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DRAFT SAMPLE

Medical Disability Examination Office

Examination Handbook

Table of Contents

Purpose This Examination Handbook provides essential details, information, guidance, and requirements for the completion of VA C&P disability examinations.

Medical Disability Examination Types The Vendor will provide, based on specific VA request, the full range of medical disability examinations for conditions of the following

1. Audiological

2. Cardiovascular

3. Dental and Oral

4. Dermatological

5. Endocrinological

6. ENT (Ear, Nose, Throat)

7. Gastrointestinal

8. Genitourinary

9. Gynecological

10. Hematologic and Lymphatic

11. Infectious Diseases

12. Musculoskeletal

13. Neurological

14. Nutrition

15. Ophthalmological

16. Psychological

17. Respiratory

18. Rheumatological Specialist Examinations Audiological, Dental and Oral, Ophthalmological, and Psychological examinations must be conducted by specialists in those fields. Additionally, for Initial Traumatic Brain Injury (TBI) examinations where a previous diagnosis of TBI has not been made by a Neurologist, Neurosurgeon, Physiatrist, or Psychiatrist, only specialists in these clinical disciplines who have also completed required VA MDE certification and TBI training courses can perform these examinations. The Vendor shall ensure examiners who perform Spina Bifida examinations shall be trained in physiatry (physical medicine and rehabilitation), neurology, neurosurgery, or occupational medicine.

Special Purpose Examinations In some cases, a claim may not be adequately captured by one of the examination types listed above in Part A, thus are referred to as special purpose examinations. These currently include Spina Bifida, Aid and Attendance or Housebound, Cold Injury Residuals, Former Prisoner of War (POW) Protocol; Gulf War General Medical Examination, Pre-discharge (Integrated Disability Evaluation System (IDES) & Benefits Delivery at Discharge (BDD)), DIC (Dependency and Indemnity Compensation) claims, and 1151 (Benefits for Persons Disabled by Treatment or Vocational Rehabilitation) case reviews with independent medical opinions. In some cases, examinations are defined by VA policies and priorities and are subject to change. Currently this category includes Camp Lejeune contaminated water subject matter independent medical opinions.

General Medical Examinations General Medical Examinations represent comprehensive base-line examinations covering all parts of the body. Cold injury residual examinations and aid and attendance or housebound status examinations, when requested, are also included in the General Medical Examination category.

Examination Requirements Claims Folder Review The following examinations require a claims folder review by the Examiner; this list is subject to change at VA’s discretion:

1. Environmental Hazards in Iraq, Afghanistan, and Other Military Installations

2. Cold Injury Residuals

3. Former Prisoner of War (FPOW) Protocol

4. Gulf War General Medical to include Burn Pits

5. Medical Opinions, including TERA opinions and etiology opinions

6. Psychological (Mental Disorders DBQ, Initial PTSD DBQ, Review PTSD DBQ)

7. Traumatic Brain Injury

8. Musculoskeletal examinations involving:

a. Ankle

b. Back (thoracolumbar spine)

c. Elbow and forearm

d. Foot, including flatfoot (pes planus)

e. Hand and finger(s)

f. Hip and thigh

g. Knee and lower leg

h. Neck (cervical spine)

i. Shoulder and/or arm

j. Temporomandibular disorders

k. Wrist

9. Board of Veterans Appeals (BVA) & Court of Appeals for Veterans Claims (CAVC) Remands

10. 1151 Claim Exams

11. Acceptable Clinical Evidence (ACE)

12. Pre-Discharge and IDES Claims

13. When specifically requested in the Examination Scheduling Request (ESR)

14. Any case in which the Examiner needs additional information to confirm or provide a clinically accurate diagnosis.

Establishing Diagnoses for Newly Claimed Conditions A Claimant can provide competent lay evidence regarding his/her symptoms or condition, and such information must be considered by the examiner in formulating a diagnosis. However, in establishing a diagnosis, the diagnosis must be based on competent medical evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Examiners can obtain competent medical evidence from existing medical records located in the Veteran’s claims folder. Additionally, if warranted, and in conformance with the DBQ, the examiner may conduct relevant objective diagnostic testing or assessments that would sufficiently confirm or establish the diagnosis. Subjective information or lay evidence from the Veteran is always relevant and essential, however, for conditions that are not fundamentally subjective conditions, diagnoses must be based on competent medical evidence.

Clarification of Medical History for Claims for Increase The medical history description for the onset of the condition is not required for claims for increase (as indicated on the ESR.) If clinically relevant medical history from the time of the last examination (such as a recent surgery) was mentioned, the examiner must report this in the medical history section.

