Section E. Service Connection for Disabilities Incurred as a Prisoner of War (POW) - Updated 3/20/11

Overview


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In this Section
This section contains the following topics:   ''' '''
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18.   General Information on POW Rating Activities
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Introduction
This topic contains general information on prisoner-of-war (POW) rating activities, including
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 ·      designating members of the rating activity to handle POW claims

 ·      the purpose of POW rating activities

 ·      the responsibilities of the Veterans Service Center Manager (VSCM) for the POW rating activity

 ·      the members of the POW rating activity, and

<span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the responsibilities of the POW rating activities. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">March 20, 2011 {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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a.   Designating Members of the Rating Activity to Handle POW Claims
<p class="MsoBlockText">Each regional office (RO) must designate at least one member of its rating activity to be specifically responsible for handling claims filed by former prisoners of war (FPOWs).
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<p class="MsoBlockText">

<p class="MsoBlockText">ROs with a rating activity composed of 25 or more Rating Veterans Service Representatives (RVSRs) must designate at least two of its members. ROs with an insufficient number of RVSRs may make alternate arrangements consistent with individual circumstances. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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b.   Purpose of POW Rating Activities
<p class="MsoBlockText">The purpose of creating special POW rating activities is to ensure POW claims are handled and decided by those RVSRs who are
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      knowledgeable on issues affecting FPOWs, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      sensitive to the POW experience. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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c.   Responsibilities of the VSCM for the POW Rating Activity
<p class="MsoBlockText">The Veterans Service Center Manager (VSCM) must select all POW rating activity members. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 18. General Information on POW Rating Activities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Members of the POW Rating Activity
<p class="MsoBlockText">Each POW rating activity
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      must consist of two regular members and one alternate, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      should include a medical member, if available.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Except in unusual circumstances, only designated members or alternate members of the special rating activity may sign rating decisions involving FPOWs. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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e.   Responsibilities of the POW Rating Activity
<p class="MsoBlockText">The primary responsibility of the POW rating activities is to ensure that disability claims filed by FPOWs are handled properly.
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<p class="MsoBlockText">

<p class="MsoBlockText">All members of the POW rating activity are expected to be thoroughly familiar with all laws, regulations, and directives concerning FPOWs.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The rating activity must exercise the utmost care and compassion in deciding FPOW claims. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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19.   Deciding Claims Involving FPOWs
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Introduction
<p class="MsoBlockText">This topic contains information on deciding claims involving FPOWs, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering all relevant laws, regulations, and directives for FPOW claims

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the liberal application of directives per 38 CFR 3.304(e) in FPOW claims

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Department of Veterans Affairs (VA) responsibilities when adjudicating claims involving FPOWs

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     the adequacy of medical evidence in FPOW claims, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     statements from FPOWs as evidence of disability symptoms

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      ensuring complete development of FPOW claims

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      finding a reasonable basis for establishing service connection in FPOW claims, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      requesting an advisory opinion in FPOW claims. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">March 20, 2011 {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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a.   Considering All Relevant Laws, Regulations, and Directives for FPOW Claims
<p class="MsoBlockText">All claims filed by FPOWs must be adjudicated with constant reference to all sections of the laws, regulations, and directives concerning such claims.
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<p class="MsoBlockText">

<p class="MsoBlockText">References:   For more information on rating claims filed by FPOWs, see

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 U.S.C. 1112

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 1.18

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 3.304(e)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 3.307(a)(5)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 3.309(c)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IV, Subpart ii, 1.G

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part III, Subpart v.1.C

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part III, Subpart iv, 3.A, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IV, Subpart ii, 2.B.5. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 19. Deciding Claims Involving FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Liberal Application of Directives Per 38 CFR 3.304(e) in FPOW Claims
<p class="MsoBlockText">The provisions of 38 CFR 3.304(e) give regulatory authority to the Department of Veterans Affairs’ (VA) consistent policy of applying liberally the directives involving awards of service connection in claims filed by former POWs.
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<p class="MsoBlockText">

<p class="MsoBlockText">This policy takes into account the following two important factors:

