M21-1, Part IV, Subpart i, 1.A
Medical examination or opinion
Order the right medical evidence when the existing record cannot decide the issue.
Define the unresolved medical question first: diagnosis, severity, nexus, aggravation, functional impact, or another material fact. Request an examination or opinion under the duty-to-assist rules when the criteria are met and the record is otherwise insufficient to decide.
Read the captured Part IV source →M21-1, Part IV, Subpart i, 1.B
When an exam is necessary
Use the evidence standard—do not order an exam by habit.
For a service-connection issue, the record generally needs a current disability or persistent symptoms, a qualifying in-service event/disease/injury or applicable presumption, and an indication of association, while still lacking sufficient evidence to decide. Apply the actual standard to the theory raised.
Read the captured Part IV source →M21-1, Part IV, Subpart i, 3.A
General exam sufficiency
A report must answer the question and support its conclusion.
Review whether the report identifies the relevant history and findings, addresses the requested question, uses an adequate rationale where required, and is consistent enough to decide. A completed DBQ or opinion is not automatically sufficient merely because it has been received.
Read the captured Part IV source →M21-1, Part IV, Subpart i, 3.B
Disability-specific sufficiency
Match the report to the requirements of the specific disability.
Some conditions require particular findings, testing, history, or functional information. Compare the report to the applicable disability-specific examination guidance and rating needs rather than relying only on a generic adequacy check.
Read the captured Part IV source →M21-1, Part IV, Subpart i, 3.C
Insufficient examinations
Return or correct an inadequate report before deciding on a missing medical fact.
If the examination or opinion does not answer the requested question, lacks required findings or rationale, is internally inconsistent, or otherwise cannot support the decision, take the prescribed corrective action. State what is missing; do not repair a medical gap with speculation.
Read the captured Part IV source →M21-1, Part IV, Subpart ii, 1.A
Need for review examinations
Check the specific authority before ordering a routine future examination.
Policy Letter 21-01 limits routine future examinations to those mandated by 38 CFR Part 4 or necessary for a reduction under 38 CFR 3.344. A possibility of improvement alone does not authorize one. The policy preserves examinations needed to decide a claim and the applicable missed-examination rescheduling rules.
Read the captured Part IV source →M21-1, Part IV, Subpart ii, 1.B
Future-exam control
Set and maintain the future-exam control accurately.
When a future review examination is warranted, establish the correct control and timing. When the reason for future review no longer exists, update or remove the control under the procedure so the system does not generate unnecessary work.
Read the captured Part IV source →M21-1, Part IV, Subpart ii, 2.A
Action on review-exam results
Use the review result to decide whether the evaluation should continue, change, or require due process.
Review the examination with the existing record, determine whether the rating action is supported, and apply the applicable notice and due-process protections before a reduction or discontinuance. A cancelled review examination may require its own controlled action.
Read the captured Part IV source →M21-1, Part IV, Subpart ii, 2.B
Failure to report
A missed review examination has a rule-driven consequence.
Before taking adverse action for failure to report, verify proper scheduling and notice, consider good cause and any applicable exceptions, and follow the required procedural sequence. Do not equate every missed appointment with permission to reduce or terminate benefits.
Read the captured Part IV source →