December 10, 2001 M21-1, Part VI

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CH. 1. PHYSICAL EXAMINATIONS, SOCIAL SURVEYS, AND FIELD EXAMINATIONS

PARAGRAPH PAGE

SUBCHAPTER I. PHYSICAL EXAMINATIONS

1.01 General 1-I-1

1.02 Types of Examination 1-I-2

1.03 Preparation of AMIE Physical Examination Requests 1-I-4

1.04 Preparation of VA Form 21-2507, "Request For Physical Examination" 1-I-5

1.05 Medical Opinions 1-I-6

1.06 Requests for Independent Medical Opinion (38 CFR 3.328) 1-I-6

1.07 Sufficiency of VA Examination 1-I-7

1.08 Failure to Report for Examination 1-I-8

SUBCHAPTER II. SOCIAL SURVEYS AND FIELD EXAMINATIONS

1.09 Social Surveys 1-II-1

1.10 Field Examinations 1-II-1

SUBCHAPTER III. REVIEW EXAMINATIONS

1.11 Scheduling Review Examinations 1-III-1

1.12 Rescheduling Review Exams 1-III-1

1.13 Canceling Unnecessary Review Examinations 1-III-1

1.14 Failure to Report for Review Examination 1-III-1

SUBCHAPTER IV. CONTROLS AND FOLLOW-UP

1.15 Control and Follow-Up 1-IV-1

1.16 Control of Future Examination in Running Awards and Claims in Which Benefits Are

Not Being Paid 1-IV-1

1.17 Joint Conferences 1-IV-2

May 19, 1997 M21-1, Part VI

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CH. 1. PHYSICAL EXAMINATIONS, SOCIAL SURVEYS, AND FIELD Exams

SUBCHAPTER I. PHYSICAL EXAMINATIONS

1.01 GENERAL

a. Acceptable Medical Evidence. A statement from any physician that includes clinical manifestations and substantiation of diagnosis by findings of diagnostic techniques generally accepted by medical authorities, such as pathological studies, X-rays, and laboratory tests as appropriate, may be accepted for rating any claim without further examination, provided it is otherwise adequate for rating purposes. See chapter 11 regarding audiological examinations, and 38 CFR 3.326(d) generally.

b. Requests for Examination. Request an examination if there is reasonable probability of a well-grounded claim and the evidence of record is insufficient for rating all of the claimed and noted disabilities. Apply a liberal interpretation of "reasonable probability." The rating activity has sole responsibility to request examination of claimants, except in the following instances:

(1) Adjudication personnel who are not rating specialists may request examinations in connection with claims for pension at the discretion of the Adjudication Officer or Veterans Service Center Manager. See part III, paragraph 5.21.

(2) The Adjudication Officer or Veterans Service Center Manager may authorize an examination in any case in which he or she believes an examination is warranted.

c. Nonveteran Claimants and Beneficiaries. Although field examinations may be authorized as necessary, schedule examination of a nonveteran claimant only at the request of the Adjudication Officer or Veterans Service Center Manager or in the following instances:

(1) To determine if the claimant is entitled to aid and attendance or housebound benefits.

(2) To determine if the claimant was insane at the time he or she caused the death of the veteran. See pt. IV, subpar. 11.10d.

(3) To determine if a child claimant is helpless and/or incompetent.

(4) To determine the competency status of any beneficiary.

d. Disabilities Subject to Periodic Exacerbation and Improvement. Whenever possible, examinations of disabilities subject to periodic exacerbation and improvement, such as skin conditions and other disabilities listed in 38 CFR 3.344, should be scheduled when the conditions would be most disabling. If there is specific information that a disability is worse at predictable times, the examination should be scheduled based on that information. For example: The examining facility may be asked to examine the veteran at the end of the day based on information that the symptoms are worse after work. For a disability subject to periodic flare-ups, where the record contains insufficient information to schedule an examination during a peak period of disability, the veteran should be asked to provide information as to the peak periods of the disability. He or she should also be asked to contact the regional office when the condition worsens. If the veteran received treatment for the worsened condition, he or she should be asked to submit evidence of the treatment. (See Bowers v. Brown, 2 Vet. App. 675, 676 (1992) and Ardison v. Brown, 2 Vet. App. 405 (1994).) Chronic fatigue syndrome, like many other disabilities, is not necessarily stable and may improve. Schedule review examinations to determine residual disability.

