evidentiary requirements to demonstrate functional impairment of earning capacity
  • impact of
    • Saunders v. Wilkie on pain alone without a diagnosis, and
    • Martinez-Bodon v. Wilkie on determinations regarding functional impairment of earning capacity
  • examples of pain alone without a diagnosis, and
  • example of functional impairment of earning capacity due to other condition.

Change Date

September 8, 2022

V.ii.3.C.2.a. Conditions Resulting in Functional Impairment of Earning Capacity

Pain alone or any condition resulting in functional impairment of earning capacity, even in the absence of a specific diagnosis or otherwise identified disease or injury, may constitute a disability under 38 U.S.C. 1110 or 38 U.S.C. 1131 for which SC may be granted. The Veteran’s pain or condition must result in functional impairment of earning capacity to constitute a disability. The term disability under 38 U.S.C. 1110 refers to the functional impairment of earning capacity, not the underlying cause of such disability. Therefore, pain alone or a condition resulting in functional impairment of earning capacity, even in the absence of a diagnosis, can qualify as a disability under 38 U.S.C. 1110 or 38 U.S.C. 1131 irrespective of the underlying cause.
  • Functional impairment of earning capacity must be demonstrated by credible medical and/or lay evidence. Functional impairment of earning capacity refers to limited ability or inability to perform occupational tasks to the extent that work performance, thus earning capacity, is impaired.
  • Examples of functional impairment of earning capacity include, but are not limited to,
    • inability to perform certain movements or tasks due to pain
    • time lost from work due to pain, or
    • pain resulting in increased fatigability or incoordination affecting job performance.
  • Subjective pain or other complaint(s) does not, by itself, establish the presence of a disability for the purpose of establishing SC. The decision maker must weigh a Veteran’s lay assertion of pain or other complaint(s) against any contrary medical or other evidence in determining the probative value of the evidence of record for the purpose of deciding whether a current disability is demonstrated.
  • The pain or other condition must cause functional impairment of earning capacity to constitute a disability, but there is no requirement that the pain manifest to a compensable level to establish the presence of a current disability under the law.
  • Pain or a condition resulting in functional impairment of earning capacity is sufficient evidence of a disability for any body system and is not limited to the musculoskeletal body system.
References: For more information on
  • considering functional impairment of earning capacity due to
    • pain alone without a diagnosis, as held in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), see M21-1, Part V, Subpart ii, 3.C.2.c, and
    • other conditions, as held in Martinez-Bodon v. Wilkie, 32 Vet.App. 393 (2020), see M21-1, Part V, Subpart ii, 3.C.2.d
  • assigning effective dates based on judicial precedents, see M21-1, Part V, Subpart ii, 4.A.7.a, and
  • determining the credibility of evidence, see M21-1, Part V, Subpart ii, 1.A.2.b.

V.ii.3.C.2.b. Evidentiary Requirements to Demonstrate Functional Impairment of Earning Capacity

The rating schedule may serve as a proxy for determining whether certain manifestations are capable of impairing earning capacity. However, there must be competent evidence specific to the claimant tending to show that the impairment rises to a level to affect earning capacity, which may include showing manifestations of a similar severity, frequency, and duration as those identified in the rating schedule as capable of causing impaired earning capacity in an average person. Merely pointing to a DC with symptoms or manifestations is not sufficient to establish that a disability with the same manifestations exists. The principles listed below apply when making a determination that pain or a condition results in functional impairment of earning capacity.
  • Subjective symptoms, such as complaints of pain, are not enough to establish the presence of a disability. The pain or condition must amount to a functional impairment (diminish the body’s ability to function).
  • An individualized assessment, which includes a preliminary evaluation of the degree of impairment, must be undertaken.
  • The mere existence of pain or a condition is not enough to constitute a disability. The pain or other condition must impair earning capacity.
Reference: For more information on the evidentiary standard to demonstrate functional impairment of earning capacity, see Wait v. Wilkie, 33 Vet.App. 8 (2020).

