Section B - Determining Service Connection - Updated 9/15/11

Chapter 2 - Rating

Overview


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In this Section
This section contains the following topics:   ''' '''
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3.   Determining Direct and Presumptive Service Connection
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Introduction
This topic contains information on determining direct and presumptive service connection, including
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 ·      establishing service connection based on

 -     chronicity, and

 -     continuity of symptoms

 ·      direct service connection under 38 CFR 3.303(d)

 ·      the definition of presumption of soundness

<span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      service requirements for presumption of soundness

<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 definition of active continuous service

<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"> ·      service requirements for presumptive service connection for

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     chronic and tropical diseases, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     radiogenic diseases

<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"> ·      presumptive of soundness for active duty for training, 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"> ·      inactive duty training considered active service. <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">September 15, 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. Establishing Service Connection Based on Chronicity
<p class="MsoBlockText">To establish service connection based on the chronicity of a disease shown in service, the evidence must include
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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"> ·      manifestations sufficient to identify the disease entity, 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"> ·      observation sufficient to distinguish chronicity from merely isolated findings or a diagnosis that includes the word “chronic.”

<p class="MsoBlockText">

<p class="MsoBlockText">When service connection is established for chronic disease shown in service, or within the presumptive period of 38 CFR 3.307, consider all subsequent manifestations of the same chronic disease as service connected, unless they are clearly shown to be due to intercurrent causes.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on chronicity, see 38 CFR 3.303(b). <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"> 3. Determining Direct and Presumptive 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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b.   Establishing Service Connection Based on Continuity of Symptoms
<p class="MsoBlockText">Service connection may be established based on continuity of symptoms when a disease noted in service, or within the presumptive period of 38 CFR 3.307
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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"> ·      is not shown to be chronic, 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 diagnosis of chronicity is questionable.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   When evidence shows that symptoms that began during service have continued after discharge, a medical opinion is generally not required to establish a link between the claimed disability and the Veteran’s service.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on continuity of symptoms, see 38 CFR 3.303(b). {| 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.   Direct Service Connection Under 38 CFR 3.303(d)
<p class="MsoBlockText">Consider whether direct service connection may be established under 38 CFR 3.303(d), even if service connection is claimed for a disease diagnosed after service has ended. Service connection may be granted for a disease diagnosed after discharge when all the evidence establishes that the disease was incurred in service.
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<p class="MsoBlockText">

<p class="MsoBlockText">Do not attempt to establish presumptive service connection for chronic or tropical diseases until the possibility of establishing direct service connection has been ruled out.

<p class="MsoBlockText">

<p class="MsoBlockText">Important:   A Veteran who lacks the requisite 90 days or six months of service may be awarded direct service connection only.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Award direct service connection only for any disability not included in 38 CFR 3.309. <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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d.   Definition:   Presumption of Soundness
<p class="MsoBlockText">The presumption of soundness means that Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service.
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<p class="MsoBlockText">

<p class="BulletText1" style="margin-left:0in;text-indent:0in;mso-list:none;  tab-stops:.5in">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 presumption of soundness applies only when the Veteran underwent a physical examination at the time of entry into service on which the claim is based.

<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"> ·      Only the conditions that are recorded in the examination report are to be considered as noted.

<p class="MsoBlockText">

<p class="MsoBlockText">When no preexisting condition is noted at entrance into service, the burden falls on the VA to rebut the presumption of soundness by clear and unmistakable evidence showing that the disease or injury

<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"> ·      existed prior to service, 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"> ·      was not aggravated by service.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on the presumption of soundness, 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. 1111

<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"> ·      VAOPGCPREC 3-2003, 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"> ·      Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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e.   Service Requirements for Presumption of Soundness
<p class="MsoBlockText">The table below shows the service requirements the Veteran must meet before VA can apply the presumption of soundness.
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f.   Definition:   Active Continuous Service
<p class="MsoBlockText">Active continuous service excludes lengthy periods of extended absence from duty, such as unauthorized absence or other extended non-pay status.
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<p class="MsoBlockText">

<p class="MsoBlockText">Example:    The following facts and findings are set forth in General Counsel (GC) Opinion 4-80:

