M21-1 Manual  /  Part VIII, Subpart ii, Chapter 1, Section A

General Information on Presumptive Service Connection (SC) for Persian Gulf Veterans

M21-1, Part VIII, Subpart ii, Chapter 1, Section A

Overview

In This Section

This section contains the topic: “General Information on Presumptive SC of Undiagnosed Illness and Medically Unexplained Chronic Multi-Symptom Illness (MUCMI) for Persian Gulf Veterans.”


1. General Information on Presumptive SC of Undiagnosed Illness and MUCMI for Persian Gulf Veterans


Introduction

This topic contains general information on presumptive SC of undiagnosed illness and MUCMI for Persian Gulf Veterans, including
  • regulatory and statutory history regarding compensation for disabilities occurring in Persian Gulf Veterans
  • references governing Persian Gulf Veteran claims
  • presumptive SC under 38 U.S.C. 1117
  • definition of
    • Persian Gulf Veteran under 38 U.S.C. 1117
    • qualifying chronic disability under 38 CFR 3.317
    • undiagnosed illness
    • MUCMI, and
    • functional gastrointestinal disorders (FGIDs)
  • partially understood MUCMIs, and
  • signs and symptoms of undiagnosed illnesses or MUCMIs.

Change Date

June 6, 2025

VIII.ii.1.A.1.a. Regulatory and Statutory History Regarding Compensation for Disabilities Occurring in Persian Gulf Veterans

The table below discusses the regulatory and statutory history regarding compensation for disabilities occurring in Persian Gulf Veterans.
AuthorityProvisionsEffective Date of Change
Public Law (PL) 103-446The PL added a new section, 38 U.S.C. 1117, authorizing the Department of Veterans Affairs (VA) to compensate any Gulf War Veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which manifested either
  • during active duty in the Southwest Asia theater of operations during the Gulf War, or
  • to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the Gulf War.
November 2, 1994
PL 105-277Note: This law was codified as 38 U.S.C. 1118.Authorized VA to compensate Veterans who served on active duty in the Southwest Asia theater of operations during the Persian Gulf War for any diagnosed or undiagnosed illness that is determined by VA regulation to warrant a presumption of service connection (SC) based on a positive association with exposure to one of the following as a result of such service:
  • a biological, chemical, or other toxic agent
  • an environmental or wartime hazard, or
  • a preventive medication or vaccine.
N/A
PL 107-103Expanded the definition of “qualifying chronic disability” under 38 U.S.C. 1117 to include not only a disability resulting from an undiagnosed illness but also
  • a medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs and symptoms, and
  • any diagnosed illness that is determined by VA regulation to warrant presumption of SC.
March 1, 2002
38 CFR 3.317 rulemakingUpdated 38 CFR 3.317 to clarify that functional gastrointestinal disorders (FGIDs) fall within the scope of the existing presumptions of SC for MUCMIs.August 15, 2011
PL 117-168, Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022Enacted the following updates to 38 U.S.C. 1117:
  • removed the manifestation period and compensability requirement for Persian Gulf Veterans, allowing for a qualifying chronic disability to manifest to any degree of disability at any time, and
  • added additional locations associated with undiagnosed illness and MUCMI. In addition to the existing recognized service in the Southwest Asia theater of operations, the PACT Act added the following new service locations:
    • Afghanistan
    • Israel
    • Egypt
    • Turkey
    • Syria, and
    • Jordan.
    Note: Until 38 CFR 3.317 is updated, the above provisions regarding compensation for Persian Gulf War Veterans are governed by the statutory authority described in 38 U.S.C. 1117.
August 10, 2022
Reference: For more information on presumptive SC, see the Effective Date Job Aid for Presumptive Disabilities.

VIII.ii.1.A.1.b. References Governing Persian Gulf Veteran Claims

As noted in M21-1, Part VIII, Subpart ii, 1.A.1.a, the PACT Act enacted several changes to the presumptive SC provisions for Persian Gulf Veterans.The table below provides details on references governing the provisions of presumptive SC for Persian Gulf Veterans.
ProvisionReferences
General requirements for presumptive SC
Persian Gulf Veteran status
Qualifying chronic disability
  • undiagnosed illness, and
  • MUCMI
Chronicity requirements
Signs or symptoms of undiagnosed illness and MUCMI.

VIII.ii.1.A.1.c. Presumptive SC Under 38 U.S.C. 1117

Under current 38 U.S.C. 1117, there is a presumption of SC for Persian Gulf Veterans with a qualifying chronic disability that became manifest to any degree at any time.

VIII.ii.1.A.1.d. Definition: Persian Gulf Veteran Under 38 U.S.C. 1117

A Persian Gulf Veteran, under 38 U.S.C. 1117, is a Veteran who served on active duty in the Armed Forces during the Gulf War period in one of the locations listed in the table below.
Locations Authority
In or the airspace above the following:
  • Iraq
  • Oman
  • Kuwait
  • Gulf of Aden
  • Saudi Arabia
  • Gulf of Oman
  • the neutral zone between Iraq and Saudi Arabia
  • Red Sea
  • Bahrain
  • Arabian Sea
  • Qatar
  • Persian Gulf, or
  • United Arab Emirates.
38 CFR 3.317(e)(2)
In the following (airspace not included):
  • Afghanistan
  • Turkey
  • Israel
  • Syria
  • Egypt, or
  • Jordan.
38 U.S.C. 1117
Note: Per 38 U.S.C. 101(33), the Gulf War period extends from August 2, 1990, through a date yet to be determined by law or Presidential proclamation. Reference: For more information on establishing Persian Gulf Veteran status, see M21-1, Part VIII, Subpart ii, 1.B.1.d.