e. Accompanying Claims Folders. Claims folders will not routinely accompany requests for examination to the examining facility. Exceptional circumstances, such as POW exams or BVA remands, may warrant claims folder review by the examiner. The VHA scheduling clinic will normally advise the person to be examined of the time and place of examination.

1.02 TYPES OF EXAMINATION

a. General Medical. A general medical examination containing a full report of complaints and functional impairments is the preferred type of examination in original compensation, individual unemployability, and all pension claims. (However, it is not necessary to request a general medical examination if an original claim for compensation is being rated many years after service separation.) A well-performed general medical examination is usually of greater value than a number of uncorrelated specialist examinations. Cite body systems to be examined, as well as conditions or particular diagnoses that require attention.

b. Specialist Examinations. VA medical centers do not schedule specialist examinations unless requested to do so. Request a specialist examination only if it is considered essential for rating purposes, e.g., the diagnosis is not well established or based on a Board of Veterans' Appeals (BVA) remand. If a BVA remand specifies that an examination must be conducted by a "Board certified specialist in ..." or "a specialist who is Board qualified," a specialist examination is required. Otherwise, the choice of examiners is up to the VA medical facility conducting the examination. If VHA does not schedule the veteran for a specialist examination recommended by the medical examiner, the rating activity must determine if such an examination is pertinent to the claim. If the rating activity decides to rate the case without requesting that specialist examination, the reason(s) must be explained in the subsequent rating decision.

c. Prisoner of War (POW). Review all POW claims (original, claim for increase, or reopened) to determine if the veteran was examined under the POW protocol to include a social survey. If not, request an examination under the POW protocol unless it would be inadvisable in light of the veteran's medical condition or it is specifically declined by the veteran or the veteran's representative. The VA medical center or clinic conducting the POW protocol examination will forward a copy of VA Form 10-0048, "Former POW Medical History," to the regional office of jurisdiction along with the medical and social survey portions of the examination. Retain this evidence in the claims folder. Give the medical protocol careful consideration in rating the POW claim as it may provide sufficient background information to relate the veteran's current symptomatology to the POW experience.

(1) POW Protocol Examinations

(a) Order initial POW protocol examinations even if medical evidence to support the claim is not of record. Request examination for all claimed and noted disabilities as well as all other conditions characteristically associated with confinement as a POW. Clearly annotate the examination request that an examination under the POW protocol is required. Enter in the remarks section a statement that the claims folder will be made available to the POW Physician Coordinator upon request.

(b) If the veteran expressed dissatisfaction with either the initial examination or the rating decisions based on the initial examination, order a reexamination. See part III, paragraph 5.16 regarding a request to the veteran for additional information.

(2) POW Social Surveys. VHA will automatically schedule a social survey upon receipt of an examination request for a special POW protocol examination. However, in cases where a special POW examination is already of record and an additional examination for a psychiatric disability is necessary for which a social survey is advisable, specifically request a social survey in the "Remarks" section of the examination request. Use the following criteria in determining whether to request a social survey in such cases. See par. 1.09.

(a) If a social survey has not been conducted within the 1-year period before receipt of the claim, request a social survey.

(b) If a social survey was conducted within the 1-year period before receipt of the claim, exercise prudent judgment in determining whether a current social survey is necessary for proper adjudication of the claim. Regardless of the above, honor all specific requests for a social survey from former POWs or their representatives.

