Decide the claim on the right facts and rule.

V.i.1.A.1.a · Rating decisions require specifically authorized staff

The rating activity consists of employees authorized to make formal rating decisions and associated actions. Some fiduciary-hub staff have expanded authority for specified incompetency decisions. A development processor can review and develop evidence without acquiring authority to make the medical rating finding.

V.i.1.A.1.b · Separate rating questions from administrative eligibility

Rating issues include service connection, evaluations, cause of death, competency, qualifying insanity findings, permanent incapacity for self-support, and 1151 additional disability or death. The source also identifies historical armed-conflict findings, specified short-service disability questions, and pension total-disability or care-level findings.

Read the list with its exceptions: authorization may deny a clearly failed nonmedical eligibility requirement and may grant qualifying nursing-home-based aid and attendance under its specific authority. Not every death claim or pension claim needs a new rating. Conversely, a processor's review of medical records does not replace a required competency or other rating decision.

V.i.1.A.1.c · Rating staff operate under designated leadership

The responsible division or designated manager directs the rating activity, including the relevant VSC, PMC, or fiduciary-hub arrangement. The location alone does not establish who is authorized to sign a particular decision.

V.i.1.A.1.d · Leadership controls authority, review, and workload

Rating leadership assigns qualified staff, monitors quality, determines single- versus additional-signature authority, and arranges concurrence and referrals for special or complex issues. Claims processors must follow those authorization and review requirements rather than infer that any available employee can finalize a rating.

V.i.1.B.1.a · Complete the required development before the rating referral

When the issue requires a rating and basic eligibility is met, refer after the needed records, examinations, and other development are complete. Supported lay evidence can matter as well as medical evidence. Ready issues need not wait indefinitely for unrelated issues: use the partial-rating rules for a supported decision.

For service connection or cause of death, do not use missing supporting evidence as an administrative shortcut around the STR duty. Obtain STRs or properly determine their unavailability, complete the associated notice and all other development, then refer to rating even if no supporting lay or medical evidence was received. The detailed partial-rating rule permits ready favorable or unfavorable issues where its safeguards are met; this paragraph's grant example is not a blanket ban on every partial denial.

V.i.1.C.1.a · Confirm rating jurisdiction and prerequisite administrative decisions

Rating staff must confirm that the issues actually require a rating. Before deciding, verify that necessary administrative findings, such as line of duty or Veteran status, are completed and authorized. Development should identify an unresolved prerequisite rather than mark a case ready solely because medical records arrived.

V.i.1.C.2.a · Confirm notice was sufficient and actually provided

Review whether the prescribed application is substantially complete and whether section 5103 notice was already supplied or another notice is required. When relevant records are identified, notify the claimant of the needed evidence or release. When records cannot be obtained, identify them, describe the efforts and next action, and explain the claimant's responsibility. For non-Federal records, the applicable notice may accompany the follow-up request.

Before final adverse action, confirm that the proposal met due process, including the required notice and response opportunity. Verify transmission through the authorized communications process; drafting a letter does not prove it was sent. A weak evidentiary claim is not automatically an inherently incredible or legally impossible claim.

V.i.1.C.2.b · Confirm the duty to assist is complete for this issue

Check special forms and evidence, complete Federal-record development or a supported futility finding, reasonable private-record efforts, and all pertinent VA records associated with the file. Vet Center records require the applicable authorization and are not simply available through CAPRI. Confirm required examination and opinion requests contained the right questions and that reports are adequate, or apply the separate failure-to-report rules when appropriate.

Do not treat a missing reply as proof that Federal records do not exist, or an examination's receipt as proof that every requested medical question was answered. Correct the actual development gap and observe the applicable duty-to-assist exceptions rather than ordering duplicative evidence by habit.

V.i.1.C.3.a · Send a clearly legal eligibility failure to authorization

A claim that cannot qualify under the governing law, such as pension based solely on peacetime service, can go to authorization for the proper administrative denial. Confirm the factual predicate and available alternative routes first; unresolved medical causation belongs to rating, not this shortcut.

V.i.1.C.3.b · Use the no-development rule only for clear legal impossibility

The source permits disposition without rating or further development when entitlement is clearly unsupported by law. This does not excuse resolving uncertain service or eligibility facts, and it does not authorize silently closing the claim without the required administrative decision and notice.

V.ii.1.A.1.a · Recognize the different kinds of evidence

Evidence is material offered to establish a fact. It can include statements, documents, physical objects, or illustrations such as maps. Direct evidence addresses the fact itself; circumstantial evidence supports a reasonable inference from other established facts. Consider what each item can actually demonstrate.

V.ii.1.A.1.b · Use VA's evidence rules and the correct timing authority

VA uses its statutes, regulations, policies, and binding precedents rather than the Federal Rules of Evidence used in court. Develop the claim sympathetically and apply reasonable doubt without treating the claimant as an adversary. The correct substantive and procedural requirements still apply.

Source qualification: its retroactivity exception conflates judicial decisions with new statutes or regulations. VAOPGCPREC 7-2003 distinguishes them: judicial rules generally apply to cases still open on direct review, while new statutes and regulations require analysis of their stated reach and prohibited retroactive effects. General Counsel precedent may be an administrative issue for effective-date purposes, but a particular award still requires the appropriate effective-date analysis.

V.ii.1.A.1.c · Separate facts from the legal outcome

First decide what facts the evidence establishes. Then apply the governing legal requirements to those facts. A conclusion that a benefit is or is not payable must be supported by the necessary factual findings.

V.ii.1.A.1.d · Confirm readiness before drafting a decision

Check that all issues have been recognized, required notice and assistance have been completed or properly discharged, and any other applicable due process has been followed. Evaluate the evidence for decision after that review; an unresolved required development action is not cured by starting the narrative.

V.ii.1.A.1.e · Keep personal reactions out of the decision

Remain objective, fair, and courteous. A claimant's criticism, anger, or abusive behavior must not influence the assessment of evidence or entitlement.

V.ii.1.A.1.f · Work through the evidence in a reasoned sequence

Identify the facts and standard of proof required for the benefit and procedural posture. Separate material evidence from information unrelated to those questions. For each relevant item, assess whether its source can establish the fact and whether there is a supported reason to question credibility.

Then weigh the persuasive evidence together, resolve factual questions, and apply the legal requirements. Explain why evidence is more or less persuasive, especially when discounting favorable material. Competency, credibility, and weight are related but different questions; do not replace this analysis with a count of documents.

V.ii.1.A.1.g · Recognize rating's evidence-review responsibility

Rating determines the admissibility and weight of evidence, whether more evidence is needed, and whether an examination is sufficient or required. Follow IV.i.2.A.1 for who may request a particular examination or opinion. Development staff still perform their assigned readiness and evidence-gathering work.

V.ii.1.A.1.h · Apply all governing authorities

Rating must consider the applicable statutes, regulations, schedule, policies, procedures, and binding administrative and court decisions. A convenient manual example does not displace a more specific controlling requirement.

V.ii.1.A.1.i · Use the standard of proof for the particular question

Relative equipoise concerns evidence in approximate balance; preponderance means the greater persuasive weight; affirmative contrary evidence can rebut the particular presumed matter under its governing rule. Clear and convincing and clear and unmistakable are stronger standards, with the latter requiring an undebatable result.

These are qualitative standards, not percentages assigned by counting favorable and unfavorable documents. Identify the standard required for the actual presumption, adverse action, or entitlement issue before evaluating whether it is met.

V.ii.1.A.1.j · Resolve approximate balance in the claimant's favor

After considering the procurable evidence, resolve reasonable doubt about service origin, degree of disability, or another covered factual point in the claimant's favor. Items of evidence do not all carry equal weight.

Read the source's tie analogy with Lynch: evidence need not be exactly equal; nearly equal or approximately balanced evidence can trigger the rule. The rule does not replace the development obligation or a separately applicable heightened standard.

V.ii.1.A.1.k · Use presumptions only after their triggering facts are established

A presumption supplies a legal inference once the required underlying facts are shown; it is not another medical document to put on the scale. Determine the specific soundness, aggravation, or service-connection presumption, its triggering facts, and the evidence and burden required to rebut it.

The source's general burden-shifting description is not a universal formula. Apply the particular presumption's rules, including any requirement that VA prove more than one element to a heightened standard.

V.ii.1.A.2.a · Distinguish receiving evidence from being allowed to consider it

Most submitted evidence becomes part of the claims record. Formal testimony certification, duplicate-record handling, and the closed evidentiary record for higher-level review have specific rules. Evidence received during an HLR is not automatically evidence the HLR reviewer may consider on the merits; use the correct lane and record-handling procedure.

V.ii.1.A.2.b · Question credibility only for a supported reason

Generally accept evidence at face value unless other evidence or sound principles raise a real concern. Assess plausibility, consistency within the statement and with other evidence, relevant witness demeanor, and supported bias. For the supplemental-claim new-and-relevant threshold, apply the credibility presumption; merits review then assesses credibility, competency, and weight normally.

The loadmaster example shows a statement consistent with verified duties and location. Do not turn the clerk/parachute example into an automatic rule that a job title or a missing entry proves an event never happened. Establish the relevant factual foundation, consider other evidence, and complete required development before making an adverse credibility finding.

V.ii.1.A.2.c · Ask whether this source can establish this fact

A medically qualified person may provide diagnoses or opinions within their education, training, and experience. Authoritative medical writings can also supply medical evidence. A lay person may establish matters personally known and observable without specialized expertise. Evidentiary competency here is different from a beneficiary's competency to manage funds.