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the deficiencies or complete absence of many FPOWs’ service treatment records (STRs) showing evidence of diseases or injuries suffered during or immediately prior to confinement, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the extreme hardships and deprivation suffered by FPOWs during confinement from which physical or mental impairment may not arise until many years later. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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c.   VA Responsibilities When Adjudicating Claims From FPOWs
<p class="MsoBlockText">Assume all disabilities claimed by the Veteran resulted from his/her POW experiences unless the Veteran specifically has stated otherwise.
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<p class="MsoBlockText">

<p class="MsoBlockText">Even though the Veteran has not alleged a specific disability, symptoms presented by the Veteran may be the result of

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the POW experience, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      diseases subject to presumptive service connection.

<p class="MsoBlockText">

<p class="MsoBlockText">In addition, give careful consideration to the Veteran’s POW experiences, particularly in reviewing disabilities that are claimed or diagnosed for the first time several years after service. Proper adjudication of a claim demands a close scrutiny of the duration and circumstances of confinement. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 19. Deciding Claims Involving FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Considering the Adequacy of Medical Evidence in FPOW Claims
<p class="MsoBlockText">Recent medical evidence that is accurate and complete is paramount. Examine medical evidence thoroughly to determine whether it is adequate to evaluate the disabilities under consideration and request a physical examination to supplement the evidence when necessary.
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<p class="MsoBlockText">

<p class="MsoBlockText">Ensure that a determination is not made on the basis of medical evidence that is old or that is incomplete with regard to the disabilities under consideration.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Evidence that is more than one year old must be supplemented by a request for a physical examination

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on protocol examinations for FPOW, see M21-1MR, Part III, Subpart iv, 3.A.6. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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e.   Considering Statements from FPOWs as Evidence of Disability Symptoms
<p class="MsoBlockText">Accept the statements of FPOWs about the disabilities or diseases incurred during or immediately prior to confinement as proof of service incurrence, as long as residual disability exists that can be attributed to the alleged service incident.
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<p class="MsoBlockText">

<p class="MsoBlockText">In addition, carefully consider the statements of former camp comrades, if offered in support.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   If these statements are inconsistent with other evidence of record, develop for clarification of any discrepancies with the Veteran. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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f.   Ensuring Complete Development of FPOW Claims
<p class="MsoBlockText">Since certain disorders, such as the chronic residuals of nutritional deficiency, may manifest themselves through a variety of symptoms,
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      ensure that examinations are complete and comprehensive, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      afford the Veteran every opportunity to present a complete and accurate picture of his/her POW-related disabilities. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 19. Deciding Claims Involving FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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g.   Finding a Reasonable Basis for Establishing Service Connection in FPOW Claims
<p class="MsoBlockText">A reasonable basis for establishing service connection must be found upon review of the Veteran’s POW experiences. The evidence of record must establish a reasonable connection between the Veteran’s current disabilities and his/her experiences while a POW.
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<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Intercurrent diseases or injuries, shown to be the cause of the disabilities under consideration, may preclude the establishment of service connection.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Evidence of treatment or observation of the claimed disability during service is not required.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      A lack of a history showing continuity or chronicity of the claimed disabilities since separation from service, although an important factor generally, is not by itself sufficient to justify denying service connection. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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h.   Requesting an Advisory Opinion in FPOW Claims
<p class="MsoBlockText">If it is unclear whether a condition is a residual of the POW experience, submit the claim to Compensation and Pension (C&P) Service (211B) for an advisory opinion.
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<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on C&P Service guidance and advisory opinions, see M21-1MR, Part III, Subpart vi, 1. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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20.   Presumption of Service Connection for FPOWs
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Introduction
<p class="MsoBlockText">This topic contains information on presumptive service connection for FPOWs, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      disabilities presumed to be SC under 38 CFR 3.309(c)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      establishing presumptive service connection under 38 CFR 3.309(c)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      minimum length of confinement as a POW

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      absence of evidence in service records or presumptive disabilities in FPOW claims