(c) If a Notice of Disagreement has been filed, and the issue on appeal is either service connection for or evaluation of a psychiatric disability, review the claims folder prior to precertification of the appeal to ensure that a social survey was considered in the denial. If not, request a social survey for reconsideration of the psychiatric issue prior to other appellate procedures.

(d) Return as inadequate for rating purposes any examination for a former POW in which a social survey was to be conducted but was not, unless it is indicated that the former POW declined to participate in the social survey. The social survey is voluntary on the part of a former POW, and no claim is to be prejudiced by the failure of a former POW to cooperate in accomplishing the survey.

d. Employee-Veteran Examinations. Make every attempt to avoid the appearance of a conflict of interest in the scheduling of examinations for VA employees. If the claims folder contains VA Form 70-4535, "Notice of Employment, Transfer or Separation of Veteran," ascertain the station of employment and annotate this information clearly on the examination request. Except as provided in part III, subparagraph 2.07a(2), the veteran is not to be examined at his or her place of employment (the same VA medical or medical and regional office center).

e. Aid and Attendance Examinations. Request a special examination if the evidence of record demonstrates reasonable probability of entitlement to aid and attendance, but is not sufficient to allow the benefit.

(1) On the AMIE examination request worksheet, check the special item for an aid and attendance and housebound examination. If using VA Form 21-2507, check the appropriate block in the item "Require Medical Examination of." (Since VHA maintains its own stock of forms, do not attach VA Form 21-2680.) The aid and attendance and housebound examination is designed to pinpoint findings relevant to aid and attendance determinations under 38 CFR 3.351 and 3.352 as well as to provide a basis for determining if the housebound benefit may be paid if need for aid and attendance is not shown.

(2) Do not use locally devised checklists for completion by physicians or others. Since functional impairment is seldom total in extent, "yes" or "no" blocks do not provide sufficient descriptive information to assess the extent of a claimant's incapacitation.

(3) See chapter 8 regarding claims for higher level of care.

f. Hospital Observation. For complex issues, the rating activity may request a period of hospitalization for observation and examination to properly visualize and evaluate the disability in question.

g. Examination of Incarcerated Veterans. When examination of an incarcerated veteran is required, the request for examination should prominently note the location and circumstances of confinement. Any difficulty conducting the examination should be discussed by the regional office and

VHA Medical Examination Coordinators (see paragraph 1.17). If a problem cannot be resolved at the local level, notify the Compensation and Pension Service (214A) for Central Office assistance. (See Bolton v. Brown, 8 Vet. App. 185 (1995)).

1.03 PREPARATION OF AMIE PHYSICAL EXAMINATION REQUESTS

a. General. The AMIE Compensation and Pension program allows regional offices to electronically transmit examination requests to medical centers. After the medical center prints the requests and schedules specific examinations, standardized examination worksheets are printed. Whenever possible use an AMIE C&P examination request rather than a hardcopy VA Form 21-2507. The medical examiner will conduct an examination for all requested disabilities and for any other service-connected disabilities the veteran identifies during the examination. Transcribed results are electronically transmitted back to the regional office for local printing.

b. Restrictions. To request examination of veterans living within the geographic jurisdiction of another regional office (or that must be examined elsewhere because they are employee-veterans) either prepare VA Form 21-2507 or request a regional office linked by AMIE to the examining facility to prepare an AMIE examination request. Requests for examination of veterans residing in foreign countries (other than the Philippines) must be prepared on VA Form 21-2507. See subpar. 1.04b.

c. Worksheets. Complete an AMIE C&P Examination Request Worksheet to request examinations, periods of hospitalization for observation and examination, medical opinions, and social surveys. Rating specialists must ensure that types of examination pertinent to the veteran's claim are requested. Since the worksheets vary from one regional office to another, instructions for completion may vary. The medical center clerk uses AMIE to generate standardized worksheets for each type of examination requested and scheduled. The examiner uses these worksheets for conducting the examination(s). The worksheet example upon which the following instructions are based is generated by Regional Office Report Menu Option #5.

d. Completion of Items. Complete the items on the AMIE C&P exam request worksheet as follows:

(1) First Name, Middle Initial, Last Name of Veteran

(a) If the person to be examined is not a veteran, enter the person's name followed by the relationship, e.g., Tony Smith, child, or Mary Jones, spouse. Enter the Social Security number of the person to be examined in the Social Security number item; in "Remarks" enter the veteran's name and VA claim number.