V.ii.1.A.2.d · Ask what the evidence makes more or less likely

Evidence is probative when it meaningfully supports or undermines a fact needed for the determination. Its value may emerge alone or together with other evidence.

V.ii.1.A.2.e · Evaluate the quality and reasoning of the evidence

Consider competency, credibility, completeness, precision, relevance, and timing. For medical evidence, assess the provider's expertise and experience, knowledge of the relevant history, accuracy of that history, review or treatment background, purpose of the assessment, reasoning, specificity, and degree of certainty.

Evidence from a source unable to address the particular fact, or evidence found not credible for supported reasons, does not establish that fact. Explain the determination instead of treating a provider's title, VA affiliation, or number of visits as an automatic ranking.

V.ii.1.A.2.f · Distinguish evidence supporting and opposing a fact

Positive evidence supports the claimant's position. Negative evidence opposes it, either through affirmative information or a properly supported inference from silence. Absence becomes negative evidence only when the required foundation exists under 2.g.

V.ii.1.A.2.g · Do not treat every missing entry as proof against the claim

Before drawing an adverse inference from silence, establish why the event or symptom would ordinarily have been recorded in the records available. Missing proof of a required element is different from evidence affirmatively disproving that element.

Consider competent lay statements with the whole record. A claim may remain unproven when no sufficient positive evidence establishes a required fact, but do not invent negative weight merely from that evidentiary gap or use it to avoid required assistance.

V.ii.1.A.2.h · Apply the limits on using silence and delayed reports

Relevant accident circumstances can support an inference when tied to the actual issue, as in the source's Forshey example. But lack of a record or report of an unreported sexual assault cannot be used as evidence that the assault did not occur.

A lengthy interval without complaints can be relevant in an appropriate factual setting, but absence of contemporary medical documentation alone does not make lay evidence incredible. Apply the full-history and foundation analysis instead of using a fixed time-without-treatment denial rule.

V.ii.1.A.2.i · A weak merits opinion may still require development

Evidence suggesting a possible relationship may meet the examination threshold even when it is too uncertain or nonspecific to establish the claim on the merits. Apply all examination-need elements. Do not use absent evidence as substantive negative evidence to declare the duty to assist satisfied.

V.ii.1.A.3.a · Do not automatically prefer or discount a treating provider

VA does not give a treating physician's opinion controlling weight merely because of the treatment relationship. Familiarity with the disability history can nevertheless make the opinion more persuasive when it supports a well-reasoned assessment.

V.ii.1.A.3.b · Identify what type of medical assessment is provided

A diagnosis identifies an injury or disease; an opinion addresses a medical question such as cause or onset; an examination gathers relevant clinical facts; and a history recounts symptoms, events, habits, or treatment. An opinion can be informed by an existing examination and records without requiring a new examination every time.

V.ii.1.A.3.c · Check the factual history and the medical reasoning separately

Do not reject a medical assessment simply because it relies partly on the claimant's history. Generally accept that foundation unless the evidence establishes that it is inaccurate or untenable, then weigh the assessment with the rest of the record.

A report that merely repeats the claimed history without supplying a medical rationale is not an adequate nexus opinion. Determine whether the clinician actually analyzed the medical question rather than assuming every recorded history is a medical endorsement.

V.ii.1.A.3.d · Use sufficient records-based examinations and correct the older ACE restriction

ACE allows a clinician to complete the relevant questionnaire using adequate existing records, with a telephone interview when needed, if the condition and request permit that process. A questionnaire still must provide an accurate, complete picture and answer the required questions.

Source update: the statement that non-VA examiners cannot use ACE is outdated. VA's contract-examination requirements permit vendor ACE when the evidence is sufficient and an in-person examination has not been required. Follow current IV.i.2.A.4 and the applicable exclusions; do not reject a report merely because an authorized contractor used ACE.

V.ii.1.A.3.e · Do not substitute your own medical opinion

Rating cannot reject expert medical evidence using an unsupported medical conclusion of its own. Identify an evidentiary or reasoning problem and obtain appropriate clarification or medical evidence when needed.

V.ii.1.A.3.f · Support medical conclusions with record evidence

A finding about the relationship between disabilities, onset, or aggravation needs supporting medical information and reasoning in the folder. If a treatise or independent medical opinion is relied on, explain that reliance in the decision.

V.ii.1.A.3.g · Check whether the opinion answers the actual questions

The opinion must address every requested medical question and connect a clear conclusion to supporting facts and analysis. Its rationale should identify the relevant medical principles, case evidence, and reasoning so competing opinions can be meaningfully compared.

Read the report as a whole, including history, tests, and findings. It is adequate when based on the correct facts and sufficiently clear, consistent, and detailed to answer the medical question. Do not require a particular phrase while ignoring an otherwise complete explanation, or accept an unexplained conclusion because it uses the expected phrase.

V.ii.1.A.3.h · Keep adjudication independent from providing medical evidence

Even a medically trained rating employee cannot write the medical opinion for the case. A person who examined or treated the claimant cannot then perform a rating role in a decision considering that report. Rating staff must not conduct a physical examination during a hearing.

V.ii.1.A.3.i · Review prisoner-of-war protocol reports carefully

A former-POW protocol examination may contain the background needed to relate current symptoms to the internment experience. Consider that information with the applicable POW presumptions and other evidence.

V.ii.1.A.3.j · Use STRs without treating them as the whole case

Service treatment records often carry substantial weight, but they do not alone resolve every service-connection issue. A current disability and any required relationship to service must also be established through the applicable evidence or presumption.

V.ii.1.A.3.k · Avoid an unnecessary repeat examination

A physician's statement can be sufficient for rating when it supplies the needed clinical manifestations and supports the diagnosis with generally accepted findings or diagnostic methods. Examples include appropriate pathology, imaging, or laboratory evidence. Do not order another examination solely because the sufficient evidence came from outside VA.

V.ii.1.A.4.a · Give non-VA evidence an objective review

Private medical and lay evidence is not inherently less valuable than VA evidence. Accept it at face value unless there is a supported competency or credibility concern, then assess both VA and non-VA material under the same evidence principles.

V.ii.1.A.4.b · Explain how conflicting accounts are resolved

Consider supported interest or bias, each witness's opportunity to know the facts, and consistency and plausibility of the accounts. Do not resolve a conflict through personal preference or an unsupported assumption that one category of witness is always more reliable.

V.ii.1.A.5.a · Weigh the complete record fairly

After assessing the individual items, consider the evidence together. Assign weight for explained reasons, not arbitrarily or to reach a predetermined outcome.

V.ii.1.A.5.b · Ask questions that test the opinion's foundation

Consider timing in relation to service, supporting clinical data, knowledge of the relevant history, clarity and detail of reasoning, and whether the source had personal knowledge or relied on another account. None of these questions replaces an overall assessment of the opinion's reasoning and factual accuracy.

V.ii.1.A.5.c · Follow persuasive evidence while still checking every required element

When the relevant evidence strongly favors one conclusion, decide consistently with it. Do not invent adverse evidence to defeat a supported claim. The source's statement about all-favorable evidence must be read with the requirement that the facts establish the necessary benefit elements; one favorable item on one element does not prove all others.

V.ii.1.A.5.d · Resolve approximately balanced evidence favorably

When the procurable evidence is in approximate balance on a covered factual matter, resolve reasonable doubt in the claimant's favor. A mathematically exact tie is not required.

V.ii.1.A.5.e · Do not mistake uncertainty for a negative opinion

An examiner's adequately explained inability to give an opinion is neither positive nor negative support on that question. Describe its limited value rather than calling it nonexistent evidence, and determine whether further clarification or development is required.

Source qualification: its phrase only when in equipoise must be understood as approximate balance, including nearly equal evidence, under Lynch. The rule does not apply when the evidence persuasively favors one side; exact equality is not the threshold.

V.ii.1.A.5.f · Use the example for balancing, not for its imprecise benefit label

The example presents opposing opinions about PTSD's role in a Veteran's suicide with no compelling reason to prefer either. Its lesson is favorable resolution of the approximately balanced disputed causal fact.

The concluding label calls this a grant of service connection for PTSD even though the described dispute concerns cause of death. Do not use that shorthand to skip identifying the actual pending benefit, the PTSD service relationship, or the cause-of-death requirements.

V.ii.1.A.5.g · Explain the final evidentiary conclusion

Discuss the material favorable and unfavorable evidence and explain why one position is more persuasive or the evidence is approximately balanced. Relate that assessment to the factual question and resulting decision.

V.ii.1.A.6.a · Make supported findings without disparaging the claimant

Assess competency, probative value, and credibility when genuinely raised, while remaining objective and courteous. Support inferences with the record and governing rules. Do not arbitrarily refuse weight to the claimant's evidence.

If evidence is not credible, explain the factual reason rather than labeling the claimant a liar. Do not diminish a treating physician's opinion merely by accusing the physician of advocating for the patient.

V.ii.1.A.6.b · Develop and decide in a non-adversarial manner

VA has no advocate assigned to defeat the claim and no policy to minimize benefits. Apply the claimant-favorable rules impartially, award when the facts and law support it or reasonable doubt resolves the necessary factual question, and deny only when the applicable requirements are not met.

V.ii.1.B.1.a · Identify testimony requiring certification

Certain formal testimony, such as material from court proceedings or depositions, must be sworn or properly certified. Do not assume that every ordinary statement about symptoms needs notarization.

