Section D - Service Connection for certain Disabilities Associated with Gulf war (GW) Service - Updated 9/16/14

Chapter 2 - Rating

Overview


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In this Section
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13.   General Information on Qualifying Disabilities Associated With Service in Southwest Asia
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Introduction
This topic contains general information on qualifying disabilities associated with service in Southwest Asia, including the
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 ·      provisions of

 -     the Gulf War (GW) Veterans’ Benefits Act

 -     the GW Veterans’ Act of 1998

 -     the Veterans Education and Benefits Expansion Act of 2001, and

 -     38 CFR 3.317

 ·      definitions of

 -     a qualifying Veteran   under 38 CFR 3.317

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     the Southwest Asia theater of operations, and

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     a qualifying chronic disability under 38 CFR 3.317

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      presumptive period for manifestation of disability under 38 CFR 3.317

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      signs and symptoms of undiagnosed or medically unexplained chronic multisymptom illnesses

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:  Symbol;mso-bidi-font-family:Symbol;color:windowtext;text-decoration:none;   text-underline:none"> ·      determining chronicity for qualifying disabilities

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      presumptive service connection for infectious diseases under 38 CFR 3.317(c), and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering long-term health effects potentially associated with infectious 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">September 16, 2014 {| 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 of the GW Veterans’ Benefits Act
<p class="MsoBlockText">On November 2, 1994, Congress enacted the “Persian Gulf War Veterans’ Benefits Act,” Title I of the “Veterans’ Benefits Improvements Act of 1994,” Public Law (PL) 103-446.
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<p class="MsoBlockText">

<p class="MsoBlockText">The statute added a new section, 38 U.S.C. 1117, authorizing the Department of Veterans Affairs (VA) to compensate any Gulf War (GW) Veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which manifested either

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      during active duty in the Southwest Asia theater of operations during the GW, or

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the GW. <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.   Provisions of the GW Veterans’ Act of 1998
<p class="MsoBlockText">The “Persian Gulf War Veterans’ Act of 1998,” PL 105-277, authorized VA to compensate GW Veterans for diagnosed or undiagnosed disabilities that   are determined by VA regulation to warrant a presumption of service connection based on a positive association with exposure to one of the following as a result of GW service
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a toxic agent

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an environmental or wartime hazard, or

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a preventive medication or vaccine.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This statute added 38 U.S.C. 1118. {| 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.   Provisions of the Veterans Education and Benefits Expansion Act of 2001
<p class="MsoBlockText">The “Veterans Education and Benefits Expansion Act of 2001,” PL 107-103, expanded the definition of “qualifying chronic disability” under 38 U.S.C. 1117 to include, effective March 1, 2002, not only a disability resulting from an undiagnosed illness but also
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs and symptoms, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      any diagnosed illness that is determined by VA regulation to warrant presumption of 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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d.   Provisions of 38 CFR 3.317
<p class="MsoBlockText">38 CFR 3.317, which implements 38 U.S.C. 1117, defines GW service and “qualifying chronic disability,” and provides
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a broad, but non-exclusive, list of signs and symptoms which may be representative of undiagnosed or chronic, multi-symptom illnesses for which compensation may be paid, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the presumptive period for service connection. <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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e.   Definition:   Qualifying Veterans Under 38 CFR 3.317
<p class="MsoBlockText">A qualifying Veteran, under 38 CFR 3.317, is a Veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the GW period.
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<p class="MsoBlockText">

<p class="MsoBlockText">Per 38 U.S.C. 101(33), the GW period extends from August 2, 1990, through a date yet to be determined by law or Presidential proclamation.