(b) If the person to be examined is rated incompetent, indicate this by adding "incompetent" after the name.

(2) VA Medical Center Where Examination Is Requested

(3) VA Claims File Number

(4) Social Security Number. Enter if different than the file number.

(5) Date of Examination Request

(6) By. Enter the Rating Specialist's Name or Initials and the Correspondence Symbol.

(7) Type of Examination. Be sure to use the designated code to indicate the examination type. Applicable codes are as follows:

OS--Original Service-Connected P--POW

ON--Original Nonservice-Connected E--Insufficient Exam

I--Claim for Increase T--Terminal

R--Review Examination OTH--Other

(8) Insufficient Exam. If the request is for additional information because a previous examination was inadequate, enter the date of the inadequate examination and a complete explanation of necessary corrective action in "Remarks."

(9) General Medical Examination. The AMIE examination request worksheet must clearly indicate if a general medical examination is necessary as opposed simply to examination of the listed disability(ies).

(10) Body System. Check the body system(s) to be examined.

(11) Remarks. If known, provide the diagnostic code and diagnosis of each disability to be examined in the "Remarks" section. Restrict other entries to any necessary clarifying remarks regarding the issue(s) to be resolved and/or the type of examination requested. Do not use manual, regulation, or code citations.

(12) Specialist Examinations. Explain the nature of the specialist examination and the reason for its request in the "Remarks" section.

e. Additions, Cancellations, or Modifications. This program provides the regional office with capabilities to add, cancel, or modify examination requests instantly. In addition, regional offices have inquiry capabilities for status requests.

f. File Copy. Reverse file the claims folder copy of the AMIE examination request worksheet pending receipt of the completed examination. Dispose of this copy under RCS VB-1, part I, item 13-052.300 upon receipt of the completed examination report.

1.04 PREPARATION OF VA FORM 21-2507, "REQUEST FOR PHYSICAL EXAMINATION"

If AMIE cannot be used, use VA Forms 21-2507 to request examinations, periods of hospitalization for observation and examination, medical opinions, and social surveys. The medical examiner will conduct an examination for all requested disabilities and for any other service-connected disabilities the veteran complains of during the examination.

a. Completion. Complete all appropriate entries on the form. Note the following items:

(1) Social Security Number. Enter if different than the file number.

(2) Period of Service. Enter the earliest entitling period of service in a pension claim or latest period of service in a compensation claim.

(3) First Name, Middle Initial, Last Name of Veteran. (a) Draw a line through the word "veteran" and substitute the appropriate designation if the person to be examined is not a veteran. If the person to be examined is rated incompetent, indicate this by adding the word "incompetent" after the name.

1-I-5

(4) Address of Veteran or Claimant. Review correspondence from the veteran or claimant to confirm the current address. For incompetent veterans, see part IV, paragraph 17.19.

(5) Please Conduct. Check block A to request a general medical examination to cover all disabilities claimed or noted. Use block B in all other cases, indicating the particular disabilities for examination.

(6) Service-Connected Disabilities. List the diagnostic code(s) for each of the service-connected disabilities shown on the latest rating decision. Verify correctness of the service-connected diagnostic code printed on VA Form 21-2507a. List the descriptive terminology for each disability as stated on the latest rating decision. Indicate by a check mark those service-connected disabilities to be examined.

(7) Other Disabilities. Provide an adequate description of the nature of all other disabilities to be examined.