<p class="MsoBlockText">''The service member was absent from duty for 1,344 days before returning to military control. The Veteran received an honorable discharge nine days later and developed a chronic disease within one year of discharge. Since the Veteran was without active, continuous service for all but nine days of the 3-3/4 years preceding separation, the continuous service requirement of 38 CFR 3.307 is not met''. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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g.   Presumptive Service Connection for Chronic and Tropical Diseases
<p class="MsoBlockText">The table below shows the service requirements the Veteran must meet before VA may establish presumptive service connection for chronic and tropical diseases. <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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h.   Presumptive Service Connection for Radiogenic Diseases
<p class="MsoBlockText">In order to be eligible for presumptive service connection for radiogenic diseases under 38 CFR 3.309(d)(3)(i), a Veteran must have participated in radiation-risk activities during a period of
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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"> ·      active duty

<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"> ·      active duty for training, 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"> ·      inactive duty training.

<p class="MsoBlockText">

<p class="MsoBlockText">Exception:   Service connection may not be established under the provisions of 38 CFR 3.311 or 38 CFR 3.309(d) for a listed cancer if it developed as a result of metastasis of a nonradiogenic cancer not listed in either of these regulations. <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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i.   Presumptive of Soundness for Active Duty for Training
<p class="MsoBlockText">In claims based on a period of active duty for training, apply the presumption of soundness only when the Veteran underwent a physical examination at the time of entry into the period of active duty for training on which the claim is based.
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<p class="MsoBlockText">

<p class="MsoBlockText">If an examination was performed, consider the Veteran to have been in sound condition when entering active duty for training except as to defects, infirmities, or disorders noted on the examination report.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information the presumption of soundness in claims based on active duty for training, see Smith (Valerie Y.) v. Shinseki, 24 Vet.App. 40, 44 (2010). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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j.   Inactive Duty Training Considered   Active Service
<p class="MsoBlockText">Inactive duty training is not considered active service unless service connection is awarded for disability or death resulting from
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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"> ·      an injury directly incurred during the period of inactive duty training, 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"> ·      an injury or one of the following events if the injury or event occurred during inactive duty training or while an individual was proceeding directly to, or returning directly from, a period of such training:

<p class="BulletText2" style="mso-list:l0 level1 lfo2;tab-stops:list .25in 27.35pt"> -     an acute myocardial infarction

<p class="BulletText2" style="mso-list:l0 level1 lfo2;tab-stops:list .25in 27.35pt"> -     a cardiac arrest, or

<p class="BulletText2" style="mso-list:l0 level1 lfo2;tab-stops:list .25in 27.35pt"> -     a cerebrovascular accident.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   If evidence establishes that an individual suffers from a disabling condition as a result of the administration of an anthrax vaccine during inactive duty training, the individual may be considered disabled by an “injury” incurred during such training.

<p class="MsoBlockText">

<p class="MsoBlockText">References:   For more information on

<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"> ·      determining duty periods, see 38 CFR 3.6, 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"> ·      injuries that occurred

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     while an individual was proceeding directly to, or returning directly from, a period of inactive duty training, see 38 CFR 3.6(e), and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     as a result of administration of an anthrax vaccine during inactive duty training, see VAOPGCPREC 4-2002. <p class="ContinuedOnNextPa" 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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4.   Determining Service Incurrence of an Injury
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Introduction
<p class="MsoBlockText">This topic contains information on determining service incurrence of an injury, 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"> ·      substantiating the circumstances of injuries

<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"> ·      evaluating evidence of scars

<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"> ·      handling examination reports of scars

<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 evidence for combat-related 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"> ·      the definition of satisfactory evidence. <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">September 15, 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.   Substantiating the Circumstances of Injuries
<p class="MsoBlockText">ROs must review the evidence of record, to include personnel and service treatment records, to ensure the injury occurred during service and in the line of duty.
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<p class="MsoBlockText">

<p class="MsoBlockText">Rationale:   The results of injuries, including gunshot wounds acquired before or after service, are frequently encountered. {| 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.   Evaluating Evidence of Scars
<p class="MsoBlockText">When considering evidence of scars, keep in mind that a claimant may have
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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"> ·      been accepted into service with a notation of one or more scars existing at the time of entrance

<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"> ·      sustained a wound, with a resulting scar, during service, 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"> ·      received an injury following separation from service that resulted in a scar that would be present at subsequent physical examinations.