V.ii.3.C.2.c. Impact of Saunders v. Wilkie on Pain Alone Without a Diagnosis

The United States Court of Appeals for the Federal Circuit, in Saunders v. Wilkie, 886 F.3d 1356 (2018), overturned the longstanding Court of Veterans Appeals holding in Sanchez-Benitez v. West, 13 Vet.App. 282 (1999), that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which SC may be granted.
  • Saunders addresses what a “disability” is for the purpose of obtaining SC under 38 U.S.C. 1110. A separate case, Petitti v. McDonald, 27 Vet.App. 415 (2015), addresses the appropriate rating under VA regulations for musculoskeletal disabilities already deemed to be service-connected (SC) disabilities.
    • Saunders pertains to the issue of entitlement to SC and governs that a claimant’s pain “must amount to a functional impairment of earning capacity” to constitute a disability. Saunders is applicable for all body systems.
    • Petitti pertains to the issue of the disability evaluation assigned for a disability already found to be SC. Petitti directs that when assigning a disability evaluation, assuming 38 CFR 4.59 and 38 CFR 4.71a, DCs 5002 or 5003 are for application, “painful, albeit nonlimited, motion” is entitled to a minimum compensable rating per joint. This holding is applicable to musculoskeletal disabilities.
  • The Saunders holding is not a liberalizing rule warranting application of 38 CFR 3.114.
  • The Saunders holding is dated April 3, 2018, and applies to all claims or legacy appeals pending or received on or after that date.
Reference: For more information on determining when pain results in functional impairment, see
  • Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016)
  • Mitchell v. Shinseki, 25 Vet.App. 32 (2011), and
  • Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011).

V.ii.3.C.2.d. Impact of Martinez-Bodon v. Wilkie on Determinations Regarding Functional Impairment of Earning Capacity

The Court of Appeals for Veterans Claims (CAVC), in Martinez-Bodon v. Wilkie, 32 Vet.App. 393 (2020), defined a disability under 38 U.S.C. 1110 as including any condition that results in a functional impairment of earning capacity. CAVC clarified that this applies more broadly than to just pain.

V.ii.3.C.2.e. Examples of Pain Alone Without a Diagnosis

Example 1: The Veteran, during a VA examination, reports bilateral knee pain while performing various activities. The examiner finds no anatomic abnormality, weakness, or reduced range of motion; however, the examiner notes that the Veteran has functional limitations on walking, is unable to stand for more than a few minutes, and sometimes requires use of a cane or brace. An assessment of subjective bilateral knee pain is rendered and the examiner comments that the pain leads to increased absenteeism and impacts the Veteran’s ability to complete daily activities. Result: Although a specific diagnosis is not provided, a current disability under 38 U.S.C. 1110 is established as the pain is shown to result in functional impairment of earning capacity. Example 2: The Veteran, during a VA examination, complains of right shoulder pain. The examiner finds no pain, weakness, or abnormality. Repetitive motion does not elicit pain, and the examiner concludes that the Veteran would not develop pain during flare-ups or repeated use over time. The examiner comments that the subjective complaints of right shoulder pain would not impact the Veteran’s ability to perform any type of occupational task. Result: Although the Veteran’s complaints of right shoulder pain are credible, a current disability under 38 U.S.C. 1110 is not established as the evidence fails to demonstrate that there is any functional impairment of earning capacity due to the subjective right shoulder pain. Example 3: During a VA examination, the Veteran reports experiencing throbbing headaches with visual changes two to three times a week, necessitating lying down for several hours to obtain relief. The examiner reviewed employment records showing that the Veteran has had to leave work several times over the past few months due to headaches and private medical records showing visits for headaches. No obvious abnormalities were found. The examiner diagnosed subjective cephalgia. The examiner’s assessment was that the cephalgia impacts the Veteran’s ability to perform occupational tasks because the frequent episodes are so painful that the Veteran needs to cease all activity for several hours to obtain relief. Result: A current disability is demonstrated under 38 U.S.C. 1110. Although the cephalgia is subjective, the evidence is credible and demonstrates that the cephalgia results in functional impairment of earning capacity. Example 4: The Veteran complains of right knee pain during a VA examination. The examiner finds no anatomic abnormality, weakness, or reduced range of motion of the right knee. The examiner indicates that flare-ups or repeated use over time would not result in additional functional loss to include pain and loss of motion. The examiner does not provide any analysis as to whether the right knee pain impacts the Veteran’s ability to perform occupational tasks. An assessment of subjective right knee pain is given. Result: In this case, the examination report should be returned for the examiner to provide analysis as to whether the right knee pain impacts the Veteran’s ability to perform occupational tasks, unless this can be established by other credible evidence of record.