(8) Specialist Examinations. Check this box to request a specialist examination. Explain the nature of the examination and the reason for its request in the remarks section. Attach a copy of any remand decision of the Board of Veterans' Appeals if the examination is based on that decision.

(9) Remarks. Restrict entries to clarifying remarks as to the issue(s) to be resolved and/or the type of examination requested. Do not use manual, regulation, or code citations.

(10) Claimant Represented By. Indicate by an appropriate check or annotation the current accredited service organization of record. If the person to be examined is represented by a person or organization that does not have an office located at the regional office, check the "Other" block in item 19 and enter the complete name and address of the person or organization.

(11) Date, Signature of Authorizing Official, and Correspondence Symbol. Enter the date the form is signed, the authorizing official (i.e., the individual completing the request for examination), and his or her correspondence symbol.

b. Jurisdiction. Forward the examination request to the clinic or medical center nearest the veteran's residence. The Washington Regional Office has jurisdiction over claims files of veterans residing in foreign countries (other than Canada, Mexico, and the Philippines) and will request necessary examinations of those veterans. The White River Junction, Houston, and Manila regional offices will process examination requests for residents of Canada, Mexico, and the Philippines, respectively. The regional office in Honolulu will process examination requests for the islands of American Samoa, Western Samoa, the Northern Marianas, Guam, Midway, and Wake.

c. File Copy. Reverse file a copy of the examination request pending receipt of the examination. Dispose of the claims folder copy under RCS VB-1, part I, item 13-052.300 upon receipt of the completed examination report.

1.05 MEDICAL OPINIONS

If a medical opinion is necessary, enter a brief statement in the "Remarks" section of the examination request indicating the issue(s) involved and the question(s) to be resolved on the basis of sound medical principles. Do not request medical authority to assume any responsibility inherent to the rating activity, e.g., to determine if there is loss of use of an extremity. Ask for a description of the remaining function.

1.06 REQUESTS FOR INDEPENDENT MEDICAL OPINION (38 CFR 3.328)

a. General. An independent medical opinion under 38 CFR 3.328 may be obtained from medical experts who are not employees of VA if warranted by the medical complexity or controversy of a pending claim. A request for an independent medical opinion in conjunction with a pending claim may be initiated by the regional office, by the claimant, or by his or her representative. This request must be submitted in writing and must set forth in detail the reasons why the opinion is necessary. All requests are to be submitted through the Adjudication Officer or Veterans Service Center Manager.

b. Referral to Central Office. If the Adjudication Officer or Veterans Service Center Manager believes a request has merit, it will be referred to the Compensation and Pension Service (212C) for review. If it is determined that an independent medical opinion is warranted, the Compensation and Pension Service will obtain the opinion. The Compensation and Pension Service will notify the claimant that the request has been approved and will furnish him or her with a copy of the opinion when it is received.

c. Denials of Requests. A determination that an independent medical opinion is not warranted may be made either by the Adjudication Officer or Veterans Service Center Manager without referral to the Compensation and Pension Service, or by the Compensation and Pension Service after referral has been

made by the Adjudication Officer or Veterans Service Center Manager. This determination may be contested as part of an appeal on the primary issue under consideration.

1.07 SUFFICIENCY OF VA EXAMINATION

a. Sufficient Examination Reports. Be sure the examination is as full and complete as possible under existing circumstances. It must include a brief medical and industrial history from the date of discharge, or last examination, to the current date. It should also record subjective complaints and a complete description of objective findings, stated in concrete terms. A diagnosis of all described conditions should be included. The examination should provide the clinical findings required by the Rating Schedule for the evaluation of the specific disability such as the range of motion in degrees when a joint is being examined. A VA examination not meeting those requirements is insufficient. A claim should not be denied, nor an evaluation reduced, based upon an insufficient examination.

b. Insufficient Reports. Return reports that are insufficient in any essential aspect to the clinic, or health care facility Director, with a statement setting forth the deficiencies to be remedied. If known, include the diagnostic code for the disability at issue. Avoid using language that can be construed as adversarial when returning reports for clarification. For example, use the term "insufficient for rating purposes" rather than "inadequate examination." Use AMIE to return an insufficient report to the examining facility if it was requested through AMIE. If necessary, the Adjudication Officer or Veterans Service Center Manager will discuss unusual cases with the health care officials to ensure proper understanding of the issue(s) at hand.