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Reference:   For a definition of the Southwest Asia theater of operations, see M21-1MR, Part IV, Subpart ii, 2.D.13.f, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 3.317(e)(2). <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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f.   Definition:   Southwest Asia Theater of Operations
<p class="MsoBlockText">The Southwest Asia theater of operations includes the following locations and the airspace above them
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Iraq

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Kuwait

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Saudi Arabia

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the neutral zone between Iraq and Saudi Arabia

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      United Arab Emirates

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Bahrain

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Qatar

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Oman

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Gulf of Aden

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Gulf of Oman

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Persian Gulf

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Arabian Sea, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Red Sea. <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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g.   Definitions:   Qualifying Chronic Disability Under 38 CFR 3.317
<p class="MsoBlockText">Qualifying chronic disability, under 38 CFR 3.317, means a chronic disability resulting from any of the following or any combination of the following
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      an undiagnosed illness

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      a medically unexplained chronic multisymptom illness (MUCMI) that is defined by a cluster of signs or symptoms, such as

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     chronic fatigue syndrome

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     fibromyalgia, or

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     functional gastrointestinal disorders, excluding structural gastrointestinal diseases.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      The effective date of the amendment to 38 CFR 3.317(a)(2)(i) to include functional gastrointestinal disorders was July 15, 2011.

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Disability patterns referred to as MUCMIs are diagnosed conditions that can occur without a conclusive etiology (i.e. are medically unexplained). If symptoms fitting the description of an MUCMI are claimed by a Veteran with Gulf War service, a medical opinion should be obtained prior to deciding the claim, even if a diagnosis is shown in the medical records.

<p class="BulletText1" style="mso-list:none;tab-stops:.5in">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Example:   Sleep apnea involves the "respiratory system" and "sleep disturbances," both of which are specifically listed under 38 CFR §3.317(b) as signs or symptoms of undiagnosed illness and MUCMIs. If a Veteran served in Southwest Asia and is claiming a disability based on that service which involves the respiratory system or sleep disturbance, then the Veteran should be scheduled for an examination and a medical nexus opinion requested, even if a diagnosis of sleep apnea is of record. <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:12.0pt;font-family:"Times New Roman","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="MsoNormal">

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h.   Presumptive Period for Manifestation of Disability Under 38 CFR 3.317
<p class="MsoBlockText">The presumptive period for manifestation of qualifying chronic disability under 38 CFR 3.317
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      begins on the date following last performance of active military, naval, or air service in the Southwest Asia theater of operations during the GW, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      extends through December 31, 2016. <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:12.0pt;font-family:"Times New Roman","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="MsoNormal">   

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i.   Signs and Symptoms of Undiagnosed or Medically Unexplained Chronic Multisymptom Illnesses
<p class="MsoBlockText">38 CFR 3.317 specifies the following 13 categories of signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      abnormal weight loss

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      cardiovascular signs or symptoms

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      fatigue

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      gastrointestinal signs or symptoms

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      headache

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      joint pain

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      menstrual disorders

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      muscle pain

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      neurological signs or symptoms

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      neuropsychological signs or symptoms

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      signs or symptoms involving the skin

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      signs or symptoms involving the upper or lower respiratory system, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      sleep disturbances.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      The list of 13 illness categories is not exclusive.

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Signs or symptoms not represented by one of the listed categories may also qualify for consideration under 38 CFR 3.317.

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      A disability that is affirmatively shown to have resulted from a cause other than Southwest Asia service may not be compensated under 38 CFR 3.317. {| 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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j.   Determining Chronicity for Qualifying Disabilities
<p class="MsoBlockText">To qualify, the claimed disability must be chronic, that is, it must have persisted for a period of six months.
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<p class="MsoBlockText">

<p class="MsoBlockText">Measure the six-month period of chronicity from the earliest date on which all pertinent evidence establishes that the signs or symptoms of the disability first became manifest.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   If a disability is subject to intermittent episodes of improvement and worsening within a six-month period, consider the disability to be chronic. <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"> 13. General Information on Qualifying Disabilities Associated With Service in Southwest Asia, 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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k.   Presumptive Service Connection for Infectious Diseases Under 38 CFR 3.317(c)
<p class="MsoBlockText">Effective September 29, 2010, presumptive service connection is established under 38 CFR 3.317(c) for the infectious diseases listed below if
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the Veteran served on active duty

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     in the Southwest Asia theater of operations during the Gulf War, as indicated in

<p class="BulletText3" style="mso-list:l14 level1 lfo7"> §   M21-1MR, Part IV, Subpart ii, 2.D.13.e, and

<p class="BulletText3" style="mso-list:l14 level1 lfo7"> §   M21-1MR, Part IV, Subpart ii, 2.D.13.f, or