V.ii.1.B.1.b · Obtain certification only when the procedure calls for it

If rating or the DRO finds the unsworn or uncertified testimony material to a favorable determination, keep an exact copy and return the original to the claimant, representative, or witness for the required certification. Follow III.i.2.D.3. Do not create a certification-development task for immaterial testimony merely because it is unsworn.

V.ii.1.B.2.a · Consider lay evidence of what happened in service

Satisfactory statements consistent with combat or prisoner-of-war circumstances may establish incurrence or aggravation despite missing official records under the applicable special rules. Noncombat statements can also establish observable service facts, after appropriate review with the other evidence.

The current disability and necessary relationship to service still must be established; use the applicable medical, lay, or presumptive route. Do not read the source's general medical-link sentence as eliminating a valid presumption or competent lay evidence where the law permits it. Missing records alone do not justify discrediting a statement without the foundation described in V.ii.1.A.2.g–h.

V.ii.1.B.2.b · Match the statement to what the person can know

Lay evidence can establish facts personally observed and described without specialized training. Consider direct knowledge, clarity and accuracy of recollection, timing, and the person's ability to address the matter. A medically untrained person's opinion generally cannot resolve a complex medical cause, but that does not invalidate their observations of symptoms or events.

V.ii.1.B.2.c · Use the claimant's description of symptoms

A sufficiently detailed statement about symptoms and their disabling effects is evidence to the extent the claimant can observe and describe them. The person's interest in the claim does not by itself justify rejecting the statement; they may be the best source for how the condition affects everyday functioning.

V.ii.2.A.1.a · Start with the three required elements

Direct service connection requires a current disability, a disease/injury/event in service, and a relationship between them. Review all relevant medical and lay evidence, including the places, types, and circumstances of service. A service event alone is not the whole claim.

The relationship may be established through the listed-chronic-disease rules in 3.303(b), or through the medical nexus and continuous-symptom evidence described in 3.303(a). Apply the evidence and reasonable-doubt rules linked in the original block.

V.ii.2.A.1.b · A disability can count even if it later resolves

A disability present when the claim was filed or while it was pending satisfies the current-disability element even if it resolves before the decision. A diagnosis near the claim date—approximately within the preceding year—can also establish this element after case-specific review. This is an evidence review, not an automatic one-year exclusion rule.

Distinguish three situations. A clear valid diagnosis that later resolves can support a grant, generally with staged evaluations, when the other requirements are met. An earlier treating or unconfirmed diagnosis that is now absent but has not been reconciled needs a medical opinion about whether it was valid. A reasoned finding that the earlier diagnosis was erroneous supports denial when no other medical evidence refutes it.

The manual contrasts well-established recurring eczema with a later examination finding no active pathology, and claimed sinusitis where the medical evidence instead establishes a traumatic deviated septum and explains why sinusitis was not actually present. Preserve the supported alternative condition rather than treating every earlier label as a confirmed diagnosis.

V.ii.2.A.1.c · An adequate direct nexus does not need a redundant opinion

Under 3.303(a), medical evidence or an opinion can establish the relationship to service. Competent medical evidence of continuous symptoms can also establish that relationship, including for conditions that are not on the 3.309(a) chronic-disease list. When nexus is already established, another nexus opinion is unnecessary.

Here continuous symptoms means symptoms continuing or regularly recurring with minimal interruption from service. Isolated symptoms that do not establish that relationship may call for a medical opinion when the examination threshold is met.

V.ii.2.A.1.d · Use the special chronicity rule only for listed diseases

The chronicity and continuity route in 3.303(b) applies to diseases listed in 3.309(a). When this rule establishes nexus, an additional nexus opinion is unnecessary. A condition being medically chronic is not by itself proof that it belongs to that regulatory list.

V.ii.2.A.1.e · Identify real chronic disease in service

For a listed chronic disease established in service, later manifestations of that same disease are service connected unless an intercurrent cause explains them. The in-service evidence must identify the disease and establish chronic disability; isolated findings or the word chronic in a diagnosis are insufficient.

The manual’s example is arthritis confirmed by X-ray during service, claimed years later, with no intervening injury. Silent later treatment records do not create a need for a nexus opinion when onset and chronicity are already established. If chronicity is legitimately uncertain, examine continuity. Nonlisted diseases use the 3.303(a) nexus route.

V.ii.2.A.1.f · Use continuity when listed-disease chronicity is uncertain

Continuity of symptomatology can establish the relationship for a 3.309(a) disease when the condition noted in service was not clearly chronic or its chronicity may legitimately be questioned. This particular 3.303(b) route is limited to the listed diseases; it does not erase other ways to establish a direct nexus.

V.ii.2.A.1.g · A diagnosis after discharge can still be related to service

Under 3.303(d), consider direct service connection even when the disease was first diagnosed after discharge. Review all evidence on whether it was incurred in service rather than treating the later diagnosis date as an automatic bar.

V.ii.2.A.1.h · Do not make your own medical finding that an injury was temporary

An acute condition is short-lived, has identifiable symptoms, and resolves without apparent residuals. A transitory condition is not permanent. The manual gives colds, pneumonia, bruises, and certain seasonal or allergen-triggered reactions as examples.

Do not independently label a service injury acute and transitory without competent medical evidence addressing chronic disability. Allergic conditions require the whole evidentiary showing under 3.380, although seasonal or acute manifestations resolving after the allergen is removed are generally acute.

V.ii.2.A.2.a · Check the actual entrance examination

Soundness generally means the claimant was sound when examined, accepted, and enrolled, except for a condition actually noted at entry or rebuttal by clear and unmistakable evidence of both preexistence and no aggravation. A reported history alone is not a notation.

An examination must have occurred, but its report need not still be available: a lost report does not defeat soundness. An entry finding must meet the applicable definition of disability. Abnormal hearing below the VA hearing-loss criteria in 3.385 does not itself establish a noted hearing-loss disability.

V.ii.2.A.2.b · Check the service period’s soundness requirements

Peacetime service before January 1, 1947 requires six months or more of active continuous service under 3.305(b). Wartime service and peacetime service from January 1, 1947 have no minimum-service requirement for this presumption under 3.304(b). The separate entrance-examination and other applicability requirements still matter.

V.ii.2.A.2.c · VA must establish both facts to rebut soundness

When the condition was not noted and soundness applies, rebuttal requires undebatable evidence that the disease or injury manifesting in service both existed beforehand and was not aggravated. Preexistence alone is insufficient.

Personality disorders are not diseases or injuries for this presumption. Even when soundness applies, service connection still requires a nexus between current disability and the service disease or injury.

V.ii.2.A.2.d · Evaluate breaks in continuous service case by case

An extended unauthorized absence or other extended non-pay period can interrupt active continuous service, but every absence does not automatically do so. Examine its nature, length, circumstances, and effect on continuous duty.

The original contrasts an absence lasting 1,344 days followed by only nine days of duty, which did not meet the relevant continuity requirement, with a 13-day absence followed by a voluntary return that did not break continuity for the cited presumption. These examples illustrate case-specific analysis rather than a new fixed absence cutoff.

V.ii.2.A.2.e · ADT soundness has additional prerequisites

For an ADT-based claim, apply soundness only when there was an examination at entry into the actual ADT period and previously established Veteran status from prior active military service discharged under conditions other than dishonorable. Prior Veteran status does not replace the examination requirement.

Read the linked aggravation article separately for the Hill exception when service connection for one disability establishes active service and Veteran status for the same training period. That exception is different from assuming all training periods carry the active-duty presumptions.

V.ii.2.A.2.f · Verify what makes an IADT period qualifying service

IADT does not count as active service merely because training occurred. The rule covers disability from a qualifying injury, and the specified acute myocardial infarction, cardiac arrest, or cerebrovascular accident during IADT, including the applicable direct-travel provisions. Ordinary disease alone is not the same as a qualifying injury or listed event.

The manual recognizes disabling injury from an anthrax or COVID-19 vaccine during IADT and PTSD resulting from MST during IADT as potential qualifying injuries. Check the actual period, event, direct travel where applicable, and linked rules.

V.ii.2.A.3.a · Verify when and under what circumstances an injury occurred

Development and rating must review STRs and personnel evidence to establish that the injury occurred during service and in line of duty. A current wound residual could instead come from an injury before or after service. Follow the linked misconduct and line-of-duty rules when raised.

V.ii.2.A.3.b · Describe an uncertain scar without inventing its cause

A scar can have existed at entry, arisen during service, or resulted from a later injury. If its origin is uncertain, describe it without calling it a gunshot or shrapnel residual unless the evidence supports that description.

V.ii.2.A.3.c · Connect a claimed scar to the actual service evidence

When an examination identifies a scar in a scarring claim, review official records to determine whether it resulted from a service wound. If the evidence is in approximate balance on that relationship, apply reasonable doubt and award service connection as the manual directs. Review the linked scope rule for scars reasonably included in another claimed issue.

V.ii.2.A.3.d · Combat evidence can establish occurrence without an official record

Accept satisfactory lay or other evidence consistent with the circumstances, conditions, or hardships of combat when clear and convincing contrary evidence does not refute it. Missing official documentation alone does not defeat that supported combat occurrence.

This lightens proof of the service disease, injury, or aggravation. It does not dispense with current disability and nexus. Follow the linked rules for establishing combat participation and weighing the evidence.