<p class="MsoBlockText">

<p class="MsoBlockText">Because the Veteran could have incurred a scar before or after service, exercise caution in characterizing a scar as the residual of a wound or injury incurred in service.

<p class="MsoBlockText">

<p class="MsoBlockText">If there is any doubt as to whether the scar is a residual of a wound or injury incurred in service, simply describe the scar, without ascribing it to a “gunshot wound,” “shrapnel wound,” and so forth. <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"> 4. Determining Service Incurrence of an Injury, Continued {| 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.   Handling Examination Reports of Scars
<p class="MsoBlockText">If the presence of a scar or scars is recorded in a physical examination report, review official records to ensure that the scar or scars are in fact a residual of wounds in service. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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d.   Considering Evidence for Combat-Related Disabilities
<p class="MsoBlockText">Accept satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat if the evidence is consistent with the circumstances, conditions, or hardships of such service even though there is no official record of such incurrence or aggravation.
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<p class="MsoBlockText">

<p class="MsoBlockText">In order for evidence submitted by the Veteran to support a factual presumption that the claimed disease or injury was incurred or aggravated in service, the evidence must

<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"> ·      be satisfactory when considered alone

<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"> ·      be consistent with the circumstances, condition or hardships of such service, 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"> ·      not be refuted by clear and convincing evidence to the contrary.

<p class="MsoBlockText">

<p class="MsoBlockText">References:

<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"> ·      For a definition of satisfactory evidence, see M21-1MR, Part IV, Subpart ii, 2.B.4.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"> ·      For more information on satisfactory proof of combat-related disability, see

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     38 CFR 3.304(d)

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     38 U.S.C. 1154(b), and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     Collette v. Brown, 82F.3d.389 (Fed. Cir. 1996).

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   38 CFR 3.304(d) is derived from 38 U.S.C. 1154(b), and lightens the evidentiary burden with respect to disabilities alleged to be the result of combat service. <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"> 4. Determining Service Incurrence of an Injury, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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e.   Definition:   Satisfactory Evidence
<p class="MsoBlockText">Satisfactory evidence generally means evidence that is credible.
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<p class="MsoBlockText">

<p class="MsoBlockText">It is proper to

<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"> ·      consider internal consistency and plausibility in determining whether evidence is credible, 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"> ·      regard statements that contradict other evidence of record as unsatisfactory. <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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5.   Determining In-Service Aggravation of Pre-Service Disability
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Introduction
<p class="MsoBlockText">This topic contains information on determining aggravation of pre-service disability, 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 the presumption of soundness at entry into service

<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 records needed to determine baseline level of disability

<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"> ·      determining whether a preexisting disability was aggravated by service

<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 flare-ups of preexisting injury or 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"> ·      considering the usual effects of medical or surgical treatment, 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"> ·      additional considerations under Splane v. West. <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">September 15, 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 the Presumption of Soundness at Entry Into Service
<p class="MsoBlockText">Presume the Veteran was in sound condition when examined, accepted, and enrolled for service, except when defects, infirmities, or disorders are noted at entrance into service.
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<p class="MsoBlockText">

<p class="MsoBlockText">When no preexisting condition is noted at entrance into service, the burden falls on the VA to rebut the presumption of soundness by clear and unmistakable evidence showing that the disease or injury

<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"> ·      existed prior to service, 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"> ·      was not aggravated by service.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The presumption of soundness applies only when the Veteran underwent a physical examination at the time of entry into the service on which the claim is based.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on the presumption of soundness, 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 CFR 3.304(b), 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.3.d. {| 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.   Records Needed to Determine Baseline Level of Disability
<p class="MsoBlockText">The baseline for determining whether a preexisting disability was aggravated by service is in all of a Veteran's medical records for that condition, not just those covering the period of enlistment and entry on active duty. <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"> 5. Determining In-Service Aggravation of Pre-Service Disability, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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c.   Determining Whether a Preexisting Disability Was Aggravated by Service
<p class="MsoBlockText">Under 38 CFR 3.306, consider a preexisting injury or disease to have been aggravated by active military service where there is an increase in disability during active military service, unless there is a specific finding that the increase in disability is due to the natural progress of the injury or disease.
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<p class="MsoBlockText">

<p class="MsoBlockText">Exception:   In claims based on active duty for training, direct evidence is required to establish aggravation (see Smith (Valerie Y.) v. Shinseki, 24 Vet.App. 40, 44 (2010)). The provisions of 38 CFR 3.306 do not apply.

