IL 10-98-010

In Reply Refer To: 131

April 28, 1998 UNDER SECRETARY FOR HEALTH’S INFORMATION LETTER   GUIDELINES FOR DISABILITY EXAMINATIONS IN GULF WAR VETERANS

1. Because of the number of Gulf War veterans who appeared to be experiencing disabilities for which no diagnosis could be established, Congress authorized the Department of Veterans Affairs (VA) to pay service-connected disability compensation to Gulf War veterans with chronic disabilities resulting from undiagnosed illnesses (Public Law 103-446). Subsequently, VA published regulations implementing the authority for such conditions whether they developed during service in the Gulf or at any time through December 31, 2001. In these respects, eligibility for disability compensation in Gulf War veterans differs from that for other veterans. For all other veterans, compensation can be paid only for disabilities with a clearly defined diagnosis that developed or were aggravated during active service, or within a limited presumptive period following release from active duty.

2. An undiagnosed illness is a disability with signs and symptoms which, by history, physical examination and diagnostic tests cannot be attributed to a known diagnosis. Common signs and symptoms associated with undiagnosed illness include, but are not limited to: fatigue; headache; muscle pain; joint pain; sleep disturbance; abnormal weight loss; menstrual disorders; neurologic or neuropsychological signs or symptoms; and signs and symptoms involving the skin, respiratory, gastrointestinal, and cardiovascular systems.

3. Disability examinations of Gulf War veterans have special requirements because of this unique provision. The Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) have jointly developed guidelines (Attachment A) to assist examiners who conduct such examinations. These guidelines will be incorporated into the Automated Medical Information Exchange (AMIE) system in the future, but, for now, they are available only in hard copy form. Examinations of Gulf War veterans must follow these guidelines, or they will be returned as insufficient for rating purposes.

4. A joint satellite broadcast for VHA and VBA personnel took place March 3, 1998, to provide training on disability examinations in Gulf War veterans.

5. Questions regarding the issues presented in this Information Letter should be addressed to Frances M. Murphy, M.D., M.P.H., Director, Environmental Agents Service (131), at 202-273-8579.

S/by Robyn Nishimi, Ph.D. for

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

Attachment

DISTRIBUTION: CO: E-mailed 4/30/98

FLD: RD, MA, DO, OC, OCRO and 200 - FAX 4/30/98

EX: Boxes 104, 88, 63, 60, 54, 52, 47 and 44 - FAX 4/30/98

ATTACHMENT A GUIDELINES FOR DISABILITY EXAMINATIONS IN GULF WAR VETERANS

1. Introduction. Disability examinations of Gulf War veterans have unique requirements because this group of veterans is eligible for compensation not only for disability due to diagnosed illnesses, but also for disability due to undiagnosed illnesses. An undiagnosed illness is established when findings are present that cannot be attributed to a known, clearly defined diagnosis, after all likely diagnostic possibilities for such abnormalities have been ruled out. Examiners should follow the guidelines in the "Handout of Instructions for Compensation and Pension Examinations" but will also need to request more laboratory tests and specialists’ examinations than average in these cases.

2. Guidelines

a. Thoroughly review the claims file.

b. Address all conditions and symptoms specified on the examination request and also address all additional conditions and symptoms that you can elicit from the veteran during the examination, even if not specified on the request form.

c. Conduct a comprehensive general medical examination, following the Automated Medical Information Exchange (AMIE) General Medical Examination worksheet. For all conditions and symptoms which the General Medical Examination worksheet does not address in detail, follow the appropriate additional AMIE worksheets, and request specialists’ examinations as indicated. Provide details about the onset, frequency, duration, and severity of all complaints and state what precipitates and what relieves them.

d. List all diagnosed conditions and state which symptoms, abnormal physical findings, and abnormal laboratory test results are associated with each. If all symptoms, abnormal physical findings, and abnormal laboratory test results are associated with a diagnosed condition, additional specialist examinations for diagnostic purposes are not needed. Diagnosed conditions will be handled as standard claims for service connection. Symptom-based "diagnoses" such as (but not limited to) myalgia, arthralgia, headache, and diarrhea, are not considered as diagnosed conditions for compensation purposes.

e. However, if there are symptoms, abnormal physical findings, or abnormal laboratory test results that have not been determined to be part of a known clinical diagnosis, further specialist examinations will be required to address these findings.

f. Provide the specialist with all examination reports and test results. Specify the symptoms, abnormal physical findings, and abnormal laboratory test results that have not been attributed to a known clinical diagnosis. Request that the specialist determine which of these, if any, can be attributed in this veteran to a known clinical diagnosis and which, if any, cannot be attributed in this veteran to a known clinical diagnosis.

g. After the specialists’ examinations have been completed and all laboratory test results received, make a final report providing a list of diagnosed conditions. Separately list all symptoms, abnormal physical findings, and abnormal laboratory test results that cannot be attributed to a known clinical diagnosis. Reconcile all differences among the examiners, by consultation or workgroup as necessary, before the examination is returned to the regional office.