Examination Specialist Unavailable In certain circumstances, Board of Veterans’ Appeals (BVA) remands may require a specific healthcare specialist (for example a neuro oncologist) to conduct an examination or provide a medical opinion. If an examination cannot be completed as requested in the Exam Scheduling Request (ESR) due to the unavailability of the specific healthcare specialist, the Contractor shall proceed to schedule the appointment(s) with an available Examiner who, as closely as possible, aligns with the specialty requested. The Contractor must also upload a document using the generic schema labeled “Specialist Unavailable” providing explanation as to why the requested examination specialist is not available to conduct the C&P examination for VA purposes (for example, rural area or Claimant with a foreign address).

The Contractor may use a general medical provider to complete a physical examination and a specialist of the type identified by BVA to complete any required Medical Opinion(s) unless Veterans Benefits Administration (VBA) guidelines specify use of a specific provider type, such as for mental health examinations. This does not supersede existing DBQ instructions and/or contract guidance regarding who may conduct an Initial Evaluation of TBI DBQ, psychological DBQ, or provide a neurology reconciliation.

Military Sexual Trauma (MST) C&P Examination — Specialized Support Veterans who have experienced MST require a heightened level of care and coordination throughout the C&P examination process. Contractors shall utilize a service model built around specialized support for MST-designated claims — from the first point of contact through final examination report submission — ensuring every Claimant feels supported, respected, and informed at each step.

All clinicians conducting MST-related examinations shall be held to an elevated standard, demonstrating specialized training in trauma-informed care, MST-specific clinical frameworks, and VA examination requirements. Contractors shall ensure that all clinicians conducting MST-related examinations are equipped with both clinical competency and their proven ability to engage trauma survivors in a compassionate, non-retraumatizing manner. Contractors shall provide end-to-end accountability that ensures every Claimant with an MST-designated claim receives not just a compliant examination, but a genuinely supportive experience.

Functional Impairment and Subjective Complaints of Pain The Federal Circuit Court case Saunders v. Wilkie pertains to the issue of entitlement to service connection and governs that a claimant’s pain “must amount to a functional impairment of earning capacity” to constitute a disability. The term disability refers to the functional impairment of earning capacity, not the underlying cause of such disability. Thus, pain alone, even in the absence of a diagnosis, can serve as a functional impairment and qualify as a disability irrespective of the underlying cause. Therefore, subjective complaints of pain alone, even in the absence of a specific diagnosis or otherwise identified disease or injury, may constitute a disability for which service connection may be granted. Consequentially, contract examiners must list the veteran’s complaints to include the veteran’s subjective complaints of pain concerning his/her disability in the Medical History section, of the respective DBQ. Examiners are reminded that pain 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. Saunders is applicable for all body systems. Accordingly, examiners are reminded they must complete the Functional Impairment section of the DBQ, along with all applicable parts of pertinent physical findings, complications, signs, symptoms and scars, when the veteran reports subjective complaints of pain, even in the absence of a diagnosis.

Diagnostic and Ancillary Testing The need for ancillary testing will vary depending on the individual being examined, the claimed condition(s), and DBQ requirements. See Part D for guidance specific to Psychological and Neuropsychological Testing Upload and Documentation. In all other cases, include results of any clinical testing or imaging results conducted in relation to the exam scheduling request or as required by the DBQ. Additionally, the examiner shall summarize or otherwise note prior diagnostic testing or imaging they deem clinically relevant to the current exam. In cases where a medical opinion is requested, current and prior clinical testing and/or imaging for the condition at issue shall be referenced and summarized. The DBQ Requirements and Compliance section identifies the most common diagnostic or ancillary testing required for each DBQ.

Required Testing Certain test results are necessary to establish a diagnosis, to provide the current status on an established diagnosis, and to properly adjudicate a claim. If there are no tests of record to establish a diagnosis or condition, the test required by the DBQ will be performed. An examination report returned with a statement that a claimed condition could not be established because the DBQ tests were not performed is deemed unacceptable. The only exceptions are when the required DBQ tests were either: (1) not medically advisable, (2) declined by the claimant, (3) VA declined to approve a requested invasive procedure, or (4) a claimant was a “no show” to the test. A statement must be included in the Remarks section explaining why the DBQ test(s) were not performed.

The DBQ Requirements and Compliance section indicates those tests that are required for each Questionnaire, whether the testing is already of record or may need to be performed in conjunction with the current examination. If recent testing has been performed within the timeframes listed in Part C, Recent Testing, and there has been no significant change in the condition since the testing, additional testing is not warranted. Invasive testing and imaging (other than x-rays) is seldom warranted and requires prior authorization as described in Part H, Invasive and Noninvasive Procedures and Tests, if requested in conjunction with a current examination.