V.ii.2.A.3.e · Assess credibility from the evidence

Satisfactory evidence generally means credible evidence. Consider internal consistency and plausibility, and assess contradictions with other evidence using the manual’s credibility and weighing rules. Explain the evidence finding rather than using an unsupported credibility label.

V.ii.2.B.1.a · Identify the exact presumption and qualifying service

Each disease/exposure rule has its own service, manifestation and sometimes compensable-degree requirements. The table is an index, not a universal one-year rule. Check the actual statute/regulation and current disease-specific guidance; 3.311 radiation development is distinct from an automatic presumption.

V.ii.2.B.1.b · Establish whether a cancer is primary or metastatic

Review pathology and obtain medical clarification when origin is unclear. A cancer at a listed site must be primary for that exposure presumption; separate primary cancers can coexist. Metastasis from a service-connected primary can support secondary service connection.

V.ii.2.B.1.c · Use the rating criteria from the manifestation period

Where a compensable level is required during a historical period, apply the criteria in force then. A later, more favorable schedule cannot by itself prove compensability during the earlier required period.

V.ii.2.B.1.d · Require affirmative, reasoned evidence to rebut a presumption

Rebuttal needs full-record affirmative evidence and sound medical reasoning. A negative exposure opinion alone, genetic predisposition, an incorrect preponderance standard or an inadequately explained alternate cause is insufficient. Address why exposure is excluded as contributory or medically unlikely under the stated standard.

V.ii.2.B.1.e · Recognize the supported metastatic-cancer example

The example finds sufficient rebuttal where medical evidence establishes that the listed-site cancer spread from a non-listed primary and specifically explains why exposure did not cause it. The actual medical reasoning, not the mere word metastatic, supports the result.

V.ii.2.B.1.f · Recognize an insufficient alternate-cause opinion

The example's opinion suggesting hepatitis caused lymphoma did not affirmatively exclude exposure as contributory and used inadequate reasoning/standard. A possible competing cause does not automatically rebut the presumption.

V.ii.2.B.1.g · Consider symptom evidence before the formal diagnosis

Review competent lay and medical evidence of onset during the required period. Observable symptoms or a reported contemporaneous diagnosis can support a later diagnosis; where appropriate, obtain an opinion connecting the current diagnosis to the earlier symptoms rather than rejecting the claim for a late diagnosis alone.

V.ii.2.C.1.a · Choose the correct legal starting point

A condition actually noted at entry uses the aggravation framework in 38 U.S.C. 1153. A condition not noted, but later alleged or shown to preexist service, requires the soundness analysis under 1111 when that presumption applies. The two situations place different burdens on VA and the claimant.

V.ii.2.C.1.b · Use supported evidence to establish preexistence

When soundness applies, only clear and unmistakable evidence establishes preexistence. Carefully weigh medical records from before, during, and after service and credible lay history. Do not rely on speculation; the medical analysis must account for the history, data, and accepted understanding of the condition’s nature and course.

V.ii.2.C.1.c · An MEB or PEB conclusion needs an explanation

Give service Medical Evaluation Board and Physical Evaluation Board reports their proper evidentiary weight. A bare conclusion that a condition preexisted service and was not aggravated, without supporting analysis, is not enough by itself to rebut soundness or deny the claim.

V.ii.2.C.1.d · Apply the rules for history and statements against interest

There is no absolute requirement for contemporaneous pre-service clinical records. A later medical opinion based on the Veteran’s history may establish preexistence if it meets the clear-and-unmistakable standard after all probative evidence is weighed.

A signed in-service statement against the claimant’s interest about onset cannot be used without other evidence establishing preexistence under 3.304(b)(3); consider the remaining evidence as if that restricted statement did not exist. Other voluntary admissions may be considered with appropriate credibility and weight.

V.ii.2.C.2.a · Where soundness applies, VA must rebut both preexistence and aggravation

VA needs clear and unmistakable evidence both that the disability preexisted service and that service did not aggravate it. The latter means undebatable evidence of no increase, or that an increase was due to natural progression.

Review the entire record. Absence of a documented injury, pre-service records, or post-service treatment does not alone answer the medical course or shift the burden to the Veteran. Its relevance depends on supported medical analysis.

V.ii.2.C.2.b · For a noted condition, first determine whether it worsened

For a preexisting condition noted at entry into active service, the claimant first establishes an increase in disability during service. Once that increase is proven, presume aggravation unless clear and unmistakable evidence shows it was due to natural progression.

Always address aggravation when claimed. A decision declining service connection must explain the relevant evidence before, during, and after service and why it establishes no increase or natural progression. Use independent medical evidence, not speculation.

V.ii.2.C.2.c · Training-period aggravation differs, with a same-period exception

Ordinarily, ADT or IADT aggravation requires direct evidence of permanent worsening during the qualifying training period beyond natural progression; the usual presumption does not automatically apply.

Under the Hill exception, if a grant for another disability establishes Veteran status and active service for the same ADT/IADT period, the presumption of aggravation applies to another preexisting disability when an entrance examination or other contemporaneous evidence establishes its baseline. A grant relating to a different period does not by itself establish this exception.

V.ii.2.C.2.d · Keep the two burdens separate

No disability noted at entry with applicable soundness: VA must clearly and unmistakably establish both preexistence and no aggravation. Disability noted at entry: a supported increase triggers aggravation unless clearly and unmistakably due to natural progression. Do not require the claimant to prove aggravation under the first situation’s unrebutted soundness presumption.

V.ii.2.C.2.e · Temporary symptoms are not always underlying worsening

Under the ordinary preexisting-condition rule, temporary or intermittent flare-ups are insufficient unless the underlying condition worsened. A condition being in remission at entry and symptomatic later is not by itself proof of aggravation. Apply the special combat/POW rules separately when relevant.

V.ii.2.C.2.f · Separate ordinary treatment effects from other aggravation

The usual effects of treatment intended to correct or improve a preexisting condition—such as ordinary postoperative scars or absent/poorly functioning parts—are not service connected unless the disease or injury was otherwise aggravated by service. Review actual medical findings about the underlying condition and residuals.

V.ii.2.C.2.g · A chronic-disease presumption can establish aggravation

The Splane rule permits presumptive aggravation when a preexisting chronic disease first reaches a degree of at least 10 percent within the applicable post-service presumptive period. Verify the disease, service, time, and degree requirements. Affirmative contrary evidence or an intercurrent post-service disease/injury can rebut it under 3.307.

V.ii.2.C.2.h · Apply the special combat and POW aggravation rules

For combat, accept satisfactory evidence of aggravation consistent with service circumstances despite missing official records, unless clear and convincing evidence refutes it. Current disability and competent nexus evidence remain required.

Under 3.306(b)(2), symptomatic manifestations during or proximately after enemy action or former-POW captivity trigger the aggravation presumption unless clear and convincing evidence establishes no increase or natural progression. Do not apply the ordinary flare-up rule without considering this exception.

V.ii.2.C.2.i · Review the entire medical history in combat cases

When assessing rebuttal, consider all relevant factors, including record availability, the nature and course of the disability, elapsed time, and periods without complaint. Missing treatment records do not necessarily mean the disability was absent, particularly in combat. Explain how the evidence bears on the actual condition rather than equating silence with no disability.

V.ii.2.C.3.a · Look beyond entrance records for the baseline

The baseline review draws on all medical records for the condition. It is not restricted to the enlistment and entry-on-duty records. Obtain and consider relevant evidence before deciding what severity was present at entrance.

V.ii.2.C.3.b · Deduct only an ascertainable entrance evaluation, with a total-evaluation exception

After in-service aggravation under 1153 is established, deduct the supported entrance evaluation from the present evaluation when the entrance percentage is ascertainable. If it is not ascertainable, do not deduct it. Do not make a baseline deduction when the disability has a total 100-percent evaluation under 4.22.

These are in-service aggravation rules. Secondary aggravation under 3.310 has different baseline and total-evaluation instructions; use the actual legal basis.

V.ii.2.C.3.c · Real aggravation can result in a zero-percent evaluation

Actual increased severity can establish aggravation even when current and baseline severities fall within the same schedular percentage. In that situation, grant service connection and assign a noncompensable evaluation. The disability need not cross a rating-percentage threshold to have worsened. The no-deduction exception for a total evaluation still applies.

V.ii.2.D.1.a · Two ways the primary disability can establish secondary service connection

First, a service-connected disability can cause another disability: the additional disability resulted from it, or would not have happened without it. Second, it can make a separate, non-service-connected disability more severe. That includes a condition that would have been less severe if the service-connected disability had not interfered with treatment.

The manual calls this the but-for standard: compare what happened with what would have happened without the service-connected disability. The service-connected condition need not be the only cause. Do not replace this with a stricter proximate-cause test.

Aggravation does not have to be permanent. The current manual also directs VA not to consider natural progression of the non-service-connected disability when deciding this kind of aggravation claim. These instructions reflect Spicer and Ward; do not import the different in-service aggravation test into a secondary claim. The original block links 3.310, 1110, Allen, Spicer, and Ward for the governing authorities.

V.ii.2.D.1.b · A later diagnosis or award does not rule out an earlier causal relationship

There must be evidence that the additional disability resulted from, or would not have occurred without, the primary service-connected disability. But the primary disability did not have to be formally diagnosed or already service connected on the day the additional disability began.

The manual's example involves longstanding back and nerve symptoms that caused a fall and shoulder injury before the nerve condition was formally diagnosed or service connected. Credible history and a supporting medical opinion can establish that sequence. The later diagnosis and award do not, by themselves, defeat causation.