V.ii.3.C.2.f. Example of Functional Impairment of Earning Capacity Due to Other Condition

Example: The Veteran reported constant shortness of breath during a VA examination. No rales, rhonchi, wheezing, or diminished breath sounds were shown on examination. Pulmonary function testing revealed no restriction or obstruction. Subjective dyspnea was diagnosed. The examiner commented that while the objective testing was normal, the Veteran’s report of constant shortness of breath is legitimate and would be expected to cause limitations in any occupation that would require only minimal exertion. Result: A current disability is shown under 38 U.S.C. 1110. Although the Veteran’s report of dyspnea is subjective, it is shown to be credible and the condition is productive of functional impairment of earning capacity.

3. Diagnoses Associated With Obesity

Introduction

This topic contains policies and procedures for claims for compensation associated with obesity, including
  • considering direct SC for obesity
  • considering secondary SC for obesity
  • reasonably raised claims for secondary SC associated with obesity, and
  • examples of obesity determinations.

Change Date

May 1, 2026

V.ii.3.C.3.a. Considering Direct SC for Obesity

Obesity per se is not a disease or injury for the purposes of 38 U.S.C 1110 and 38 U.S.C. 1131 and therefore may not be SC on a direct basis. Obesity cannot qualify as an in-service event because it occurs over time and is based on various external and internal factors, as opposed to being a discrete incident or occurrence, or a series of discrete incidents or occurrences. References: For more information on
  • considering SC for obesity, see VAOPGCPREC 1-2017, and
  • whether CAVC has jurisdiction to review Board of Veterans’ Appeals decisions that obesity and dysmetabolic syndrome are not disabilities for the purposes of 38 U.S.C. 1110, see Larson v. McDonough, 10 F.4th 1325 (Fed. Cir. 2021).

V.ii.3.C.3.b. Considering Secondary SC for Obesity

Obesity per se is not a “disability” for the purpose of secondary SC under 38 CFR 3.310. If obesity resulting from an SC disease or injury is found to produce impairment beyond that contemplated by the applicable provisions of the rating schedule, consider an extra-schedular rating under 38 CFR 3.321(b)(1) for SC based on that impairment. Obesity may be an intermediate step between an SC disability and a current disability that may be SC on a secondary basis under 38 CFR 3.310(a) or on the basis of aggravation under 38 CFR 3.310(b). To determine whether obesity is an intermediate step between an SC disability and the development of a current disability that may be SC on a secondary basis, including by aggravation, the following criteria must all be satisfied:
  • the SC disability must have caused the Veteran to become obese
  • the obesity as a result of the SC disability must have been a substantial factor in
    • causing the claimed disability, or
    • aggravating the claimed disability, and
  • the claimed disability would not have occurred but for the obesity caused or aggravated by the SC disability.
Example: A Veteran claims secondary SC for hypertension, asserting that inability to exercise from SC back symptoms caused obesity leading to hypertension. To grant SC, an adjudicator would have to resolve the following issues: (1) whether the SC back disability caused the Veteran to become obese; (2) if so, whether the obesity as a result of the SC disability was a substantial factor in causing hypertension; and (3) whether the hypertension would not have occurred but for obesity caused by the SC back disability. If these questions are answered in the affirmative, the hypertension may be SC on a secondary basis. References: For more information on
  • considering SC for obesity, see VAOPGCPREC 1-2017
  • considering SC based on aggravation of obesity, see Walsh v. Wilkie, 32 Vet.App. 300 (2020), and
  • extra-schedular consideration, see M21-1, Part V, Subpart ii, 3.D.3.

V.ii.3.C.3.c. Reasonably Raised Claims for Secondary SC Associated With Obesity

Obesity as an intermediate step for secondary SC is only reasonably raised when there is evidence in the record that draws an association or suggests a relationship between the Veteran’s obesity, or weight gain resulting in obesity, and an SC disability. Incidental references to a Veteran’s weight or weight gain are not sufficient to reasonably raise the issue. Reference: For more information on identifying reasonably raised claims for SC for obesity, see Garner v. Tran, 33 Vet.App. 241 (2021).