All Questionnaires require inclusion of pertinent past test results for newly claimed conditions, and interim new test results that are available and pertinent since the last time a service-connected condition was evaluated for a Compensation and Pension (C&P) claim. Any testing that is performed as part of the current C&P examination must be documented in the Questionnaire and the full report included as part of the submitted Results Available Package (RAP). See Part D for guidance specific to Psychological and Neuropsychological Testing Upload and Documentation.

Repeat Testing Performing repeat testing to confirm an established diagnosis or condition is unnecessary unless the current testing of record does not accurately reflect the Claimant’s current status and repeat testing is needed to determine severity of the condition (this does not apply to already established degenerative or post traumatic arthritis of a joint as described in Section IX. DBQ Requirements and Compliance, Musculoskeletal).

Recent Testing If test results are documented in the record and available to the examining clinician for review, those tests need not be repeated unless specifically requested by the VARO or there is indication of recent changes in the condition examined. For a new diagnosis, testing should be obtained if not already of record. For an established diagnosis, if testing is not reflective of the current state of the condition, it should be repeated EXCEPT in the case of new imaging for an established diagnosis of arthritis which is not required. A non-diagnostic test should not be repeated unless required by the examining clinician to determine the severity of a condition.

The following defines what is considered current physical examination findings, laboratory results, and other diagnostic results:

Physical Examination: Findings not older than 12 months should be used, including vital signs (BP, pulse/HR, weight, etc.).

Lab: For current status of a condition, results should be no older than 12 months (e.g., CBC, Chem, LFT, UA, HbA1c, hormonal values, etc.).

Radiological imaging: For an increase in a service-connected condition, imaging should be no older than 12 months (e.g., X-rays, CT scan, MRI’s, Ultrasound). Note that the diagnosis of arthritis requires initial imaging: repeat imaging shall not be conducted once the diagnosis is confirmed, even if the condition has worsened. Procedures such as a CT scan, MRI or ultrasound are generally not warranted for evaluation of new or currently service-connected conditions.

Echocardiogram (Echo) and Pulmonary Function Tests (PFTs): No older than 12 months.

Invasive workup: For increase in a service-connected condition, the procedure should be no older than 12 months (e.g., cardiac stress test, biopsies, colonoscopies, EGD, EEG, EMG, etc.). EMG studies are not required to diagnose peripheral nerve conditions and should not be ordered.

Audiologic test results: Not older than 12 months.

Sleep studies:

If a sleep study is of record, repeat testing shall not be performed when an existing diagnosis is present and accurately reflects the claimant's current sleep apnea condition.

Documenting Testing in the DBQ In all cases, include results of any clinical testing or imaging results conducted in relation to the exam scheduling request or as required by the DBQ. Additionally, the examiner shall summarize or otherwise note prior diagnostic testing or imaging, they deem clinically relevant to the current exam. In cases where medical opinion is requested current and prior clinical testing and/or imaging for the condition at issue shall be referenced and summarized.

Unless otherwise specified in the DBQ instructions, Contractors should cite one of the following for diagnostic testing:

Month and year of the study/test date, or Month and year of the read/interpretation/signed date in the DBQs.

Psychological and Neuropsychological Testing Upload and Documentation There are legal, clinical, and ethical constraints on the disclosure of psychological and neuropsychological test data and test materials. Psychologists and Neuropsychologists shall comply with guidelines for professional practice as required by ethics codes, licensing regulations, and other relevant standards that can vary substantially depending on the specific assessment instrument, the vulnerabilities of a given Claimant, and the release of test data to non-clinicians.

Therefore, to limit legal and professional risk exposure, psychological/neuropsychological testing materials (e.g., assessment instruments, forms, or test protocols; interpretation reports; claimant responses; etc.) shall not be uploaded to the eFolder. Examiners who administer or order psychological/neuropsychological testing must document in the Remarks or appropriate testing section of the associated DBQ which assessment instruments were administered and summarize the findings. If the psychological/neuropsychological testing is completed by a clinician other than the examiner signing the DBQ, the Contractor must upload the testing report outlining the tests performed and findings, ensuring no test data or test materials are included.

For any psychological or neuropsychological testing performed, the full instrument’s raw scoring and results must be available for MDEO review as requested. Examiners must follow their local licensing board requirements for storage and record retention of psychological testing materials.

Screening instruments (i.e., brief, non-diagnostic) do not constitute psychological/neuropsychological testing; however, the same upload and documentation requirements outlined above shall apply.

Ancillary Diagnostic and Screening Testing

Ancillary testing will vary depending on the individual being examined.

Approved diagnostic and screening testing includes, but is not limited to:

Audio ScreeningSnellen’s Visual Acuity Screening HemOccult

PSA

EKG

Chest X-Ray Complete Blood Count (CBC) Lipid panel: Comprehensive Metabolic Panel (CMP) Hepatitis C Screening Urinalysis PAP Smear HIV Screening Fasting Glucose Rapid Plasma Reagent (RPR) Contraindicated Testing and Procedures An examiner may be unable to conduct certain medical testing when a testing procedure is contraindicated in the setting of a disability examination, as opposed to a treatment setting, because it is potentially harmful, goes against medical standards, or would require follow-up care after the examination.