<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"> ·      Always address the issue of aggravation when service connection for a preexisting disability is claimed.

<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 service connection is not found, indicate in the Reasons for Decision part of the rating decision the relevant findings from the medical records before, during, and after service that demonstrate that the condition which existed prior to service had not increased in severity. {| 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 Flare-ups of Preexisting Injury or Disease
<p class="MsoBlockText">Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened.
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<p class="MsoBlockText">

<p class="MsoBlockText">Do not concede aggravation merely because a Veteran’s condition was in remission at the time of entry on active duty. {| 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.   Considering the Usual Effects of Medical or Surgical Treatment
<p class="MsoBlockText">As required under 38 CFR 3.306(b)(1), unless a disease or injury that was incurred prior to service is otherwise aggravated by service, do not establish service connection for the usual effect of medical or surgical treatment in service to correct or improve the condition, such as postoperative scars and/or absent or poorly functioning parts or organs. {| 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.   Additional Considerations Under Splane v. West
<p class="MsoBlockText">In Splane v. West, 216 F.-3d 1058 (Fed. Cir. 2000), the U.S. Court of Appeals for the Federal Circuit held that 38 U.S.C. 1112(a) establishes a presumption of aggravation for chronic diseases that existed prior to service but first manifested to a degree of disability of 10 percent or more within the presumptive period after service.
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<p class="MsoBlockText">

<p class="MsoBlockText">Under 38 CFR 3.307, this presumption may be rebutted by affirmative evidence to the contrary or evidence to establish that such disability is due to an intercurrent disease or injury suffered after separation from service. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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6.   Determining Secondary Service Connection, Including by Aggravation
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Introduction
<p class="MsoBlockText">This topic contains information on determining secondary service connection, including by aggravation, 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 provisions for service connection under 38 CFR 3.310(a) and (b)

<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 medical evidence required to show a nonservice-connected (NSC) disability was aggravated by an SC disability

<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"> ·      developing claims based on aggravation of an NSC disability by an SC disability

<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"> ·      information that must be included in the examiner’s report, 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"> ·      determining the extent to which an NSC disability was aggravated by an SC disability. <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">September 8, 2009 {| 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.   Provisions for Service Connection Under 38 CFR 3.310(a) and (b)
<p class="MsoBlockText">Grant service connection for the following under the provisions of 38 CFR 3.310(a) and (b):
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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 that are proximately due to, or the result of, a SC condition, 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 increase in severity of a nonservice-connected (NSC) disability that is attributable to aggravation by an SC disability, and not to the natural progress of the NSC disability.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on service connection for aggravation of NSC disabilities by SC disabilities, 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 CFR 3.310(b), 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"> ·      Allen v. Brown, 7 Vet.App. 439 (1995). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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b.   Medical Evidence Required to Show an NSC Disability Was Aggravated by an SC Disability
<p class="MsoBlockText">Do not concede an NSC disability was aggravated by an SC disability unless the baseline level of severity of the NSC disease or injury was established by
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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"> ·      medical evidence created before the onset of aggravation, 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 earliest medical evidence created between the

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     onset of aggravation, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     receipt of medical evidence establishing the current level of severity of the NSC disability. <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"> 6. Determining Secondary Service Connection, Including by Aggravation, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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Based on Aggravation of an NSC Disability by an SC Disability
<p class="MsoBlockText">When developing a claim for secondary service connection based on aggravation of an NSC disability, ask the Veteran to furnish medical evidence showing 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"> ·      current level of severity of the NSC disability, 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"> ·      its level of severity

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     before aggravation by the SC disability, or

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     as soon as possible after aggravation.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   Enclose VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, in the request letter.