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      assigning noncompensable evaluations in FPOW claims, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      denying presumptive service connection for an FPOW claim. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">March 20, 2011 <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 20. Presumption of Service Connection for FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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a.   Disabilities Presumed to be SC Under 38 CFR 3.3.09(c)
<p class="MsoBlockText">The following disabilities are presumed to be SC under 38 CFR 3.309(c):
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      atherosclerotic heart disease or hypertensive vascular disease (including hypertensive heart disease) and their complications (including myocardial infarction, congestive heart failure, arrhythmia)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      avitaminosis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      beriberi, including beriberi heart disease

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      chronic dysentery

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      cirrhosis of the liver

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      dysthymic disorder, or depressive neurosis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      helminthiasis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      irritable bowel syndrome

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      malnutrition, including optic atrophy associated with malnutrition

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      organic residuals of frostbite

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      pellagra

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      peptic ulcer disease

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      peripheral neuropathy, except where directly related to infectious causes

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      post-traumatic osteoarthritis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      psychosis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      stroke and its complications, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      any

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     of the anxiety states, or

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     other nutritional deficiency, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      osteoporosis.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      “Beriberi heart disease” includes ischemic heart disease in an FPOW who had experienced localized edema during captivity.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Irritable bowel syndrome normally includes the symptoms noted under diagnostic code 7319, irritable colon syndrome.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      A presumption of service connection exists for

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     osteoporosis in association with posttraumatic stress disorder (PTSD) under 38 CFR 3.309(c)(1), and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     osteoporosis by itself under 38 CFR 3.309(c)(2).

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on diseases and disabilities subject to a presumption of service connection, see 38 U.S.C. 1112. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">   Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 20. Presumption of Service Connection for FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Establishing Presumptive Service Connection Under 38 CFR 3.309(c)
<p class="MsoBlockText">The diseases specified in 38 CFR 3.309(c)(1) and (2) must be presumed to be SC if they become 10 percent or more disabling at any time after service.
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<p class="MsoBlockText">

<p class="MsoBlockText">Any disability that develops secondary to one of those listed in 38 CFR 3.309(c)(1) and (2) are also subject to presumptive service connection.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on establishing presumptive service connection for disabilities that are 10 percent or more disabling, see 38 CFR 3.307(a)(5). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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c.   Minimum Length of Confinement   as a POW
<p class="MsoBlockText">Use the table below to determine whether internment as a POW for a minimum of 30 days is a prerequisite to establishing service connection on a presumptive basis for the disabilities listed. <p class="MsoNormal"> <p class="MsoNormal"> <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 20. Presumption of Service Connection for FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Absence of Evidence in Service Records of Presumptive Disabilities in FPOW Claims
<p class="MsoBlockText">Since the disabilities listed in 38 CFR 3.309(c) are presumed to be SC, a record of their treatment or existence during service is not required.
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<p class="MsoBlockText">

<p class="MsoBlockText">Do not deny service connection for one of these conditions predicated solely upon a deficiency in the Veteran’s service medical records.

<p class="MsoBlockText">

<p class="MsoBlockText">Exception:   The absence of evidence in service medical records showing treatment or observation of a disability may be used to deny direct service connection. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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e.   Assigning Noncompensable Evaluations in FPOW Claims
<p class="MsoBlockText">Consider the possibility that the disability at issue was more severely disabling in the past, if residuals currently exist but not to a degree warranting the assignment of a compensable evaluation.
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<p class="MsoBlockText">

<p class="MsoBlockText">If this is the case, the establishment of service connection with a noncompensable evaluation may be in order.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The law and regulations do not require a current finding of disability warranting the assignment of a compensable evaluation at the time the claim for service connection is filed. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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f.   Denying Presumptive Service Connection for an FPOW Claim
<p class="MsoBlockText">Before denying presumptive service connection, at least one of the following two conclusions must be reached based on a thorough review of the evidence of record:
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the disability in question cannot be associated with the Veteran’s POW experiences (for example,   the claimed condition was the result of an intercurrent disease or injury per 38 CFR 3.307(d)), or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Veteran was never diagnosed with the disability in question. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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21.   Considering Service Connection for Certain Disabilities of FPOWs
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Introduction
<p class="MsoBlockText">This topic contains information on considering service connection for certain disabilities of FPOWs, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering service connection for