When completing an examination, if it is determined specific testing is medically contraindicated, whether it is part of a standard VA examination or part of a Board remand directive, the examiner must clearly state in the examination report:

· What testing procedure was not completed.

· The reason that particular test was needed or requested.

· An explanation of why the testing procedure is contraindicated for a disability examination.

· If appropriate, an explanation why the testing procedure could not be completed due to a persistent characteristic of the Veteran’s condition that is not reasonably expected to change.

· Why another testing procedure or already available evidence is sufficient as an alternative to the requested testing procedure, if applicable.

Unsuccessful Diagnostic Testing When diagnostic testing cannot be completed due to unforeseen issues arising on the part of the claimant (e.g., difficult blood draw; incomplete data from sleep study; claimant uncomfortable in testing environment; poor effort or lack of cooperation during pulmonary function testing), the examiner should annotate and explain within the DBQ what the issue was, which test(s) could not be completed, and whether a diagnosis was or was not able to be rendered based on the evidence in the claims folder.

Example, the Veteran was unable to give satisfactory effort during the pulmonary function test (PFT). The examiner should note that the Veteran did not give satisfactory effort with the testing and that the PFTs are not a valid indication of the respiratory condition, however a diagnosis of Asthma is provided based on the indicated evidence. If the testing cannot be completed because of unforeseen circumstances arising on the part of the vendor examiner, test administrator, or equipment, the tests must be rescheduled and/or recompleted.

Requesting Invasive and Noninvasive Procedures and Tests Determining the Need for Invasive and Noninvasive Procedures and Tests Prior to requesting an invasive or non-invasive procedure or diagnostic test outside of what is required by the DBQ, the Contractor examiner must:

1) Examine the Claimant’s claims file (e-Folder) to verify if there is already an established diagnosis for the claimed condition, to include pertinent diagnostic tests.

2) Obtain the history of the claimed condition, perform a physical examination of the Claimant, and develop the differential diagnoses for any newly claimed or undiagnosed condition, taking into account the evidence of record.

3) Note both the subjective complaints and objective clinical findings and ensure that they are consistent with the proposed diagnosis for the claimed condition.

4) Review the accompanying medical records within the Claimant’s e-Folder:

a. Identify the evidence of record for any documented signs and symptoms which are consistent with the claimed condition and support a diagnosis.

b. Determine whether the testing or procedure being considered has previously been conducted in the course of medical evaluation and/or treatment related to the claimed condition in order to avoid unnecessary testing simply to confirm prior test results.

c. If the Contractor examiner believes that repeat testing is needed due to the condition worsening, or the existing tests do not accurately reflect the current severity, and no other method is available to do so, the submitted request should include comments on the clinically relevant test(s) already of record and explain why the proposed testing is necessary.

5) Adhere to the following guidelines when considering whether an invasive or non-invasive procedure or testing request is warranted:

a. For an initially claimed condition or diagnosis, if invasive or non-invasive testing is of record and establishes or confirms the diagnosis, even if it is from many years prior, repeat testing is not required solely to reconfirm the previous diagnosis. For example, if prior diagnostic and current clinical findings support a diagnosis of chronic gastritis, including an esophagogastroduodenoscopy (EGD) with biopsy result from 10 years ago, and the Claimant reports their symptoms have not significantly changed, subsequent testing is not required to confirm the previous diagnosis, regardless of the age of the EGD report.

b. For established service-connected conditions:

i. If there is an invasive test or procedure result of record, regardless of its age, and symptoms remain consistent with previous assessments or other evidence supporting the examination findings, the test or procedure does not need to be repeated from a disability examination perspective. Exceptions may include situations in which repeat testing is specifically indicated by a Board of Veterans’ Appeals directive or special request, taking into consideration whether testing would be medically contraindicated for the particular Claimant, and if it meets medically accepted standards to answer a particular medical question. Non-invasive testing methods should be utilized as the most appropriate first line choice when possible.

ii. If a non-invasive test or procedure result is of record and there is no evidence of significant change in the Claimant’s subjective symptom severity or other objective evidence on examination or in the medical records, the test or procedure does not need to be repeated unless it is required by the DBQ, the Board of Veterans’ Appeals, or a special request.

c. Historical acute episodes that have fully resolved without residuals do not justify requesting an invasive or non-invasive test or procedure and do not support a diagnosis of a chronic condition.

d. The need for diagnostic testing should be determined using clinical findings from treatment records reviewed within the e-Folder, findings obtained during the relevant examination, the requirements listed within the DBQ, and the Contractor examiner's professional medical judgement. Contractor examiners must avoid routinely requesting any invasive test or procedure for evaluation of a particular condition without first considering the medical contraindications and absolute clinical necessity in the context of a VA disability examination.

e. If there is an absence of clinical findings to support a diagnosis during an examination, an invasive or non-invasive test or procedure is not required by VBA to confirm the lack of a diagnosis.