<p class="MsoBlockText">

<p class="MsoBlockText">Upon receipt of this evidence, request a medical examination and opinion, to include a review of the claims folder by the examiner, to establish whether increased manifestations of the NSC disability are proximately due to an SC disability.

<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"> ·      Do not request an examination if the Veteran has failed to furnish medical evidence establishing a baseline level of the severity of the NSC disability.

<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 examiner must have all available evidence for review when providing an opinion on the issue of aggravation.

<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"> ·      Identify the evidence of particular relevance in the claims folder for the examiner. {| 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.   Information That Must Be Included in the Examiner’s Report
<p class="MsoBlockText">The examiner’s report must separately address all of the following medical issues in order to be considered adequate for rating a claim for secondary service connection based on aggravation:
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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 current level of severity of the NSC disease or injury

<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"> ·      an opinion as to whether an SC disability proximately caused the NSC disability to increase in severity, 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 medical considerations supporting this opinion. <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"> 6. Determining Secondary Service Connection, Including by Aggravation, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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e.   Determining the Extent to Which an NSC Disability Was Aggravated by an SC Disability
<p class="MsoBlockText">To determine the extent to which, if any, an NSC disability was aggravated by an SC disability
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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"> ·      determine the baseline and current levels of severity of the NSC disability under 38 CFR Part 4, Schedule for Rating 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"> ·      deduct the baseline level of severity of the NSC disability, as well as any increase of the disability due to natural progression, from the current level.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This policy applies even when the current level of severity of the NSC disability is 100 percent. <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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7.   Determining Service Connection for Congenital, Developmental, or Hereditary Disorders
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Introduction
<p class="MsoBlockText">This topic contains information on determining service connection for congenital, developmental, or hereditary disorders, 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 definition of congenital or developmental defects

<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 service connection for congenital, developmental, or hereditary disorders

<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 the

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     development of symptoms of hereditary disease in service, and

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     aggravation of a hereditary disease in service. <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">September 5, 2008 {| 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.   Definition:   Congenital or Developmental Defects
<p class="MsoBlockText">Congenital or developmental defects are normally static conditions that are incapable of improvement or deterioration.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   A disease, even one that is hereditary in origin, such as retinitis pigmentosa, polycystic kidney disease, sickle cell disease, or Huntington’s chorea, is usually capable of improvement or deterioration. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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b.   Establishing Service Connection for Congenital, Developmental, or Hereditary Disorders
<p class="MsoBlockText">Establish service connection, if warranted, for
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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"> ·      diseases of congenital, developmental, or familial, hereditary origin that

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     first manifest themselves during service, or

<p class="BulletText2" style="mso-list:l0 level1 lfo2"> -     preexist service and progress at an abnormally high rate during service, 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"> ·      a hereditary or familial disease that first became manifest to a compensable degree within the presumptive period following discharge from service pursuant to 38 CFR 3.309(a), provided the rebuttable presumption provisions of 38 CFR 3.307 are satisfied.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on awarding service connection for diseases of familial or hereditary origin, see VAOPGCPREC 1-90, March 16, 1990. <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"> 7. Determining Service Connection for Congenital, Developmental, or Hereditary Disorders, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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c.   Considering the Development of Symptoms of Hereditary Disease in Service
<p class="MsoBlockText">Consider diseases of hereditary origin to be incurred in service if the pathological sign or symptoms were manifested after entry on duty.
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<p class="MsoBlockText">

<p class="MsoBlockText">Even if the individual is almost certain to eventually develop a disease, a genetic or other familial predisposition does not constitute having the disease.

<p class="MsoBlockText">

<p class="MsoBlockText">Only when actual symptomatology or signs of pathology are manifest may he/she be said to have developed the disease.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   At what point the individual starts to manifest signs or symptoms is a factual, medical determination that must be based upon

<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 medical evidence of record in each case, 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"> ·      sound medical judgment. {| 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 Aggravation of a Hereditary Disease in Service
<p class="MsoBlockText">A hereditary disease that manifests some symptoms before entry on duty may be found to have been aggravated during service if it progresses during service at a rate greater than normally expected according to accepted medical authority.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This is a factual, medical determination that must be based upon the evidence of record and sound medical judgment. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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