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     in Afghanistan on or after September 19, 2001, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the disease becomes manifest to a compensable degree within the time limit specified in the table. <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"> 13. General Information on Qualifying Disabilities Associated With Service in Southwest Asia, 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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l.   Considering Long-Term Health Effects Potentially Associated with Infectious Diseases
<p class="MsoBlockText">The Institute of Medicine of the National Academy of Sciences has identified the conditions listed in column B in the table below as potential long-term health effects associated with the infectious diseases (column A) shown in M21-1MR, Part IV, Subpart ii, 2.D.13.k.
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<p class="MsoBlockText">

<p class="MsoBlockText">If a Veteran who is presumed service connected for a disease listed in column A is diagnosed with a disease in column B within the time period specified in the table (if no time period is specified, at any time), VA will request a medical opinion as to whether it is at least as likely as not that the condition was caused by the Veteran having had the associated disease in column A.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This does not preclude a finding that other manifestations of disability or secondary conditions were caused by an infectious disease.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on requesting a medical opinion, see M21-1MR, Part III, Subpart iv, 3.A.9. <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"> 13. General Information on Qualifying Disabilities Associated With Service in Southwest Asia, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

<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"> '''

<p class="MapTitleContinued"> 13. General Information on Qualifying Disabilities Associated With Service in Southwest Asia, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

<p class="MsoNormal"> <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt"> <p class="MsoNormal">

'''<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"> '''

14.   Processing Claims for Service Connection for Qualifying Disabilities
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Introduction
<p class="MsoBlockText">This topic contains information about processing claims for service connection for qualifying disabilities under 38 CFR 3.317, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      rating a symptoms of a chronic qualifying illness as a single or multiple issue

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      information required to decide the issue of service connection for a chronic qualifying illness

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the relevancy, in identifying or describing symptoms or non-medical indicators, of

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     medical evidence

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     the Veteran’s testimony, and

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     lay evidence in

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      lay evidence consisting of non-medical indicators

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      determining inclusion in the Veterans Heath Administration (VHA) Persian Gulf Health Registry

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      determining the disability pattern for claims for qualifying disabilities

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      the rating action taken based on disability pattern determination, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      considering the need for a future examination of a chronic qualifying illness. <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 <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"> 14. Processing Claims for Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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a.   Rating Symptoms of a Qualifying Chronic Illness as a Single or Multiple Issue
<p class="MsoBlockText">The decision to rate multiple symptoms or signs of a qualifying chronic illness together as a single issue or separately as multiple issues depends on the outcome most favorable to the Veteran.
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<p class="MsoBlockText">

<p class="MsoBlockText">Although rating multiple manifestations under a single body system will in most cases provide the maximum benefit, be alert to symptoms affecting fundamentally different body systems that may clearly warrant separate consideration.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      If service connection for several symptoms or signs is denied for the same reason, consider such symptoms and signs as a single issue.

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Assign one hyphenated diagnostic code (DC) in the coded conclusion to each issue that is separately considered, whether service connection is awarded or denied. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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b.   Information Required to Decide the Issue of Service Connection for a Chronic Qualifying Illness
<p class="MsoBlockText">The following information is required in order to determine whether service connection for a chronic qualifying illness is in order:
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      when the illness arose

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      whether the illness was severe enough to warrant the assignment of a compensable evaluation at any time during the presumptive period, unless manifested while in the Southwest Asia theater, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      whether the illness chronically persisted for at least six months. {| 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.   Relevancy of Medical Evidence in Identifying Illnesses Under 38 CFR 3.317
<p class="MsoBlockText">When the object of service connection is identification of a diagnosed illness, medical evidence is of paramount importance because a physician specializes in identifying disabilities through diagnoses.
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<p class="MsoBlockText">

<p class="MsoBlockText">The concept of “objective indications” expressed in 38 CFR 3.317 makes clear that the evidence required for undiagnosed illnesses, or illnesses which are outside the scope of medical understanding, is not so dependent on formal medical evidence. <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"> 14. Processing Claims for Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Relevancy of the Veteran’s Testimony in Describing Symptoms
<p class="MsoBlockText">When combined with an examining physician’s inability to make a diagnosis, the Veteran’s testimony that he/she is experiencing the symptoms described may be sufficient to establish the existence of the illness. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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e.   Relevancy of Lay Evidence in Describing Non-Medical Indicators
<p class="MsoBlockText">Lay statements from knowledgeable individuals may be accepted as evidence of objective indications of chronic disability. Lay evidence is credible if
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      its source was in a position to know the alleged facts, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      it is not contradicted by evidence of record that is more credible.