Requesting Invasive and Non-Invasive Procedures and Testing

1) The Contractor examiner must follow all guidance and procedures outlined above to determine whether an invasive or non-invasive procedure or test is clinically necessary in the context of a VA disability examination and able to be performed. If the Contractor examiner determines that an invasive or non-invasive procedure or test is definitively indicated and pre-authorization is required, they shall provide their reasoning to the Contractor Requestor for submission to MDEO for consideration of approval by an MDEO Medical Officer.

2) Requests shall be submitted by the Contractor Requestor through the Contractor Request for Invasive & Non-Invasive Test & Procedure Portal – Power Apps, which will also send a notification to the respective CORs. Information required to be submitted in the portal is listed below. Contractor Requestors must have secure PIV access to be able to initiate requests within the portal since they become the Contractor Point of Contact (POC) for the request and response.

3) The Contractor Requestor must submit the request by filling out the form located at Request for Invasive and Non-Invasive Testing and Procedures - Power Apps link.

4) All information required by MDEO Medical Officers and to notify MDEO CORs to process the query is to be included in the Request for Invasive and Non-Invasive Testing and Procedures Form in the portal.

5) Placing a request in the portal requires the following information:

i. Veteran’s Last Name

ii. Veteran’s First Name

iii. Veteran’s File Number (This is the Claimant’s 8- or 9-digit file number)

iv. Is this request based on a BVA remand?

v. Contractor

vi. Contract/Region

vii. Contractor examiner’s Name (This is the name of the Contractor examiner who is requesting the procedure or test; first name/last name.)

viii. Contractor examiner Type (This is the Contractor examiner’s title, i.e., Dentist or Doctor of Dental Surgery (DDS) / Doctor of Dental Medicine (DMD)/ Doctor of Chiropractic (DC)/ Doctor of Medicine (DM)/ Doctor of Osteopathic Medicine (DO)/ Nurse Practitioner (NP, APRN, ARNP, DNP)/ Physician Assistant (PA / PA-C))

ix. This request is for: (select one) Invasive procedure/test OR Non-invasive procedure/test

x. Procedure Requested: (This is the name or type of procedure or test being requested by the Contractor examiner.)

xi. Claimed Contention: (This is the Claimant’s contention for which the procedure or test is being requested.)

xii. DBQ Requested: (This is the DBQ being completed for the claimed condition and for which the procedure or test is being requested.)

xiii. Reason for Request: (This is the rationale or reason provided by the Contractor examiner for needing the requested procedure or testing. This should include notation of any relevant prior testing, procedures or evidence of record reviewed that led to this determination.)

xiv. Contractor Requestor (The individual placing this request; will also be the POC to whom MDEO will send the evaluation and decision (approval or denial) via encrypted email with explanation, therefore PIV access to receive encrypted email required.)

Invasive Tests and Procedures to Avoid The list below identifies tests and procedures that should be avoided due to concerns regarding medical contraindications, safety, and potential need for follow-up care. This list is not intended to be all inclusive and may be updated at any time.

· Endoscopies to include cystoscopy, upper endoscopy, gastroscopy, esophagogastroduodenoscopy (EGD), bronchoscopy, laryngoscopy, nasal endoscopy, colonoscopy

· Biopsies including bone marrow

· Colposcopy

· Laparoscopy

· Arthroscopy

· Joint aspiration and/or injection

· Lumbar puncture (spinal tap)

· Thoracentesis

· Paracentesis

· Cardiac catheterization

· Transesophageal echocardiogram

· Endoscopic retrograde cholangiopancreatography (ERCP)

· Electromyography (EMG)

· Any procedure generally requiring a signed informed consent form by the Veteran

· For additional definitions of invasive procedures, please see VHA Directive 1039(3) Noninvasive Tests and Procedures to Avoid

· Nuclear testing including cardiac stress test, PET scan

· Imaging with contrast including certain types of x-rays (e.g., barium swallow), computed tomography (CT), magnetic resonance (MR)

· Unusual or expensive blood tests or stool testing not on the DBQ such as genetic testing, panels for antibody testing such as for autoimmune diseases, etc.

· Testing that does not meet standard guidelines for diagnostic purposes

Abnormal Findings Abnormal Findings Alert The Contractor shall alert the Claimant of any abnormal findings identified during the examination, noting that the Claimant should follow up with their primary physician. Confirmation that findings were communicated through approved methods to the Claimant shall be documented in the Vendor Portal and the Claimant Portal.