Verify the actual history and current status of the primary disability. Do not assume entitlement to a still-pending primary claim. When a secondary claim predates the primary claim, apply the separate effective-date procedure in V.ii.4.A.3.g; this causation rule does not supply an effective date by itself. The original also links Frost.

V.ii.2.D.1.c · Establish how severe the condition was before the added worsening

For secondary aggravation, the baseline is the condition's severity before the worsening attributable to the service-connected disability. A baseline is required both to establish entitlement on this basis and to determine the evaluation.

Look for medical evidence created before aggravation. If that is not available, consider the earliest medical evidence created between the onset of aggravation and receipt of the evidence establishing current severity. Also consider other credible evidence that helps establish the baseline, including lay evidence.

A lay statement may not establish the baseline by itself, but it can support the finding or show that more evidence needs to be obtained. Do not disregard it simply because it is not a medical report. Follow the lay-evidence procedure in V.ii.1.B.2 and the baseline-development steps that follow.

V.ii.2.D.1.d · Help obtain baseline evidence before deciding that it is missing

The claimant ultimately must provide evidence supporting a baseline, but VA still has its duty to assist. Obtain relevant identified evidence and consider an examination or medical opinion when the examination threshold is met.

The evidence should show severity before aggravation, or as soon afterward as possible while still preceding receipt of the evidence that establishes current severity. Missing a pre-aggravation treatment record does not automatically mean every possible baseline source has failed.

The rating activity makes the legal baseline determination from the whole record. An examiner can provide medical findings and analysis that help with it. When warranted under IV.i.1.B.1.e, request a claims-folder review and an opinion addressing whether the increased manifestations resulted from, or would not have occurred without, the service-connected disability. Do not add an already-established baseline as an extra prerequisite for ordering that warranted assessment.

V.ii.2.D.1.e · Check what the aggravation report actually answers

The report must separately provide the current severity of the claimed condition; an opinion on the required secondary-aggravation relationship; and an adequate medical explanation supporting that opinion.

The relationship question is whether there was any increase that would not have occurred without the service-connected disability, or whether the condition would have been less severe without it. Include interference with or impeded treatment when the record raises that possibility.

A report that only says the primary disability did not cause the secondary condition does not answer a separately raised aggravation question. Likewise, an unexplained conclusion or a permanent-worsening requirement does not satisfy the current instructions. Use the original-request and provider-correction rules to obtain what is missing; do not substitute your own medical conclusion.

V.ii.2.D.1.f · If the baseline still cannot be established after assistance is complete

The manual directs denial of secondary aggravation when no baseline can be established, but only after VA completes the necessary evidence assistance. That can include an examination or opinion when warranted. Missing baseline evidence at the start of development is not the same as an unsupported baseline after development is finished.

Never assume the baseline was zero percent just because the evidence does not establish it. The rating narrative must explain why the degree of aggravation cannot be determined from the available evidence and why the aggravation claim therefore must be denied.

Keep any separate causation or other service-connection theory under review. A baseline is part of this aggravation analysis; failure to establish it does not itself answer a distinct causation question. The original block links the records-assistance, examination, and pre-decision duty-to-assist procedures.

V.ii.2.D.1.g · Calculate the evaluation from the established current and baseline severities

For an aggravation grant, the rating activity determines what schedular percentage represents the established baseline and what percentage represents the current disability. Subtract the baseline percentage from the current percentage to obtain the evaluation attributable to aggravation.

This subtraction still applies when current severity is rated 100 percent, including a temporary total evaluation under 4.29 or 4.30. Do not treat a current total evaluation as automatically erasing the baseline deduction. Apply the correct rating criteria to each supported severity level; the tool does not infer those percentages from a diagnosis.

V.ii.2.D.1.h · Actual worsening can support service connection at zero percent

A condition can genuinely worsen without moving into a higher schedular percentage. When competent, credible evidence establishes worsening from an established baseline because of the service-connected disability, the manual directs a grant at zero percent if baseline and current severity fall in the same schedular evaluation level.

Do not require worsening by at least one full schedular level to establish secondary aggravation. Distinguish this supported zero-percent result from an unknown baseline: an unknown baseline must not be assumed to be zero. The original block links Browder and Hensley for the underlying distinction.

V.ii.2.E.1.a · A defect is generally static

A congenital or developmental defect is a normally static structural or inherent abnormality, usually present from birth and generally incapable of improvement or deterioration. Examples include certain fused vertebrae, an atrial septal defect, pectus excavatum, mental deficiency, and undescended testicles.

Soundness does not apply to such a defect because it is not a disease or injury within the relevant statutes. Still review whether a superimposed service disease or injury caused additional disability under the later block.

V.ii.2.E.1.b · A hereditary disease can change over time

A congenital, developmental, or hereditary disease can improve or deteriorate and may first appear in adulthood. The manual gives polycystic kidney disease, sickle cell disease, retinitis pigmentosa, and Huntington’s chorea as examples. Follow the linked disease-specific rules where applicable.

V.ii.2.E.1.c · Heredity does not automatically prevent service connection

Congenital defects, refractive error, personality disorders, and mental deficiency are ordinarily not compensable diseases or injuries under 3.303(c). But a congenital or hereditary disease can qualify if it first manifests during service, progresses abnormally during service when preexisting, or meets the listed-chronic-disease presumption after discharge. Additional disability caused by an overlying disease or injury to a congenital defect can also qualify.

A degenerative condition is not a congenital defect. Genetic predisposition alone cannot rebut soundness or the chronic-disease presumption, sever service connection, or reduce a disability evaluation.

The original explains that historical retinitis pigmentosa guidance did not prohibit in-service aggravation grants; the subsequent opinions and manual changes were therefore not liberalizing changes. Keep that distinction in any effective-date review and follow the linked eye, severance, presumption, and abnormal-laboratory-finding rules.

V.ii.2.E.1.d · Ask a medical question that distinguishes defect from disease

When the classification is unclear and medical input is needed, ask whether the condition can improve or deteriorate. The opinion helps decide whether it is a disease process or a static abnormality. Weigh the opinion with the rest of the record; it is probative, but not the sole legal determination.

V.ii.2.E.1.e · Use actual manifestation rather than inherited risk as onset

An inherited likelihood of eventually developing a disease is not the disease itself. Actual signs or symptoms of pathology followed by a diagnosis establish manifestation, using case-specific medical evidence and sound medical judgment. A hereditary disease can be incurred in service when those manifestations begin after entry.

Apply soundness when its entrance and service requirements are met. A clear entry examination cannot be overcome merely by heredity; rebuttal still requires clear and unmistakable evidence of both preexistence and no aggravation.

V.ii.2.E.1.f · Abnormal progression requires medical support

When hereditary disease had symptoms before service, it may be aggravated if it progresses during service faster than normally expected according to accepted medical authority. This is a factual medical determination based on the record and sound judgment. Apply the appropriate noted-versus-unnoted entrance and aggravation rules when deciding the claim.

V.ii.3.A.1.a · Review more than the exact words in the contention list

Identify expressly claimed issues, reasonably encompassed conditions and complications, subordinate and ancillary benefits, and entitlement matters raised by VA's review such as a supported reduction, CUE, Nehmer adjustment, or competency issue. Clarify and develop what is needed before deciding. Recognizing an issue does not eliminate its distinct evidence, notice, and decision requirements.

V.ii.3.A.1.b · An express claim identifies both the condition and requested benefit

An expressly claimed issue identifies the disability and benefit on the required claim form. The example lists epilepsy on the compensation application. Use the proper form and claim-status rules without demanding medical precision from the claimant's wording.

V.ii.3.A.1.c · Read the claim sympathetically to identify related conditions

A condition may fall within scope even if not named precisely on the form. Consider related diagnoses, complications, ancillary benefits, and a qualifying unclaimed cause of the claimed secondary condition. Examples include rhinitis developed from a sinusitis claim, unemployability raised by PTSD evidence, a surgical scar related to a claimed knee disability, and hyperacusis encompassed by an audiological claim.

If the evidence is adequate, rating addresses the supported encompassed condition; if not, obtain the needed examination or clarification. Sympathetic reading expands a reasonably supported scope without inventing unrelated claims or assuming every medically similar diagnosis has the same procedural history.

V.ii.3.A.1.d · A subordinate issue can follow from the primary decision

A subordinate issue arises from another issue's facts or outcome. For example, a denied compensation claim may still support treatment eligibility under 1702 for the qualifying mental-health circumstances. Consider it under the specific healthcare rules; do not automatically deny an unclaimed treatment issue when no entitlement is shown.

V.ii.3.A.1.e · A primary award can raise additional benefits

Ancillary benefits arise from established disability entitlement or the death circumstances. A severe ALS award with care needs may require consideration of SMC, DEA, housing, and automobile benefits. Basic eligibility and actual payment approval are different steps; each benefit retains its own criteria.

V.ii.3.A.1.f · Some entitlement reviews arise without a new claimant application

VA may identify a supported reduction, CUE, Nehmer earlier date, or competency review while deciding another claim. The example's evidence of knee improvement requires the applicable reduction analysis and proposal when payment would fall; one examination does not automatically establish every reduction requirement. A supported Nehmer earlier date can be addressed without demanding a new claim merely to raise that issue. Use the full issue-specific safeguards rather than treating discovery as automatic authority to change payment.