<p class="MsoBlockText">

<p class="MsoBlockText">A lay person’s statement regarding the Veteran’s complaints, when they began, how long they lasted, and the severity of the observed symptoms/illness, may be sufficient to satisfy the requirements for objective indications of chronic disability. {| 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.   Lay Evidence Consisting of Non-Medical Indicators
<p class="MsoBlockText">Lay evidence may consist of non-medical indicators, such as
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      time lost from work

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      evidence that the Veteran sought medical treatment for his/her symptoms, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      relevant observations, such as changes in the Veteran’s

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     appearance

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     physical abilities, and/or

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     mental or emotional status. <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"> 14. Processing Claims for Service Connection for Qualifying Disabilities, 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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g.   Determining Inclusion in the VHA Persian Gulf Health Registry
<p class="MsoBlockText">In all cases, ask the Veteran if he/she was
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      included in the Veterans Heath Administration (VHA) Persian Gulf Health Registry, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      examined as part of the Registry, and, if so, where he/she was examined.

<p class="MsoBlockText">

<p class="MsoBlockText">If he/she has been examined, secure examination results from the appropriate VA medical center (VAMC). {| 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.   VA Examiner’s Determination of Disability Pattern for Claims Based on Southwest Asia Service
<p class="MsoBlockText">In each VA examination report, the examiner must characterize the Veteran’s claimed disability(ies) associated with Southwest Asia service as belonging to one of four disability patterns
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      (1) an undiagnosed illness

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      (4) a disease with a clear and specific etiology.

<p class="MsoBlockText">

<p class="MsoBlockText">If the examination report does not contain the examiner’s determination of disability pattern

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      send the examination report and claims folder back to the examiner with a copy of the “notice to examiner” shown in M21-1MR, Part IV, Subpart ii, 1.E.19.g, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·        ask the examiner to provide the medical statement requested in the notice. <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"> 14. Processing Claims for Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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i.   Rating Action Taken Based on Disability Pattern Determination
<p class="MsoBlockText">The table below shows the rating action taken based on the VA examiner’s determination of disability pattern. <p class="MsoNormal"> <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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j.   Considering the Need for a Future Examination of an Undiagnosed Illness
<p class="MsoBlockText">Because the course of an undiagnosed illness cannot be predicted, monitor it by establishing the necessary controls for a future examination within 24 months of the last examination of record.
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<p class="MsoBlockText">

<p class="MsoBlockText">At the expiration of the control period, review the evidence of record to determine whether reexamination is necessary. <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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15.   General Information About Rating Decisions for Qualifying Disabilities
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Introduction
<p class="MsoBlockText">This topic contains general information about rating decisions for qualifying disabilities, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      stating the issue in rating decisions for undiagnosed qualifying chronic disabilities

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      language for the Decision section of the rating decision

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      referencing relevant dates in the rating decision

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      termination or reduction of benefits previously awarded under 38 CFR 3.317, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Southwest Asia Veterans’ participation in VA-sponsored research projects. <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">April 23, 2013 {| 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.   Stating the Issue in Rating Decisions for Undiagnosed Qualifying Chronic Disabilities
<p class="MsoBlockText">State the issue in the rating decision in claims for undiagnosed qualifying chronic disabilities as Service connection for [specify signs or symptoms] as due to a qualifying chronic disability. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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b.   Language for the Decision Section of the Rating Decision
<p class="MsoBlockText">For every disability for which service connection was considered, state the following in the Decision section of the rating decision:   Service connection for [disability] is denied, or Service connection for [disability] is awarded with an evaluation of [percent] percent effective [date].
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   The earliest effective date for entitlement to service connection under the provisions of 38 CFR 3.317 is November 2, 1994. <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"> 15. General Information About Rating Decisions for Qualifying Disabilities, 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.   Referencing Relevant Dates in the Rating Decision
<p class="MsoBlockText">In the rating decision, explicitly refer to any date that is pertinent to the decision.
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<p class="MsoBlockText">