Abnormal Findings Claimant Communication If other critical and/or life-threatening conditions such as cancer or heart disease are identified during the examination, the Examiner shall advise the Claimant of the existence of the condition and provide confirmation in the Remarks section of the DBQ that the Claimant was advised of the condition. Critical and/or life-threatening testing results requiring immediate care or hospitalization, as determined by the Examiner and consistent with Standard of Care, shall be communicated immediately with the Claimant by the most expedient means available. Abnormal but not critical results shall be communicated within 48 hours. Abnormal findings do not have to be limited to a claimed condition.

These findings are not typically applicable to psychological examinations (Initial Posttraumatic Stress Disorder (PTSD), Review PTSD, Mental Disorders, Eating Disorders). In cases of life-threatening mental health findings, the Protecting Vulnerable Claimants guidance in the contract shall be followed to document specific results which may be life-threatening or require immediate care or hospitalization.

Abnormal Findings Documentation In the event of new abnormal findings upon exam, the Contractor must add the following in the Remarks section of each DBQ (excluding the Initial PTSD, Review PTSD, Mental Disorders, and Eating Disorders DBQs):

1) New Abnormal Findings were noted on this exam

a) Is there a need for the Claimant to follow up with his/her primary care provider regarding any life threatening or abnormal findings in this examination (not limited to claimed condition(s))? YES/NO.

b) If YES: Was the Claimant notified to follow up with his/her primary care provider? YES/NO

2) Was a copy of the test result identifying the life threatening or abnormal findings provided to the Claimant or Claimant’s primary care provider? YES/NO NOTE: Providing a copy of life threatening or abnormal findings to the Claimant is an acceptable exception to the rule concerning release of information.

In cases when the DBQ is not completed due to abnormal findings, the Contractor will document that abnormal findings were identified without a DBQ exam, and notify the COR. The COR will be notified within 24 hours of all events resulting in the hospitalization of the Claimant, or transport to the Emergency Department.

If abnormal findings are noted prior to the completion of the DBQ, the Contractor will document the information and upload to the VBMS eFolder as required. The MDEO office email address (Contract.Exam.VBAVACO@va.gov) and the COR will be notified via an Incident Report of any events resulting in the hospitalization of the Claimant, or transport to the Emergency Department, within 24 hours of the incident. Medical documentation identifying critical and or life-threatening test results shall be released to the VA within 24 hours.

Telehealth for Compensation and Pension (Tele-C&P) Medical Disability Examinations Tele-C&P can provide accurate and fully descriptive face-to-face evaluations for VBA rating purposes through the utilization of telehealth video technologies. Claimants should be offered Tele-C&P as an option for disability examination appointments when applicable and available. Tele-C&P expands Claimants’ options to obtain medical disability examinations nationwide and in supporting territories and nations.

Tele-C&P examinations shall not be conducted solely by telephone; the examiner shall have “face to face” interaction with the Claimant. The conference shall take place in real time and not be “store and forward” case review.

DBQ Suitability for Tele-C&P For medical disability examination purposes, the DBQs that are most suitable for Tele-C&P are those that do not always require hands-on interaction between the C&P Examiner and Claimant. With the high-quality equipment currently available, many components of the C&P evaluation can be completed with telehealth technologies. If there are no equipment considerations, or there are alternative forms of technology that are medically acceptable and can be utilized, then Tele C&P may be applicable. However, if it is anticipated or determined that an examiner is unable to satisfy certain DBQ requirements using Tele-C&P technologies, such as obtaining vital signs (e.g., blood pressure, weight, etc.) and/or the potential recording of scars of an uncomplicated nature (e.g., no pain, stable, less than 39 square CM, not located on the head, face or neck) then use of Tele C&P may not be possible or appropriate.

The DBQ Requirements and Compliance section identifies DBQs potentially suitable for being completed using Tele-C&P for medical disability examination purposes and considerations for equipment that potentially may be needed or required by each DBQ.

An in-person examination may still be required for additional and/or triggered DBQs identified during a Tele-C&P examination.

Tele-C&P Requirements Tele-C&P examinations shall adhere to the following requirements:

a) Use of clinical video conferencing, also referred to as telehealth technologies, shall adhere to industry standards in performing medical examinations through the use of telehealth.

b) The Contractor shall document on the DBQ that clinical videoconferencing was used for the referred examination

d) The Contractor shall ensure examiners are properly trained to perform telehealth examinations, including a standardized training manual for clinicians that the Contractor shall develop

e) The Contractor shall outline a procedure to positively identify Claimants at the start of each telehealth examination

f) The Contractor shall verify the Claimant’s physical location and address for emergency purposes at the time of exam

g) Claimant shall be willing to participate in Tele-C&P examination.

h) Claimant shall acknowledge and accept limits of clinical videoconferencing for their compensation and pension examination Tele-C&P Equipment The Contractor shall only utilize software and technology which has been certified as HIPAA compliant by the US Department of Health and Human Services. It is the responsibility of the Contractor to ensure that the examiner has the appropriate equipment to complete Tele-C&P examinations The Contractor shall not require the Claimant to purchase any equipment for the examination.