VIII.ii.1.A.1.e. Definition: Qualifying Chronic Disability Under 38 CFR 3.317

Qualifying chronic disability, under 38 CFR 3.317, means a chronic disability resulting from any of the following or any combination of the following:
  • an undiagnosed illness, or
  • an MUCMI.
References: For more information on

VIII.ii.1.A.1.f. Definition: Undiagnosed Illness

An undiagnosed illness is a type of chronic qualifying disability where qualifying signs and/or symptoms cannot be attributed to any known clinical diagnosis by history, physical examination and laboratory tests. References: For more information on
  • signs and symptoms of undiagnosed illness, see M21-1, Part VIII, Subpart ii, 1.A.1.j, and
  • reviewing the examiner’s determination of disability pattern, see M21-1, Part VIII, Subpart ii, 1.B.2.p.

VIII.ii.1.A.1.g. Definition: MUCMI

A medically unexplained chronic multi-symptom illness (MUCMI) is a type of chronic qualifying disability in which there is a diagnosed illness that has
  • either an inconclusive etiology or an inconclusive pathophysiology
  • overlapping symptoms and signs, and
  • features such as
    • fatigue and pain
    • disability out of proportion to physical findings, and
    • inconsistent demonstration of laboratory abnormalities.
Note: A multi-symptom illness is not an MUCMI if both the etiology and the pathology of the illness are partly understood.MUCMIs include but are not limited to
  • chronic fatigue syndrome
  • fibromyalgia, or
  • FGIDs, excluding structural gastrointestinal diseases.
Reference: For more information on the definition of an MUCMI, see Stewart v. Wilkie, 30 Vet.App. 383 (2018).

VIII.ii.1.A.1.h. Definition: FGIDs

Functional gastrointestinal disorders (FGIDs) are a group of diagnosed conditions that are a type of MUCMI. They are characterized by chronic or recurrent symptoms that are
  • unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease, and
  • may be related to any part of the gastrointestinal tract.
Characteristic FGID symptoms include
  • abdominal pain
  • substernal burning or pain
  • nausea
  • vomiting
  • altered bowel habits (including diarrhea, constipation),
  • indigestion
  • bloating
  • postprandial fullness, and
  • painful or difficult swallowing.
FGID diagnoses include but are not limited to
  • irritable bowel syndrome, and
  • functional
    • dyspepsia
    • vomiting
    • constipation
    • bloating
    • abdominal pain syndrome, or
    • dysphagia.
Diagnosis of a FGID under generally accepted medical principles normally requires
  • symptom onset at least six months prior to diagnosis, and
  • the presence of symptoms sufficient to diagnose the specific disorder at least three months prior to diagnosis.
Important: FGIDs do not include structural gastrointestinal diseases, such as inflammatory bowel disease (such as ulcerative colitis or Crohn's disease) and gastroesophageal reflux disease, as these conditions are considered to be organic or structural diseases characterized by abnormalities seen on x-ray, endoscopy, or through laboratory tests. Note: The effective date of the amendment to 38 CFR 3.317(a)(2)(i) to include FGIDs was July 15, 2011.Reference: For more information on FGIDs and MUCMIs, see Atencio v. O’Rourke, 30 Vet.App. 74 (2018).

VIII.ii.1.A.1.i. Partially Understood Chronic Multi-symptom Illnesses

Chronic multi-symptom illnesses of partially explained etiology and pathophysiology, such as diabetes and multiple sclerosis, are not considered medically unexplained and cannot be considered a qualifying chronic disability for purposes of 38 CFR 3.317. When adjudicating conditions with partially explained etiology, SC can only be awarded on another basis such as direct SC under 38 CFR 3.303 or presumptive SC under 38 CFR 3.307 and 38 CFR 3.309(a).Reference: For more information on direct SC for non-presumptive disabilities, see the PACT Act Implementation Standard Operating Procedure.

VIII.ii.1.A.1.j. Signs and Symptoms of Undiagnosed Illnesses or MUCMIs

38 CFR 3.317 specifies the following 13 categories of signs or symptoms that may be manifestations of an undiagnosed illness or an MUCMI:
  • joint pain
  • muscle pain
  • neurological signs or symptoms
  • headache
  • neuropsychological signs or symptoms
  • gastrointestinal signs or symptoms
  • abnormal weight loss
  • fatigue
  • sleep disturbances
  • respiratory signs and symptoms (upper and lower)
  • cardiovascular signs or symptoms
  • skin signs and symptoms, and
  • menstrual disorders.
Notes: Example: Sleep apnea cannot be presumptively service-connected (SC) under the provisions of 38 CFR 3.317 since it is a diagnosable condition. If claimed, sleep apnea must be considered on a non-presumptive SC basis.

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