<p class="MsoBlockText">This particularly includes the

<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      dates during which the Veteran served in the Southwest Asia theater of operations, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      earliest date that a qualifying chronic disability may have become manifest.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.C. {| 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.   Termination or Reduction of Benefits Previously Awarded Under 38 CFR 3.317
<p class="MsoBlockText">Situations may arise that will require termination or reduction of payments previously awarded under 38 CFR 3.317.
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<p class="MsoBlockText">

<p class="MsoBlockText">Follow the normal procedures for reduction of benefits or severance of service connection outlined in M21-1MR, Part I, 2.

<p class="MsoBlockText">

<p class="MsoBlockText">Notes:

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      Termination or reduction of benefits paid under 38 CFR 3.317 does not preclude continuation of payments if entitlement is established under other regulations governing the establishment of service connection based on incurrence or aggravation during service, or on a presumptive basis.

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      38 CFR 3.500 was amended by the addition of 38 CFR 3.500(y), which specifically requires that severance of service connection or reduction of benefits under 38 CFR 3.105(d) or 38 CFR 3.105 (e) be effective the first of the month, 60 days after final notice of the adverse action has been issued to the Veteran.

<p class="MsoBlockText">

<p class="MsoBlockText">Example:   A physician diagnoses a previously undiagnosed illness for which compensation was paid under 38 CFR 3.317. <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"> 15. General Information About Rating Decisions for Qualifying Disabilities, 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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e.   Southwest Asia Veterans’ Participation in VA-Sponsored Research Projects
<p class="MsoBlockText">Effective December 27, 2001, if a Veteran with Southwest Asia service participates in a VA-sponsored medical research project, service connection established for a disability under 38 U.S.C. 1117 or 38 U.S.C. 1118 is protected, regardless of the project’s findings.
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<p class="MsoBlockText">

<p class="MsoBlockText">Exception:   Service connection is not protected if the original award was based on fraud, or military records clearly show that the Veteran did not have the requisite service or character of discharge.

<p class="MsoBlockText">

<p class="MsoBlockText">Note:   A list of VA-sponsored medical research projects for which service connection is protected is published in the Federal Register. <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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16.   Granting Service Connection for Qualifying Disabilities
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Introduction
<p class="MsoBlockText">This topic contains information about granting service connection for qualifying disabilities, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      establishing service connection for a qualifying chronic disability that began during Southwest Asia service

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      establishing service connection for a compensable qualifying chronic disability that arose during the presumptive period

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      evaluating the level of impairment from an undiagnosed disability by analogy

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      using hyphenated diagnostic codes (DCs) for undiagnosed disabilities

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      assigning appropriate DCs for disabilities under 38 CFR 3.317

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      list of appropriate DCs for undiagnosed disabilities, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      examples of analogous codes for undiagnosed disabilities. <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">April 23, 2013 {| 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 for Qualifying Chronic Disability That Began During Southwest Asia Service
<p class="MsoBlockText">Establish service connection if the qualifying chronic disability, per M21-1MR, Part IV, Subpart ii, 2.D.13.i, became manifest, whether to a compensable degree or not, while the claimant was on active service in the Southwest Asia theater of operations during the GW period.
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<p class="MsoBlockText">

<p class="MsoBlockText">Include the following sentence in the rating decision:   Service connection is established for [disability] as due to an undiagnosed illness which began in the Southwest Asia theater of operations during the Gulf War period.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.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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<p class="MapTitleContinued"> 16. Granting Service Connection for Qualifying Disabilities, 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 for a Compensable Qualifying Chronic Disability That Arose During the Presumptive Period
<p class="MsoBlockText">Establish service connection if the qualifying chronic disability arose to a compensable degree after the Veteran last served in the Southwest Asia theater of operations during the GW period, regardless of the Veteran’s active duty status at the time.
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<p class="MsoBlockText">