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     residuals of frostbite

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     peptic ulcer disease, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     peripheral neuropathy

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      weighing evidence related to arthritis in an FPOW claim

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      distingushing between posttraumatic arthritis and degenerative arthritis in an FPOW claim

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      requesting medical opinions on the origin of arthritis for an FPOW claim

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      final responsibility for determining service connection for posttraumatic osteoarthritis in an FPOW claim

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering service connection for osteoporosis when

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     PTSD is diagnosed, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     PTSD is not diagnosed, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      FPOW claims with diagnoses of both osteoporosis and arthritis. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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Change Date
<p class="MsoBlockText">March 20, 2011 <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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a.   Considering Service Connection for Residuals of Frostbite
<p class="MsoBlockText">Internment as a POW in climatic conditions consistent with the occurrence of frostbite is a prerequisite to establishing service connection on a presumptive basis for organic residuals of frostbite.
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<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Frostbite injury may occur at different temperatures and after different lengths of exposure, depending on the individual.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      If a Veteran was a POW during seasons other than winter, the possibility of exposure to climatic conditions consistent with permanent frostbite injury must not be eliminated without careful consideration.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on rating residuals of cold injury, see M21-1MR, Part III, Subpart iv, 4.E.21. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 21. Considering Service Connection for Certain Disabilities of FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Considering Service Connection for   Peptic Ulcer Disease
<p class="MsoBlockText">A proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established for rating purposes if it
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      provides an adequate basis for a differential diagnosis from other conditions with like symptomatology.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on rating peptic ulcer disease, see the Schedule for Rating Disabilities, 38 CFR 4.110. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page
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c.   Considering Service Connection for Peripheral Neuropathy
<p class="MsoBlockText">Peripheral neuropathy is subject to a presumption of service connection, except for peripheral neuropathy that is related directly to infectious causes.
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<p class="MsoBlockText">

<p class="MsoBlockText">The law does not require a denial of presumptive service connection for peripheral neuropathy due to infectious causes unless

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the evidence establishes that the infectious agent was an intercurrent cause of peripheral neuropathy, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a review of the circumstances of internment definitely rules out exposure to the infectious agent during confinement.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      The possibility of nutritional deficiency during internment and resultant lowering of the body’s resistance to infection must be considered.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Medical evidence must also establish a current diagnosis of peripheral neuropathy. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 21. Considering Service Connection for Certain Disabilities of FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Weighing Evidence Related to Arthritis in an FPOW Claim
<p class="MsoBlockText">Give due weight to both the Veteran’s
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      statements of trauma resulting in arthritis, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      medical history so far as it is available.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Do not hesitate to develop for clarification of the traumatic incident if it cannot be determined satisfactorily from the evidence at hand that arthritis due to trauma is actually the issue. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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e.   Distinguishing Between Posttraumatic Arthritis and Degenerative Arthritis in an FPOW Claim
<p class="MsoBlockText">If a Veteran of advanced age with multiple joint arthritis alleges trauma as the cause of arthritis at all or some of the disease sites, it is important to distinguish between posttraumatic arthritis and degenerative arthritis, the latter being a common development as a person ages.
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<p class="MsoBlockText">

<p class="MsoBlockText">In such situations, obtain the most complete account possible of the traumatic incident. Information that should be available for consideration includes

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the nature of the trauma

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a statement of the type and severity of the injuries received, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the frequency of traumatic injury, such as how often a FPOW might have been beaten by his captors.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   A reasonable basis for an award of service connection might include

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the appearance of arthritis at an earlier age than would be expected normally, or

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      confinement of arthritis to the location of the alleged trauma, regardless of the age at which it appears. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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f.   Requesting Medical Opinions on the Origin of Arthritis in an FPOW Claim
<p class="MsoBlockText">POW rating activities must consider the value of requesting an opinion from the physician designated by the medical facility to conduct POW examinations as to whether or not a diagnosis of arthritis resulting from trauma would be consistent with the injuries received in the traumatic incident mentioned by the FPOW.
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<p class="MsoBlockText">