(1) Reconciliation of Diagnoses. The precise cause of a disability is often difficult to determine. It is important that the same disability is not covered by more than one diagnosis. It is also essential that any inconsistency and duplication between the findings of various specialists and the general examination be resolved by conference among the examiners. It is of equal importance that a definite and unambiguous diagnosis be made for each complaint or symptom having a medical cause.

(2) Return an examination as insufficient for rating purposes if all claimed disabilities are not covered. See chapter 3 regarding partial rating decisions. Return a report as insufficient for rating purposes if the same disability is differently diagnosed by different examiners.

(3) Return the examination for clarification if an examination report shows a change in the diagnosis or etiology for a disability previously recognized as service-connected, and the medical examiner(s) has not made the required certification that the previous diagnosis or attributing etiology upon which service connection was based was "in error."

(4) Return an examination as insufficient for rating purposes whenever conclusions or findings have been expressed in ambiguous or equivocal terms. For each disability, complaint, or symptom listed on the examination request or noted at the time of examination, the examination report should include a diagnosis or indicate that a chronic disease or disability was ruled out.

(5) Return an examination as insufficient for rating purposes whenever the examiner has not discussed the impact of musculoskeletal pain on the functional loss of an affected joint. Include a description of these findings in the reasons and bases section of the rating as required by the provisions of 38 CFR sections 4.40 and 4.45. (See Floyd v. Brown, 9 Vet. App. 88 (1996).)

(6) 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 and annotate it to show that reexamination is necessary. Include the name and VA station of the medical examiner who conducted the prior examination.

c Board Examinations. The rating activity also has the authority to request "board examinations" to resolve complex issues, including but not limited to reconciliation of differing diagnoses, grant of special monthly compensation, and entitlement to specially adapted housing. There should be at least two physicians (preferably three) on "board examinations" and at least one (preferably all) should be a recognized specialist in the particular field involved.

d. Medical Examiner's Signature. VA medical facilities are responsible for ensuring that examiners are adequately qualified. Although Adjudication employees are not expected to review the credentials of clinical personnel to determine the acceptability of their reports, all examination reports must be signed by physicians or clinical or counseling psychologists. Copies transmitted by AMIE without signatures are acceptable, since signed copies will be maintained by the VHA examining facility. If an unsigned examination report is otherwise received, return the report as insufficient for rating purposes.

e. Examination by Fee-Basis Medical Examiner. There is no prohibition against acceptance of a VA examination for rating purposes by a fee-basis medical examiner who has previously submitted a statement in the claimant's behalf.

f. Hospital Summaries (VA Form 10-1000, "Discharge Summary"). Hospital summaries from a VA medical center must be signed by the physician in charge of the case. In most cases a photocopy is submitted and not the signed original. Return unsigned or improperly signed copies for signature before undertaking any adjudicative action. The Adjudication Officer or Veterans Service Center Manager will contact the Registrar of the medical facility concerned to prevent the frequent submission of unsigned summaries.

1.08 FAILURE TO REPORT FOR EXAMINATION

The claims folder will be referred to the rating activity for consideration of evidence of record under 38 CFR 3.326(c) and (d) if a claimant fails to report for a VA examination and no other requests for evidence are pending. The rating activity must then make a rating based on the evidence of record and dispose of the issue. (This includes unsuccessful requests for SMRs when the claimant has been provided an opportunity to furnish such records.) If the claim is not well grounded, the rating should address that

consideration. In addition to an itemization of all pieces of evidence received, the "Evidence" section of the rating should describe all unsuccessful attempts to acquire evidence, which includes failure to report for examination. See chapter 3.