<p class="MsoBlockText">If service connection is established during the presumptive period, include the following statement in the rating decision:   ''Service connection may be presumed for disabilities resulting from undiagnosed illnesses or diagnosed illnesses which arose to a compensable degree after service in the Southwest Asia theater of operations during the Gulf War period. Service connection for [disability] has been awarded on the basis of this presumption''.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.C. <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">
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c.   Evaluating the Level of Impairment From an Undiagnosed Disability by Analogy
<p class="MsoBlockText">Evaluate the level of impairment of qualifying chronic undiagnosed disabilities by drawing an analogy to an existing DC in the rating schedule per 38 CFR 4.27.
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<p class="MsoBlockText">

<p class="MsoBlockText">Precede a discussion of the evaluation criteria in the rating decision with the following statement:   Since the disability at issue does not have its own evaluation criteria assigned in VA regulations, a closely related disease or injury was used for this purpose.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.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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<p class="MapTitleContinued"> 16. Granting Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Using Hyphenated DCs for Undiagnosed Disabilities
<p class="MsoBlockText">Use hyphenated DCs for all undiagnosed disabilities.
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<p class="MsoBlockText">

<p class="MsoBlockText">The table below describes each of the codes that comprise a complete hyphenated DC

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on analogous DCs, see

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IV, Subpart ii, 2.D.16.f, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      M21-1MR, Part IV, Subpart ii, 2.D.16.g. <p class="MsoNormal"> {| 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.   Assigning Appropriate DCs for Disabilities Under 38 CFR 3.317
<p class="MsoBlockText">In order to properly identify and track disabilities for which service connection is granted or denied based on the Persian Gulf War Veterans’ Act, a DC series beginning with “88” has been established.
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<p class="MsoBlockText">

<p class="MsoBlockText">The 88 code is the first element of an analogous code. The second two digits of the 88 code are assigned according to the body system of the analogous code that it precedes.

<p class="MsoBlockText">

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

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      DCs, see M21-1MR, Part IV, Subpart ii, 2.D.16.f, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      analogous codes, see M21-1MR, Part IV, Subpart ii, 2.D.16.g. <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"> 16. Granting Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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f.   List of Appropriate DCs for Undiagnosed Disabilities
<p class="MsoBlockText">The table below lists the first element in a hyphenated analogous code and the type of undiagnosed condition to which each code refers. <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"> 16. Granting Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

<p class="MsoNormal"> {| 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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g.   Examples of Analogous Codes for Undiagnosed Disabilities
<p class="MsoBlockText">The table below contains examples of analogous codes that may be used when evaluating undiagnosed illnesses manifest by the 13 signs or symptoms found in 38 CFR 3.317. For the second code, use a DC with rating criteria that most accurately evaluates manifestations of the disability.
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<p class="MsoBlockText">

<p class="MsoBlockText">Note:   This list does not contain all possible analogous codes.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference:   For more information on the 13 signs or symptoms of an undiagnosed illness, see 38 CFR 3.317. <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"> 16. Granting Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

<p class="MsoNormal"> <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"> '''

17.   Denying Service Connection for Qualifying Disabilities
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Introduction
<p class="MsoBlockText">This topic contains information on denying service connection for qualifying disabilities, including
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<p class="MsoBlockText">

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      discussing the denial in the rating decision

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      addressing

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     diagnosed illnesses

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     an illness that is not chronic

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     an illness that is attributable to some other etiology

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     a condition that is not shown to exist by the evidence of record, and

<p class="BulletText2" style="mso-list:l1 level1 lfo8"> -     a qualifying chronic disability that is less than 10-percent disabling. <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">April 23, 2013 {| 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.   Discussing the Denial in the Rating Decision
<p class="MsoBlockText">Begin a discussion of the denial of service connection in the rating decision with a description of the general requirements for service connection under 38 CFR 3.317, including the following statement:
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<p class="MsoBlockText">