<p class="MsoBlockText">The physician is not required to give an opinion, but if one is made, it merits serious consideration and cannot be ignored. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 21. Considering Service Connection for Certain Disabilities of FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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g.   Final Responsibility for Determining Service Connection for Posttraumatic Osteoarthritis in an FPOW Claim
<p class="MsoBlockText">The rating activity has the final responsibility for determining whether a relationship exists between the development of arthritis and the Veteran’s experiences as a POW.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Any reasonable doubt arising after review of the evidence must be resolved in favor of the Veteran. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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h.   Considering Service Connection for Osteoporosis – PTSD Diagnosed
<p class="MsoBlockText">Effective October 10, 2008, a presumption of service connection was established for osteoporosis under 38 CFR 3.309(c)(1) for FPOWs who
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      were detained or interned for any period of time, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      have a diagnosis of PTSD.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   PTSD is the only anxiety disorder recognized under 38 CFR 3.309(c)(1) as being associated with osteoporosis. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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i.   Considering Service Connection for Osteoporosis – PTSD Not Diagnosed
<p class="MsoBlockText">Effective September 28, 2009, a presumption of service connection was established for osteoporosis under 38 CFR 3.309(c)(2) for FPOWs who were detained or interned for 30 days or longer.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This presumption is based, at least in part, on the likely nutritional deprivation experienced during longer (30 days or more) periods of captivity. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
 * }

<p class="MapTitleContinued"> 21. Considering Service Connection for Certain Disabilities of FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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j.   FPOW Claims With Diagnoses of Both Osteoporosis and Arthritis
<p class="MsoBlockText">Many FPOWs who claim service connection for osteoporosis, evaluated under diagnostic code (DC) 5013 based on joint manifestations, have already established service connection for arthritis, which is also evaluated based on symptoms in skeletal joints.
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<p class="MsoBlockText">

<p class="MsoBlockText">If a claim involves diagnoses of both osteoporosis and arthritis, obtain a medical opinion as to the etiology of the symptoms affecting a particular joint or joints.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Arthritis is described as inflammation of a joint or joints.

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Osteoporosis is described as inadequate bone formation resulting in low bone mass, microscopic deterioration of bone tissue, and increased bone fragility, which results in an increased incidence of fracture. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
 * }

22.   Preparing a Rating Decision Involving a Presumption of Service Connection
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Introduction
<p class="MsoBlockText">This topic contains information on preparing a rating decision involving a presumption of service connection, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the information required in the POW rating decision

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      citing disabilities in an FPOW claim

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      providing the Reasons for Decision  in a POW rating decision

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering results of the POW protocol examination

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      coding specific FPOW disabilities, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      reviewing POW rating decisions prior to promulgation. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">March 20, 2011 {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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a.   Information Required in the POW Rating Decision
<p class="MsoBlockText">Rating decisions must contain a summary of all available information about the Veteran’s confinement as a POW, such as the
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      dates of confinement, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      name(s) of specific camp(s) or sector(s) in which the Veteran was confined. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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b.   Citing Disabilities in an FPOW Claim
<p class="MsoBlockText">Cite the disabilities alleged to have been incurred or aggravated during the Veteran’s period of confinement as a POW apart from other claimed disabilities.
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<p class="MsoBlockText">

<p class="MsoBlockText">If the Veteran claims all disabilities were incurred or aggravated as a result of the POW experience, state the issue as “Disabilities Incurred or Aggravated as a Result of Confinement as a Former POW,” with the specific disabilities listed by number. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
 * }

<p class="MapTitleContinued"> 22. Preparing a Rating Decision Involving a Presumption of Service Connection, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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c.   Providing the Reasons for the Decision in an POW Rating Decision
<p class="MsoBlockText">The Reasons for Decision section of the rating decision must
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      contain a statement as to

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     whether or not the claimant was examined under the POW protocol, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     the availability and adequacy of STRs

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      indicate that available secondary evidence, such as statements of the Veteran’s camp comrades during internment, has been considered thoroughly, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      explain fully the reasons for awarding or denying service connection and the rationale for any disability evaluations assigned.