A technology failure is only considered such once the video conference has been successfully established at the outset of the Tele-C&P examination and is then unexpectedly disrupted and cannot be restored back to the intended full use of that modality alone (i.e., an alternative process is needed). Contractors will follow a consistent process in addressing technology failures during telehealth appointments, prioritizing ethical practice and patient safety.

The source of the technology failure can be on the part of the Contractor or the Veteran/Service Member being examined, or both, and in some cases the source may be unknown. Regardless, in the event of a technology failure during a Tele-C&P examination, any steps to re-start, re-connect, and fix the problem should be attempted first, communicating such with the Veteran or Service Member if possible.

In the event that the technology failure cannot be fixed, the Contractor shall implement and document, in accordance with the VBA Tele-C&P Examination Technology Failure Plan, developed by Contractor, using the alternatives outlined.

Procedures: Technology failures during videoconferencing may include but are not limited to one or more of the following:

• Video Failure

• Audio Failure

• Loss of Internet Connectivity

• Device Failure (i.e., computer/laptops, tablet, smartphone)

• Other issues In the event that one or more of the noted common technology failures occurs during the clinical videoconference and after at least one unsuccessful attempt of at least five minutes to restore the Tele-C&P examination back to the intended full use of that modality alone, the following alternatives are offered:

1) If there is audio failure, attempt to add an audio component via the telephone.

2) If there is video failure continue the examination using the audio component.

3) If there is video or audio failure and if at a point in the examination where it is clinically feasible to complete the examination via the telephone, then do so.

4) If there is a loss of internet connectivity, device failure, other issues and if at a point in the examination where it is clinically feasible to complete the examination via telephone, then do so.

5) In the event that the examiner determines that it is not clinically feasible to complete the remainder of the examination using these alternatives, the examiner should ensure safety to end the examination due to technology failure and reschedule (notifying the Claimant and the Contractor).

In the event of a technology failure, the examiner should make every attempt to keep the Claimant apprised of any actions being taken to re-establish connection, resume with alternatives, or reschedule the examination.

Claimant Eligibility for Tele-C&P Participation To determine eligibility to participate in a telehealth evaluation, called a Tele-C&P exam, the Contractor shall contact the Claimant by phone. During the phone contact there is to be an explanation addressing concerns of privacy, dignity, and confidentiality, and assurance that the Tele-C&P session is not recorded. The Claimant must consent to the Tele-C&P examination modality. If during this telephone contact the Contractor establishes that any of the following exclusionary factors render the Claimant unable to effectively communicate using telehealth technologies, the Claimant shall not be scheduled for a Tele-C&P examination:

a. Hearing impairment

b. Vision limitations

c. Language barrier

d. Speech impediment

e. Memory deficit

f. Impaired ability to verbalize/express information.

Tele-neuropsychological Testing It is permissible for Neuropsychologists to administer testing using telehealth technologies (Tele-neuropsychological testing) when the Claimant possesses the mental capacity and adequate sensory abilities to participate and the following conditions are met:

a. Neuropsychologists shall make the final determination that remote Tele-neuropsychological testing is appropriate based on a specific Claimant’s individual circumstances, presentation, and relevant case details.

b. Neuropsychologists shall perform Tele-neuropsychological testing only when it is within their scope of practice and training.

c. Neuropsychologists shall make clinical decisions that are consistent with applicable, up-to-date standards of practice, professional guidelines, and medical knowledge.

d. Neuropsychologists shall use only assessment instruments that are appropriate for administration via telehealth technologies as supported by, e.g., test publisher instructions, peer-reviewed literature, wide acceptance within the community of practice, etc.

e. Neuropsychologists shall adjust their test selections to best fit the needs of a particular case, prioritizing tests that have demonstrated similar outcomes when compared to standard face-to-face administration and require minimal to no deviation from the test’s standardized administration and/or scoring protocols.

f. Neuropsychologists shall describe limitations of the testing modality in their clinical reports, including modifications to standardized test administration and/or scoring, and how these may have affected test results and interpretations.

g. Neuropsychologists shall discontinue Tele-neuropsychological testing sessions when they are ineffective, and the Contractor shall make alternative arrangements to complete testing.

h. Neuropsychologists shall establish procedures for storing (e.g., filing, archiving) and disposing (e.g., shredding) of test materials, incorporating relevant ethical, legal, and professional record retention standards.