V.ii.3.A.1.g · Do not replace the claimant's intent with a convenient assumption

Consider each expressly claimed condition on its facts unless a supported broader reading better reflects the claim. A new PTSD claim is not automatically the same issue as an earlier depression denial, and a sleep-apnea claim is not automatically just an asthma increase. Consider diagnosis, symptoms, theory, prior decision, and applicable combined-rating restrictions without narrowing the requested benefit merely to simplify processing.

V.ii.3.A.1.h · Clarify an unclear condition before deciding it

When the claimed disability is not identifiable, complete and document the prescribed clarification process before rating. Do not select a convenient diagnosis and issue a decision on something the claimant may not have meant.

V.ii.3.A.2.a · Recognize the major ancillary programs

The listed programs include DEA, SAH, SHA, automobile and adaptive equipment, chapter 31 rehabilitation or employment services, and survivor home-loan eligibility. Use the linked program criteria to determine what the rating establishes and what further application or processing remains.

V.ii.3.A.2.b · Consider supported related benefits without manufacturing denials

Generally address an unclaimed subordinate or ancillary benefit when it can be granted, rather than adding it solely to deny. A specific exception is 3.324: when applicable multiple noncompensable service-connected disabilities exist without a compensable evaluation, consider the 10-percent provision even if denied, including applicable confirmed ratings and cases with separate SMC.

Review severe qualifying losses for SMC, permanent total service-connected disability including qualifying IU for DEA, and applicable total-disability cases for supported aid and attendance or housebound. Consider qualifying retroactive pension and inform the claimant, and consider pension extraschedular entitlement when schedular requirements are unmet. These triggers are not substitutes for each benefit's full criteria or the independent IU extraschedular route.

For a survivor claim, consider supported service-connected death, or applicable 1318 entitlement when death service connection cannot be granted; consider DEA when the qualifying basis is established. Review initial qualifying housing, automobile, or adaptive-equipment findings for the corresponding ancillary issue. Consider treatment under 1702 only under its specific circumstances, secondary hypertension with diabetes only when the governing evidence criteria are met, and reasonably raised IU where indicated. Competency concerns use the separate competency procedure and presumption, not an ancillary-benefit shortcut.

V.ii.3.A.2.c · Develop reasonably raised complications of the claimed condition

Consider the medical and lay evidence for complications or residuals of the claimed disability, including diabetes complications, cancer or treatment residuals, surgical scars, spine-related neurological conditions, and effects of progressive or systemic disease. A new form is not required for a genuinely within-scope complication. Obtain adequate medical evidence when a possible complication needs evaluation.

An unclaimed complication generally becomes a separately adjudicated grant when entitlement is established; when not established, discuss relevant evidence in the primary issue's reasons as appropriate. This is not permission to skip development of a reasonably raised complication or to deny it invisibly. The diagnostic code's usual residual categories do not necessarily exhaust the scope of a cancer-treatment claim.

V.ii.3.A.2.d · Investigate an unclaimed primary cause when the claimed secondary issue raises it

If evidence indicates that the claimed condition was caused or aggravated by an unclaimed condition potentially related to service and the examination-development criteria are met, investigate both. If supported, the primary condition can be within scope without a separate claim form. The example links a shoulder injury from a fall to service-related knee instability; evidence must establish the actual causal facts, not simply that two conditions coexist.

V.ii.3.A.3.a · Use the correct follow-on analysis for each type of issue

Outside the claim's reasonable scope, the presence of an unrelated chronic diagnosis does not itself establish intent to claim; invite the appropriate application when required. Within scope, address supported causal and aggravation theories, including the relevant baseline evidence, and determine which PTSD stressor rule applies. For Gulf War illness, develop qualifying service and chronic-disability evidence under the actual presumptive rule; do not turn the overview's nexus wording into an extra ordinary service-nexus requirement for a qualifying presumption.

For 1151, use the appropriate care or rehabilitation causation rules and do not solicit an application solely because records suggest a possible 1151 issue. When evaluating disability, consider applicable old and revised criteria, functional loss, any supported extraschedular referral, and the rule for higher versus lower evaluations where it legally applies. A lower-than-maximum evaluation does not automatically require the next higher one; the evidence and type of rating criteria control.

For pension, consider schedular and extraschedular criteria and qualifying retroactive entitlement. A pension supplemental claim with new disabilities or changed evaluations may need a formal coded rating. A pending disability claim at death may raise accrued or substitution processing with the proper application. Treat temporary hospitalization or convalescence claims as increased-evaluation issues for the underlying disability, and handle permanent-total requests under their specific procedures. Proposed reduction notice under 3.105(e) depends on both the evaluation reduction and its effect on compensation payable.

V.ii.3.B.1.a · Order additional evidence to resolve a real gap

Further records, examination, or opinion may be needed to complete the picture or resolve conflicting evidence. Explain the actual need and weigh the claimant's evidence objectively. Do not develop merely to obtain evidence supporting a denial or repeat adequate examinations without a reason.

V.ii.3.B.1.b · A partial rating decides ready issues and leaves others pending

A partial decision resolves some issues while deferring at least one that needs further development. The deferred issue is not denied and still requires a specific development action and control.

V.ii.3.B.1.c · Move ready issues forward without arbitrary suspense extensions

A partial decision is appropriate when at least one issue can be decided, favorably or unfavorably, while another needs development, or when a supported proposed or final entitlement action can proceed. Take the most complete supported action each time, including development and award processing. Every suspense extension must correspond to a real adjudicative task; do not move dates merely to postpone the claim. Return-to-active-duty cases use their specific exception, and cause-of-death denials have the safeguard in 1.e.

V.ii.3.B.1.d · Do not let mixed automation eligibility conceal undeveloped issues

For a mixed claim routed ready for decision, review the automation-eligible contentions for a supported partial decision and defer the noneligible issues that have not received initial development. Automation eligibility alone does not establish medical sufficiency or completion of the duty to assist. Use the current automation job aids for the actual controls.

V.ii.3.B.1.e · Do not deny cause of death while a potentially causal condition is still developing

If another condition possibly involved in death is still under development, do not use a partial rating to deny service connection for the cause of death. Those theories bear on the same ultimate issue and cannot be treated as unrelated ready and unready claims.

V.ii.3.B.1.f · A deferral must identify the development on which the issue depends

Defer when an underdeveloped or incomplete issue cannot be properly resolved until a needed action is completed. Specify that action and use the applicable VBMS deferral guidance. A generic return to development without explaining the gap is not useful completion guidance.

V.ii.3.B.1.g · Preserve the earlier denial when recording a deferred issue

For a previously denied issue now deferred, verify the master-record entry and original denial date, establish or select the current issue, and record Deferred through the appropriate rating decision entry. Keep the original denial date in its designated field and complete the remaining required entries. The exact screens remain in the user guide; a current deferral must not erase the prior decision history.

V.ii.3.B.1.h · Develop deferred death service connection while paying supported pension

Request the evidence identified in the deferral, award pension if independently established and not already paid, and set the source's 30-day evidence control. Review and return the death-service-connection issue to rating when ready. Expiration of that control does not cancel outstanding Federal-record efforts, an examination requirement, or another duty-to-assist obligation; resolve those before treating the issue as ready for a final decision.

V.ii.3.C.1.a · Identify the actual disability requirement

Service connection requires a current disability. Some conditions have specific regulatory diagnostic requirements, such as hearing loss, hypertension, and mental disorders; others do not. Review the diagnosis and its supporting evidence under the applicable rule rather than imposing one universal diagnostic test.

V.ii.3.C.1.b · Do not convert a preliminary label into a confirmed diagnosis

A treatment label such as prediabetes or prehypertension may be useful clinically without establishing the claimed ratable diagnosis. If the required diagnostic criteria clearly are not met, do not return the report merely to demand confirmation of that diagnosis.

Read this with section 2: a subthreshold label alone does not establish the named disease, but the evidence may raise a different disability or qualifying functional impairment. Do not use the label to bypass assessment of those matters or condition-specific regulatory requirements.

V.ii.3.C.1.c · Distinguish an elective procedure from an unexpected disability

An elective procedure itself, such as the listed vasectomy, cosmetic reduction, or donation, ordinarily does not establish an in-service disease or injury for compensation. An unusual or unanticipated disabling outcome of an in-service procedure may support service connection. Develop and identify the actual residual and apply the specific body-system rules.

V.ii.3.C.1.d · A laboratory finding can still identify a complete claim

An abnormal laboratory value alone, such as cholesterol or glucose, is not a compensable disability. But a claim identifying that finding can satisfy the disability-description element of a complete claim and requires a rating decision when the other filing requirements are met.

Clarify whether the claimant means an underlying disease, such as diabetes described as high blood sugar, and obtain relevant evidence. Do not solicit a new claim merely because an abnormal result appears in service records. Do not administratively reject an otherwise complete claim solely because its wording names a laboratory finding.

V.ii.3.C.2.a · Assess functional impairment when no diagnosis is established

Pain or another condition may constitute a disability when it impairs earning capacity, even without a named underlying disease. Credible medical or lay evidence must show the actual effect, such as inability to perform work tasks, time lost, fatigue, or impaired coordination. Subjective complaints alone are not enough.

This principle is not limited to the musculoskeletal system and does not require a compensable-level evaluation merely to establish disability. Apply any specific regulatory diagnostic requirement, including the mental-disorder exception in 2.d, and still establish the other elements of service connection.