SUBCHAPTER II. SOCIAL SURVEYS AND FIELD EXAMINATIONS

1.09 SOCIAL SURVEYS

a. General. A social survey is an acceptable type of examination for social or industrial impairment if the rating issue pertains to evaluation of disability and a VA examination has established the diagnosis. Examples of this may occur in veterans with psychiatric illness; arrested tuberculosis; loss of limbs, sight, or hearing; or with physical disfigurement resulting in feelings of inferiority. Cases involving epilepsy also fall into this category. Do not request an economic and social survey in a case involving epilepsy without first obtaining the consent of the claimant. See subpar. 1.02c(2) re POW Social Surveys.

b. Request. Comprehensive social surveys for medical and rating purposes are the duty of social workers. These are to be conducted in accordance with paragraph 1.13 of the "General Overview for Conducting Disability Evaluation Examinations" contained in the electronic Physician's Guide for Disability Evaluation Examinations. Include ample information on the AMIE examination request worksheet or VA Form 21-2507 concerning the purpose of examination and evidence requested to assist the social worker conducting the survey. If determined to be insufficient for rating purposes by the rating activity, they must be returned for clarification.

1.10 FIELD EXAMINATIONS

Request a field examination, if necessary, to check on employment and social adjustment, or to substantiate items of evidence as to existence of disease or injury prior to enlistment. See part III, chapter 8.

SUBCHAPTER III. REVIEW EXAMINATIONS

1.11 SCHEDULING REVIEW EXAMINATIONS

Base the dates of review examinations on the facts and circumstances in each case; however, schedule the examination as far in the future as possible, preferably five years from the date of the last (or initial) VA examination. Consider whether the veteran's current condition is an acute exacerbation or whether the veteran is still recuperating following hospitalization. Consider whether improvement or recovery can be anticipated. If not, do not schedule a future review examination. Medical evidence from any of the sources listed in 38 CFR 3.326(c) may satisfy the need for reexamination.

a. Compensation Cases. Exercise prudent judgment and refer to 38 CFR 3.327(b) in determining the need for reexamination. For information on scheduling review examinations following periods of convalescence, see chapter 10.

b. Pension Cases. Do not routinely request reexamination in disability pension cases. If a reexamination is scheduled, fully explain the reason for reexamination in the reasons and bases section of the rating decision. See 38 CFR 3.327c.

c. Disabilities Subject to Periodic Exacerbation and Improvement. See subpar. 1.01d.

1.12 RESCHEDULING REVIEW EXAMINATIONS

If the date of a currently-scheduled review examination is less than five years from the date of the last (or initial) VA examination, consider rescheduling the examination when the diary expires. Annotate VA Form 21-2507 and the rating decision that the examination is being rescheduled for a future date, and refer the case to authorization activity to have the old diary canceled and the new one established.

1.13 CANCELING UNNECESSARY REVIEW EXAMINATIONS

a. General. Do not request an examination solely to confirm evidence listed in 38 CFR 3.326(c) that is otherwise adequate for rating. The criteria for requesting a reexamination are contained in 38 CFR 3.327(b) and (c). If it is determined that a future examination is to be canceled, a rating specialist must annotate VA Form 21-2507a to this effect and sign and date this form.

b. Total Disability Rating. Take the following action if the veteran is receiving total compensation, either by reason of a 100 percent schedular evaluation or by entitlement to individual unemployability, and it is determined that a future examination should be canceled:

(1) Prepare a rating under paragraph 4.14d if there are eligible or potentially eligible claimants for Dependents' Educational Assistance (DEA). Action will then be taken to provide notice of potential entitlement to DEA under part IV, paragraph 14.09.

(2) If there are no eligible or potentially eligible claimants for DEA, annotate VA Form 21-2507a that the examination is canceled. Sign and date the annotation.