Terminating Tele-C&P Examinations If the following factors apply during a Tele-C&P session, the session shall be terminated:

a. Claimants who are or become acutely violent or unstable with poor impulse control. Additionally, the examiner should follow procedures for protecting vulnerable Claimants.

b. Claimants who show signs of cognitive disturbance and/or become uncomfortable with the Tele-C&P process.

c. Claimants are unwilling or unable to participate in a meaningful way.

d. Claimants are actively psychotic and unable to participate secondary to the nature of their illness.

e. Claimants with psychotic disorders that may be exacerbated through use of technology. (e.g., ideas of reference regarding television) Acceptable Clinical Evidence (ACE) Process When appropriate, a method for responding to requests for C&P disability examinations is the Acceptable Clinical Evidence (ACE) process. For information about VA’s use of AI in ACE process development, please refer to the section on Artificial Intelligence.. .

The ACE process involves completing DBQs using the medical evidence currently in existence in a Claimant’s eFolder or medical records, and supplemented by an interview (phone or video) with the Claimant when necessary, instead of requiring some Claimants to be examined in-person. ACE is an alternative to an in-person examination for those conditions that do NOT require a physical examination to determine the severity of a disability and still requires a complete and thorough evaluation of the evidence available for the claimed condition. The examination is reviewed based on the same quality standards as in-person examinations.

ACE is only to be used when: 1) VBA has not specified that an in-person or telehealth examination be conducted, 2) when a Contractor examiner determines that available medical evidence of record exists that is considered current and up-to-date to complete the DBQ and render the medical opinion as requested, 3) when any missing information may be obtained through conducting an interview with the Veteran, 4) the addition of the embedded “ACE” statement is selected by the clinician on any DBQs completed by the ACE process, and 5) when not otherwise listed as an ACE Exclusion per the Contract. When using the ACE process, all current MDE exam criteria, DBQ requirements, and VBA policies remain applicable and are to be fulfilled.

DBQs completed through the ACE process have the same goal and are held to the same quality criteria as DBQs completed through traditional in-person examinations. There are instances in which all the information required to diagnose, confirm treatment, etc., is not available or obtainable via the ACE process. DBQs must not be completed and submitted to VA without accurate, complete, and current information.

Medical Evidence of Record for ACE Consideration Determining medical evidence to be adequate for completing the evaluation as required by DBQ instructions will be specific to the exam type requested. If the existing medical and other pertinent evidence is not adequate to sufficiently complete the evaluation, or additional information is required beyond that which could reasonably be obtained by a phone or video interview, the Claimant must be scheduled for an in-person medical examination or Tele-C&P examination as appropriate.

For new disability exam requests, examiners need to ensure that they are utilizing the most recent physical exam findings, laboratory results, and other diagnostic results available in the medical records. For Review and Increase disability exam requests, examiners need to ensure that the physical exam findings, laboratory results, and other diagnostic results they are recording in the DBQs are new information since the last examination, adequately reflect the current status of the disability, and have NOT been previously documented/used in VA disability exams.

Current physical exam findings, laboratory results, and other diagnostic results for the purpose of using ACE are the same as those outlined in the Recent Testing section of this handbook.

The examiner will ensure the appropriate entries are made on the DBQ where specified to report the use of the ACE process. The examiner will document the source of the medical evidence relied on to complete the DBQ. The examiner will identify the medical evidence and other information used to complete the DBQ and/or render the medical opinion. Documentation of medical information identifiers will include, at a minimum, date of exam/procedure, professional name and credentials responsible for the exam/procedure, and clinic name and location where exam/procedure was completed.

Supplemental Interview for ACE Process The ACE supplemental interview may be completed using telephone or video communication technology. If an interview is required, the examiner will identify themselves, state the purpose of the call, and will authenticate the Claimant’s identity using the following questions:

i. Full legal name, including middle name

ii. Birth date, including year

iii. Branch of service and service dates

iv. Home address If the Claimant does not remember their exact service dates but answers all the other questions correctly, this is acceptable. If a Claimant refuses to answer the questions, the ACE process cannot be completed and the Claimant will need to report for an in-person or Tele C&P examination.

The Claimant must possess mental capacity and adequate sensory abilities to participate in an interview, as determined by the following exclusionary factors:

i. Inability to effectively communicate due to:

A. Hearing impairment B. Language barrier C. Speech impediment D. Memory deficit

ii. Inability to effectively verbalize/express information.

The following factors apply during an interview session, and the session will be terminated:

i. Claimant shows signs of cognitive disturbance and/or becomes uncomfortable with the telephone interview process.

ii. Claimant is unwilling or unable to participate in a meaningful way.

Regardless of the communication technology used for the interview, the exam will…