V.ii.3.C.2.b · Assess this claimant's impairment

Evaluate the severity, frequency, duration, and occupational effect shown by competent evidence for the individual. Rating criteria may help identify manifestations capable of impairing earning capacity, but pointing to a code with similar symptoms does not prove that this claimant has the disability. Record the functional effect rather than inferring it from the existence of pain alone.

V.ii.3.C.2.c · Distinguish establishing disability from assigning a percentage

Saunders concerns whether pain without an identified diagnosis constitutes a disability because it impairs earning capacity. Petitti concerns evaluating an already service-connected musculoskeletal disability under the applicable painful-motion rules. Neither means that every report of pain automatically establishes service connection or a compensable rating.

The source applies Saunders to claims and legacy appeals pending or received on or after April 3, 2018, and treats it as judicial precedent rather than a liberalizing VA issue under 3.114. Use the separate judicial-precedent effective-date rules for the actual procedural history.

V.ii.3.C.2.d · Retain specific psychiatric diagnostic requirements

Martinez-Bodon explains that functional impairment can arise from conditions other than pain, but the applicable mental-disorder regulations still require a DSM-5 diagnosis. Do not substitute an impairment-only analysis for that specific requirement.

The source identifies the August 11, 2020 holding, affirmed in 2022, and applies it to claims and legacy appeals pending or received from that date. It is not treated as a liberalizing issue under 3.114.

V.ii.3.C.2.e · Use the examples to decide whether clarification is needed

The knee example with limited standing, walking, and work attendance establishes disability despite no specific anatomical diagnosis. The shoulder example does not establish disability because the evidence shows no occupational functional impairment. Frequent headaches that require stopping work can establish disability even when testing shows no obvious abnormality.

When the examiner reports subjective knee pain but never analyzes its occupational effect, return the report for that analysis unless other credible evidence already establishes it. Normal motion or testing does not answer every functional-impairment question. These examples address the disability element, not automatic service connection.

V.ii.3.C.2.f · Normal testing does not end every impairment inquiry

In the shortness-of-breath example, pulmonary testing is normal but the clinician finds credible symptoms that limit even minimally demanding occupational activity. That establishes functional impairment for the disability element. The remaining service-connection requirements still need support.

V.ii.3.C.3.a · Distinguish direct obesity claims from secondary claims

The captured manual excludes obesity itself as a disease or injury incurred directly in service and says gradual weight gain is not the discrete in-service event contemplated by that analysis. Adams v. Collins, decided July 8, 2025, left the direct-service-connection prohibition undisturbed but rejected the blanket secondary-disability exclusion. Read 3.b before disposing of a claim involving an already service-connected condition.

V.ii.3.C.3.b · Do not use the older blanket exclusion for secondary obesity

Source update: the opening sentence predates Adams v. Collins. The court rejected the categorical secondary-service-connection exclusion and required consideration of functional impairment and the claimed secondary relationship; it did not automatically award a rating for obesity. The Federal Circuit appeals were dismissed May 15, 2026. Obtain the needed impairment and relationship evidence and apply current adjudication guidance rather than denying solely because the condition is obesity.

Separately, obesity can be an intermediate step linking an established service-connected disability to another claimed disability. Address whether the service-connected condition caused or aggravated obesity, whether that obesity was a substantial factor in causing or aggravating the claimed condition, and whether the claimed outcome would have occurred without it. The source's first bullet mentions only causation, but Walsh requires consideration of aggravation of obesity when raised. Do not require the service-connected condition to have originally caused all of the weight gain.

The source also describes considering extraschedular evaluation of the established service-connected condition when associated impairment falls outside the schedule. That requires the separate referral criteria and is not the only possible route after Adams.

V.ii.3.C.3.c · Look for a supported intermediate-step theory

Incidental weight references alone do not reasonably raise obesity as an intermediate step. Look for evidence suggesting a relationship between the service-connected condition or treatment and the obesity or weight gain. When the theory is expressly claimed or reasonably raised, address the relevant causal and aggravation questions.

V.ii.3.C.3.d · Keep the two examples' routes separate

In the arthritis example, medical evidence links the service-connected condition to obesity and additional impairment not contemplated by the ordinary evaluation; assess whether extraschedular referral is warranted. The example is not an automatic extraschedular grant.

In the psoriasis example, sustained treatment leads to obesity that is medically linked to coronary disease. The supported chain permits consideration of coronary disease as secondary through obesity. The example does not establish that every person prescribed the medication develops that chain, and it does not replace the separate secondary-obesity analysis recognized in Adams.

V.ii.3.C.4.a · Identify the cause of infertility

For this compensation procedure, infertility means inability to procreate successfully, with or without medical intervention, because of a service-connected injury or disease. Obtain evidence of the actual underlying condition and relationship rather than drawing that medical conclusion yourself.

V.ii.3.C.4.b · Treat the infertility claim as a claim for its underlying cause

Do not establish a standalone infertility diagnosis under this procedure. Develop and rate the injury or disease causing it. If the examination identifies infertility without its cause, return it for clarification. If thorough review still identifies no cause, follow the claim-clarification instructions in V.ii.3.A.1.h.

A processor cannot supply an unsupported medical diagnosis or cause. Consider the relevant reproductive, genitourinary, and elective-procedure instructions for the actual evidence.

V.ii.3.C.4.c · Address special monthly compensation when warranted

When service connection is granted for the condition producing infertility, address SMC for anatomical loss or loss of use of a creative organ under the cited criteria. Record the qualifying medical basis; do not overlook SMC merely because the underlying schedular evaluation is low.

V.ii.3.C.4.d · Follow the examples through development and decision

If evidence establishes service-related endometriosis causing infertility, grant the underlying endometriosis and the applicable creative-organ SMC. If diabetes causes erectile dysfunction and infertility, address the erectile-dysfunction complication and SMC without assuming an unclaimed worsening of the diabetic process.

If neither the claim nor a thorough evidence review identifies an underlying cause, attempt the required clarification. The source's final example denies only after that review and an unsuccessful clarification attempt; it is not a direction to reject every claim initially worded infertility.

V.ii.4.A.1.a · Gather the facts that drive the date

Identify the issue, actual claim/ITF receipts, entitlement onset, prior decisions and continuous pursuit, plus possible liberalizing or Nehmer authority. The effective date is a decision based on those facts, not merely an EP field.

V.ii.4.A.1.b · Check specific exceptions before the general rule

The general rule uses the later of claim receipt and entitlement arising, but a more specific rule may govern. Claim date and award effective date are not synonymous.

V.ii.4.A.1.c · Identify when the entitlement facts were first met

Date entitlement arose means when the facts establish the necessary benefit criteria. It is not automatically the date a clinician later documented an already existing disability.

V.ii.4.A.1.d · Reconcile complete, incomplete and intended claims

Consider a timely perfected ITF or incomplete claim and use the earliest one perfected within its own required period. An incomplete claim does not extend an expired ITF. Check applicable temporary receipt guidance for documented emergencies or processing events.

V.ii.4.A.1.e · Do not automatically use a later examination date

A later diagnosis can confirm disability already present at claim receipt. Use a later entitlement date only when the evidence clearly shows the entitling criteria were not met earlier; evaluate the full lay and medical history.

V.ii.4.A.1.f · Separate entitlement from the first payable month

Section 3.31 generally starts payment the first day of the month following entitlement on an initial or supplemental award. Apply its actual exceptions rather than moving the underlying entitlement date to match the payment line.

V.ii.4.A.1.g · Preserve the expressly claimed issue's date for within-scope findings

A supported disability found within the scope of another claim is guided by that expressly claimed issue's receipt date. Do not create a later claim date merely because development identified a more accurate diagnosis or related within-scope issue.

V.ii.4.A.1.h · Limit the special FDC retroactivity to its historical authority

Certain historical fully developed claims qualified for special retroactive dates under the cited law and archived instructions. Ordinary FDC participation does not otherwise create an earlier effective date.

V.ii.4.A.1.i · Compare all supported theories for the best lawful date

Different valid theories can produce different dates. Consider direct, secondary, presumptive and special retroactivity rules and choose the most advantageous one supported by the facts; do not stop after finding the first grantable theory.

V.ii.4.A.2.a · Treat an ITF as a receipt rule, not an award rule

A properly submitted ITF and timely complete application can establish deemed receipt. A historical online initiation date may affect effective-date analysis without replacing the actual claim-receipt field in every VA system.

V.ii.4.A.2.b · Preserve a timely post-service ITF

An applicable claim completed within a year of its active ITF can be treated as received on the ITF date. An ITF within a year of separation can therefore preserve possible day-after-discharge entitlement when the application is timely completed.

V.ii.4.A.2.c · Check duplicate, consumed and supplemental ITFs carefully

An active duplicate ITF does not restart the year; the next applicable complete claim can consume it before a later claim arrives. The examples also show how an applicable ITF can preserve supplemental continuous pursuit under the current rule. Verify the actual receipt, active status, benefit and prior decision dates for each issue.

V.ii.4.A.3.a · Verify all day-after-discharge conditions

For direct SC within a year, check qualifying discharge, continuous active service from incurrence/aggravation and whether entitlement existed the day after separation. Otherwise consider later entitlement or the general rule. Reinstatement after active duty has its own authority, separate from new disabilities.

V.ii.4.A.3.b · A late claim generally cannot use the discharge exception

The example's claim arrived more than one year after discharge, so the later claim/entitlement rule applies. A disability present since service does not by itself eliminate the filing requirement.