<p class="MsoBlockText">

<p class="MsoBlockText">The explanations must be phrased clearly and must cite the appropriate authority upon which the decision is based.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on examinations under the POW protocol, see

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part III, Subpart iv, 3.A.6, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part III, Subpart iv, 3.A.7. {| border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse:collapse;mso-table-layout-alt:fixed;mso-padding-alt: 0in 5.4pt 0in 5.4pt"
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d.   Considering the Results of the POW Protocol Examination
<p class="MsoBlockText">If the results of the POW protocol examination were considered as evidence, dispose of the following under the appropriate rating codes:
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      all disabilities identified by the medical examiner, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      all complaints mentioned by the Veteran that are indicative of a specific, ratable disorder. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 22. Preparing a Rating Decision Involving a Presumption of Service Connection, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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e.   Coding Specific FPOW Disabilities
<p class="MsoBlockText">Use the information below to code specific FPOW disabilities. <p class="MsoNormal"> <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 22. Preparing a Rating Decision Involving a Presumption of Service Connection, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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f.   Reviewing POW Rating Decisions Prior to Promulgation
<p class="MsoBlockText">The VSCM must review all rating decisions involving FPOWs prior to promulgation.
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<p class="MsoBlockText">

<p class="MsoBlockText">The review must ensure compliance with all laws, regulations, and directives affecting claims from FPOWs.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Authority for reviewing these ratings may not be delegated to a designee lower than a coach, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the reviewer must annotate the rating “''POW rating reviewed. ''[signature and title][date].” <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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23.   History of Disabilities Subject to Presumptive Service Connection for FPOWs
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Introduction
<p class="MsoBlockText">This topic contains information on the history of disabilities subject to presumptive service connection for FPOWs, including the
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      history behind the length of confinement requirement for POWs, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      history of Public Laws (PLs) and Federal Register citations for FPOW diseases. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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Change Date
<p class="MsoBlockText">March 20, 2011 <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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a.   History Behind the Length of Confinement Requirement for POWs
<p class="MsoBlockText">Effective December 16, 2003, the Veterans Benefits Act of 2003 eliminated the length of confinement requirement of 30 days or longer for the following disabilities:
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      psychosis

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      any of the anxiety states

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      dysthymic disorder (or depressive neurosis)

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      organic residuals of frostbite, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      post-traumatic arthritis.

<p class="MsoBlockText">

<p class="MsoBlockText"> From October 1, 1981, through December 15, 2003, an FPOW must have been confined for 30 days or longer to be eligible for a presumption of service connection for any of the disabilities listed in 38 CFR 3.309(c).

<p class="MsoBlockText">

<p class="MsoBlockText"> Before October 1, 1981, confinement of six months or longer was required.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The following disabilities are established under 38 CFR 3.309(c)(1), which has no length of confinement requirement:

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      atherosclerotic heart disease

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      hypertensive heart disease

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      stroke, and

<p class="BulletText1" style="mso-list:l1 level1 lfo1"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      osteoporosis, if PTSD has also been diagnosed.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on length of confinement requirements, see M21-1MR, Part IV, Subpart ii, 2.E.20.c. <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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b.   History of PLs and Federal Register Citations for FPOW Diseases
<p class="MsoBlockText">The table below contains the history of the Public Laws (PLs) and Federal Register  citations that have authorized a presumption of service connection for the disabilities listed in 38 CFR 3.309(c). <p class="MsoNormal"> <p class="ContinuedOnNextPa" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">Continued on next page '''<span style="font-size:16.0pt; mso-bidi-font-size:10.0pt;font-family:"Arial","sans-serif";mso-fareast-font-family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA"> '''
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<p class="MapTitleContinued"> 23. History of Disabilities Subject to Presumptive Service Connection for FPOWs, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

<p class="MsoNormal">