V.ii.3.C.3.d. Examples of Obesity Determinations

Extra-Schedular Evaluation Example: A Veteran is SC for rheumatoid arthritis with a 40-percent evaluation and is shown to be unable to exercise due to the debilitating nature of the disease. Competent medical evidence shows that the Veteran developed obesity as a result of the inability to exercise and the obesity results in additional pain, weakness, and instability of the joints that produces functional loss beyond that shown to solely result from the rheumatoid arthritis. The evidence does not support a higher schedular evaluation under 38 CFR 4.71a, DC 5002 or a higher evaluation based on separate evaluation of the affected joints. Result: In view of the record showing that obesity results from the SC rheumatoid arthritis and produces impairment beyond that contemplated by the regular rating criteria, a determination should be rendered as to whether referral for consideration of an extra-schedular evaluation under 38 CFR 3.321(b)(1) is warranted. Intermediate Step Example: The Veteran’s SC psoriasis is manifested by constant flare-ups that require near-continuous treatment with Prednisone for management. The near-continuous use of Prednisone on a long-term basis resulted in obesity, which was medically shown to lead to the development of coronary artery disease (CAD). Result: Based on the evidence, the obesity is shown to be an intermediate step between the SC psoriasis and CAD, which satisfies the causation requirement under 38 CFR 3.310(a) to establish SC for CAD on a secondary basis. Reference: For more information on extra-schedular evaluations, see M21-1, Part V, Subpart ii, 3.D.3.


4. Claims Involving Contentions of Infertility

Introduction

This topic contains information on claims involving contentions of infertility, including
  • the definition of infertility
  • rating a claim for a disability resulting in infertility
  • special monthly compensation (SMC) associated with SC conditions resulting in infertility, and
  • examples involving infertility.

Change Date

September 30, 2025

V.ii.3.C.4.a. Definition: Infertility

Infertility, for the purpose of SC disability benefits, is the inability to successfully procreate (with or without medical intervention), as a result of a Veteran’s SC injury or disease.

V.ii.3.C.4.b. Rating a Claim for a Disability Resulting in Infertility

Do not establish SC for “infertility” as a stand-alone condition for compensation purposes. Instead, a claim for infertility should be accepted as a claim for the underlying injury or disease causing infertility and rated as such.Notes:References: For more information on

V.ii.3.C.4.c. SMC Associated With SC Conditions Resulting in Infertility

When SC is granted for a condition resulting in infertility, award special monthly compensation (SMC) based on anatomical loss or loss of use (LOU) of a creative organ.Reference: For more information on entitlement to SMC (k) for anatomical loss or LOU of a creative organ, see

V.ii.3.C.4.d. Examples Involving Infertility

Example 1: A Veteran files a claim for SC for “infertility.” The evidence shows a diagnosis of endometriosis beginning in service, with treatment for endometriosis and infertility treatments post-service. VA examination diagnoses endometriosis with resultant infertility. Result: Grant SC for endometriosis, the underlying disease that causes the infertility. Do not establish SC for “infertility.” Award SMC based on LOU of a creative organ.Example 2: A Veteran who is SC for type 2 diabetes mellitus files a claim for “infertility.” The evidence shows that after SC was established, the Veteran developed erectile dysfunction related to the diabetes. No worsening of the underlying diabetic process is claimed or shown by the evidence. Result: Grant SC for erectile dysfunction as a complication of type 2 diabetes mellitus, the underlying injury or disease that causes the infertility. Do not establish SC for “infertility.” Award SMC based on LOU of a creative organ.Example 3: A Veteran files a claim for SC for “infertility” but does not claim or identify any underlying cause of infertility and is not SC for any disabilities that could account for infertility. A thorough review of the evidence does not identify an underlying injury or disease causing infertility. Result: The claims processor attempts to contact the Veteran for clarification of the claim as outlined in M21-1, Part III, Subpart i, 2.D.1.c, but is unsuccessful. Deny SC for infertility.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart ii, Chapter 3, Section C (U.S. government work, reproduced for reference). Browse all sections →