1.14 FAILURE TO REPORT FOR REVIEW EXAMINATION

See chapter 9 and part IV, paragraph 25.05.

SUBCHAPTER IV. CONTROLS AND FOLLOW-UP

1.15 CONTROL AND FOLLOW-UP

a. Adjudication Officer Responsibility. The Adjudication Officer will maintain continuing liaison with the clinic or medical center Director to determine the appropriate initial control period based on the current examination workload. A telephone or personal conference between the Adjudication Officer and clinic Director may be necessary if special circumstances require an expedited follow-up. Telephone contact may also be used to request an expedited examination or inquiry on the status of an overdue examination.

b. AMIE. Use AMIE to check the status of an AMIE examination request upon expiration of the control period. The suspense date will be updated based on the anticipated completion of the examination.

c. VA Form 21-4199. For examinations not requested via AMIE, the status of the pending examination will be requested upon the expiration of the initial control period, by completing VA Form 21-4199, "Status of Requests for Physical Examinations." The original VA Form 21-4199 will be sent to the appropriate Chief Medical Officer and reverse file the carbon control copy. The copy will be disposed of under RCS VB-1, part I, item 13.052 upon return of the original. The reason provided for delay will be considered and the suspense date will be updated based on the anticipated completion date of the examination when the original VA Form 21-4199 is returned without the completed examination.

1.16 CONTROL OF FUTURE EXAMINATION IN RUNNING AWARDS AND CLAIMS IN WHICH BENEFITS ARE NOT BEING PAID

a. Control in Running Awards. If reexamination is scheduled 3 or more months in the future, establish and maintain control under reason code 01. Enter "NONE" in the future physical examination block of the rating decision if reexamination is not to be scheduled, or if a future examination previously established is to be canceled. See chapter 4 regarding determination of basic eligibility to Dependents' Educational Assistance.

b. Control When Benefits Are Not Being Paid. If the rating activity determines that a review examination is necessary in a claim in which benefits are not being paid, the rating activity must either schedule an at-once examination or request that a future date control be established for the examination.

(1) If there is an active master record and the examination date is at least 2 months but less than 5 years in the future, the DIAR command will be used to establish control.

(2) If there is no active master record and the new examination date is neither less than 10 days nor more than 1 year in the future, control will be maintained by establishing a future pending issue under EP 310. See part II, paragraph 1.05.

(3) If the future examination cannot be controlled under either subparagraph (1) or (2) above, control will be maintained by use of a local diary. The manner chosen to control these cases is at local option, but the control system selected must ensure cases are promptly reviewed when the diary expires.

c. Maturity of Future Date Control. When VA Form 21-2507a, "Request for Physical Examination" (Hines), is generated or the future pending issue or local diary matures, the claims file will be sent to the rating activity for review to determine whether to proceed, advance the date, or cancel the examination. If the decision is to proceed with the examination and an AMIE C&P examination is possible, complete an AMIE examination request worksheet. If the examination is to be postponed until a future date, prepare a deferred rating providing the reasons and the new date of examination.

1.17 LIAISON WITH VA MEDICAL FACILITIES

a. Medical Examination Coordinator. The Adjudication Officer at each regional office is designated as the Medical Examination Coordinator. Each VA Medical Center will have a corresponding Medical Examination Coordinator. The Medical Examination Coordinators are responsible for ensuring that examinations meet quality and timeliness standards, and that appropriate action is taken to correct any deficiencies.

b. Joint Conferences. Adjudication Division officials will hold conferences with VA health care facility personnel as frequently as needed but at least once a year. The conferees will discuss the sufficiency of medical examinations for rating purposes, timeliness of reports, administrative procedures, preparation of forms, social service reports, and other problems of mutual interest to insure that both VBA and VHA personnel provide the highest quality of services. Meetings with VHA Medical Examination Coordinators should be an integral part of liaison visits.