<p class="MsoBlockText">Service connection may be established for disability resulting from undiagnosed illness or a medically unexplained chronic multi-symptom illness that is defined by a cluster of symptoms, or a diagnosed illness that is determined by VA regulation to warrant a presumption of service connection which manifested itself either during active service in the Southwest Asia theater of operations during the Gulf War period, or to a degree of ten percent or more after the date on which the Veteran last performed service in the Southwest Asia theater of operations during the Gulf War period.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.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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<p class="MapTitleContinued"> 17. Denying Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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b.   Addressing Diagnosed Illnesses
<p class="MsoBlockText">Service connection may not be granted under 38 CFR 3.317 for an illness having a known clinical diagnosis unless it meets the criteria for a qualifying chronic disability shown in M21-1MR, Part IV, Subpart ii, 2.D.13.g. However, service connection under other provisions of the law must be considered.
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<p class="MsoBlockText">

<p class="MsoBlockText">If service connection for a claimed undiagnosed illness is denied on this basis, include the following language in the rating decision:   Service connection for [claimed disability] is denied because this disability is determined to result from a known clinical diagnosis of [diagnosed disability], which neither occurred in, nor was caused or aggravated by, service.

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.C. {| 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.   Addressing an Illness That Is Not Chronic
<p class="MsoBlockText">The fact that a claimed disability is not found on the Veteran’s last VA examination does not necessarily preclude his/her entitlement to compensation under 38 CFR 3.317.
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<p class="MsoBlockText">

<p class="MsoBlockText">The requirement for chronicity is fulfilled if the disability has persisted for at least six months. Disabilities subject to episodic improvement and worsening within a six-month period are considered chronic.

<p class="MsoBlockText">

<p class="MsoBlockText">If the disability does not meet the six-month requirement, include the following statement in the rating decision:   ''The disability must have persisted for a period of at least six months. Service connection for [disability] is denied since this disability was first manifested on [date] and lasted less than six months.''

<p class="MsoBlockText"> 

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.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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<p class="MapTitleContinued"> 17. Denying Service Connection for Qualifying Disabilities, Continued <p class="BlockLine" style="margin-left:0in;mso-border-between:.75pt solid windowtext; mso-padding-between:1.0pt">

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d.   Addressing an Illness That Is Attributable to Some Other Etiology
<p class="MsoBlockText">Service connection under 38 CFR 3.317 may not be established if there is affirmative evidence that an undiagnosed illness was not incurred during active service or was caused by some intercurrent circumstance.
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<p class="MsoBlockText">

<p class="MsoBlockText">Important:   Affirmative evidence that the illness is caused by willful misconduct or alcohol or drug abuse will also preclude entitlement.

<p class="MsoBlockText">

<p class="MsoBlockText">Include the following statement in the rating decision if service connection is denied on this basis:   ''Service connection under this provision is precluded if there is affirmative evidence that the disability was unrelated to service in the Southwest Asia theater of operations. Service connection for [disability] is denied because evidence established that this disability resulted from ''[unrelated event, accident, injury, etc.].

<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.C. {| 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.   Addressing a Condition That Is Not Shown to Exist by the Evidence of Record
<p class="MsoBlockText">If the evidence of record fails to show that a condition exists or has existed in the past, include the following statement in the rating decision: There is no evidence that the condition ever existed.
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<p class="MsoBlockText">

<p class="MsoBlockText">Reference: For more information on documenting a decision see M21-1MR III.iv.6.C. {| 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.   Addressing a Qualifying Chronic Disability That Is Less Than 10-Percent Disabling
<p class="MsoBlockText">If the Veteran fails to qualify for service connection because the severity of the qualifying chronic disability is noncompensable, include the following statement in the rating decision:   Service connection for [disability] is denied since this disability neither arose during service in the Southwest Asia theater of operations, nor was it manifested to a compensable degree after the last date of service in the Southwest Asia theater during the Gulf War period.
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<p class="MsoBlockText">

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

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      qualifications for service connection, see M21-1MR, Part IV, Subpart ii, 2.D.13.a, and

<p class="BulletText1" style="mso-list:l12 level1 lfo5"><span style="font-family:Symbol;mso-fareast-font-family:Symbol;mso-bidi-font-family:  Symbol;color:windowtext"> ·      documenting a decision see M21-1MR III.iv.6.C.
 * }