V.ii.4.A.3.c · A recent separated period does not cover every old disability

The example involves a disability incurred during an earlier, noncontinuous period without later incurrence/aggravation. Filing within a year of the latest discharge does not automatically give the earlier disability that discharge's next-day date.

V.ii.4.A.3.d · Distinguish a barred final period from earlier eligible service

A dishonorable final period does not qualify for the day-after-discharge exception. Earlier eligible service generally uses the general rule; a pre-discharge claim can still produce entitlement the day after separation because active-service pay barred an earlier payment, not because the barred period became qualifying.

V.ii.4.A.3.e · Check the hospital-rating exception

For a qualifying VA/approved hospitalization exceeding 21 days, service connection granted during hospitalization can support the stated temporary total entitlement from admission. Verify the disability treated and 4.29 requirements rather than applying the exception to every inpatient claim.

V.ii.4.A.3.f · Use the general rule for a separate secondary claim

Ordinary secondary SC is not an increase for effective-date purposes and does not begin merely at the earliest nexus evidence. Distinguish a separately claimed secondary disability from a required complication/residual or other within-scope issue.

V.ii.4.A.3.g · Keep secondary dates consistent with causal entitlement

Secondary SC cannot predate SC of the causal disability. When an unclaimed causal condition is within scope, its date can be guided by the expressly claimed secondary issue; obtain the actual scope and entitlement findings.

V.ii.4.A.4.a · Separate in-service and post-service presumptive onset

For a timely post-service claim, day-after-discharge entitlement requires the stated in-service manifestation and continuous-service conditions. If entitlement first arose afterward, use that date. Outside the year, apply the general rule unless another authority such as 3.114 governs.

V.ii.4.A.4.b · Use actual post-service entitlement onset

The example's hypertension became compensable after service, although the claim was within a year of discharge. The effective date is when entitlement arose, not automatically the day after discharge.

V.ii.4.A.4.c · A new diagnosis after the law change may defeat 3.114 retroactivity

The example's diabetes first arose years after the presumptive law change. The ordinary claim-date result applies on those facts because continuous eligibility from the liberalizing date was not established.

V.ii.4.A.5.a · Identify which increase rule applies

Ordinary increases use 3.400(o), including its factual-worsening lookback. Continuously pursued issues use 3.2500(h)(1); A&A/housebound can use 3.401(a), and terminated basic entitlement has its own bar to retroactive additional benefits.

V.ii.4.A.5.b · Find actual worsening within the preceding year

The one-year lookback requires a factually ascertainable increase during that year before the qualifying claim/ITF. Worsening more than a year earlier does not automatically justify a date exactly one year before receipt.

V.ii.4.A.5.c · Develop all IU criteria and the related evaluation history

Identify when schedular eligibility and inability to maintain substantially gainful employment were met, including a remaining criterion first arising during the year. A related evaluation claim can affect the IU date; IU still requires all applicable criteria and cannot predate underlying SC.

V.ii.4.A.5.d · Distinguish old unemployment from the relevant increase claim

The example does not backdate IU to employment ending years earlier. It ties the later timely IU claim to the related evaluation claim and established eligibility under the specific increase-date rule.

V.ii.4.A.5.e · Treat required complications as increased manifestations

Where governing criteria require separate evaluation of complications/residuals, use the increase rule for their dates. VBMS's secondary coding convention does not convert that case into an ordinary new secondary claim for effective-date purposes.

V.ii.4.A.5.f · Separate increase from active-duty reinstatement

A claim can seek both restoration after service and an increased evaluation. Use the applicable increase facts/lookback and separate reinstatement rule; an increased compensation date cannot fall during active duty.

V.ii.4.A.5.g · Consider A&A or housebound during a retroactive primary award

Section 3.401(a) can support additional benefits when qualifying need arises within the retroactive primary-award period, including spouse A&A. Develop the actual onset instead of limiting every ancillary award to the new claim's receipt date.

V.ii.4.A.6.a · Identify the kind of guidance change

A change in statute, regulation or interpretation can affect dates differently depending on its nature and the claim's pending/final status. Establish the actual change before selecting a retroactivity rule.

V.ii.4.A.6.b · Recognize a substantive liberalizing law

A liberalizing law creates a new and different substantive entitlement. A clarification, procedural change or more readable instruction is not automatically a liberalizing law.

V.ii.4.A.6.c · Determine applicability without unauthorized mass review

Compare the changed standard with the actual pending or new claim and consider favorable or adverse effects. Do not initiate a general review of prior beneficiaries without the specific agency authority directing it.

V.ii.4.A.6.d · Use 3.114 only for a grant pursuant to the change

A qualifying liberalizing law, regulation or VA issue may permit retroactivity for pending, denied or later-filed claims. Identify actual potential entitlement when the change took effect and the substantive basis of the grant.

V.ii.4.A.6.e · Identify where the liberalizing authority originated

Congressional statutes and VA regulations can create liberalizing entitlement. Use the actual enacted or issued text and effective date, not the date a training aid explained it.

V.ii.4.A.6.f · Identify the actual VA issue

A VA issue arises through the relevant existing or new regulation. Establish whether it substantively changes entitlement before applying the law-change award rules.

V.ii.4.A.6.g · Confirm the grant rests on the favorable change

Section 5110(g) requires a liberalizing authority and a grant pursuant to it. Compare supported theories for the most advantageous lawful result; a law change unrelated to the actual basis of the grant does not supply retroactivity.

V.ii.4.A.6.h · Develop continuous eligibility from the liberalizing date

For 3.114, establish the required eligibility on the law's effective date and continuously through the award and retroactive period. Apply the requirements to the actual benefit rather than assuming every now-presumptive condition existed when the law changed.

V.ii.4.A.6.i · Keep pension and Parents' DIC income rules separate

For these benefits, income and pension net worth are not continuous eligibility factors for 3.114 in the same way as the underlying entitlement criteria. Actual payable retroactive periods still require their benefit-specific income/net-worth calculation; do not import this exception into compensation generally.

V.ii.4.A.6.j · Review the entire historical pension example

The example meets age-related eligibility but income exceeds the applicable rate for the claimed retroactive period. Liberalizing-law eligibility alone does not prove a payable pension amount or allow choosing a convenient date to avoid the actual facts.

V.ii.4.A.6.k · Account for intervening income in the retroactive period

The example permits initial retroactivity but requires counting a later inheritance and stopping/restarting payment as the income rules direct. A claimant requesting the earlier period receives a review of all its material facts, not only favorable ones.

V.ii.4.A.6.l · Use the correct initiative and timing branch

Review within one year of the law can allow its effective date; later review may allow one year before the actual administrative determination or claimant request. Preserve continuous eligibility, the law's effective-date limit and timely perfected ITF where applicable.

V.ii.4.A.6.m · Compare the old and new versions for favorability

A new rule may allow a grant or greater award; an old rule can remain more favorable by allowing the same result from an earlier date. Compare the actual applicable versions and facts rather than assuming newer is always better.

V.ii.4.A.6.n · Give due process for an adverse law-change adjustment

A previously proper award affected by changed law/interpretation needs the specified proposal and evidence period. Apply the special first-of-month effective-date provision and timely evidence received within the stated processing interval before reducing or discontinuing.

V.ii.4.A.6.o · Allow different evaluations during a retroactive period

The example supports a liberalizing earlier SC date but uses staged evaluations as severity changed. Earlier entitlement does not mean the latest higher evaluation applies to the entire retroactive period.

V.ii.4.A.6.p · Do not apply revised rating criteria before their effective date

Compare versions; apply more favorable amended criteria only from their effective date and the prior criteria to earlier periods. If the older version is more favorable, use it as directed for the pending claim.

V.ii.4.A.7.a · Apply binding precedents according to claim finality

A precedent applies on issuance to relevant pending and later claims, but does not alone reopen finally adjudicated decisions or turn their old interpretation into CUE. A court decision itself is not a 3.114 liberalizing issue; an implementing statutory/regulatory change can be.

V.ii.4.A.7.b · A pending claim can predate the favorable court decision

The example's claim was pending when the precedent issued, so the applicable claim date can precede the court's date. Do not automatically restrict every precedent-based allowance to the day of the opinion.

V.ii.4.A.7.c · Review a still-nonfinal decision under the binding holding

The example shows a favorable holding applied while the earlier decision remained nonfinal. The actual notice, review and finality history determines whether the earlier claim remains available.

V.ii.4.A.7.d · Distinguish a court ruling from its liberalizing regulation

When VA issues an actual liberalizing regulation implementing a holding, 3.114 can affect a later claim's date. Identify that regulation and effective date rather than treating the court opinion alone as the liberalizing issue.

V.ii.4.A.7.e · A later claim gets no automatic court-based lookback

Without a liberalizing regulatory change, the example's claim filed after the favorable precedent uses the applicable claim-date rule. The favorable ruling alone does not produce one-year retroactivity.

V.ii.4.A.7.f · Identify whether a General Counsel opinion changes law

Most opinions clarify existing law and do not trigger 3.114. A specific new interpretation replacing an erroneous prior one can be different; examine the actual opinion rather than assigning retroactivity to every precedent opinion.

V.ii.4.A.8.a · Do not adjudicate a freestanding date request against a final decision

A finally adjudicated RO date cannot be changed through a bare request for an earlier date. A valid CUE allegation must identify the factual or legal error; verify finality and any actual pending review before applying this rule.

V.ii.4.A.8.b · Route a specific CUE allegation or give the required response

A stated CUE with specific errors follows X.ii.5.A.2.a–b. A request lacking a specific qualifying allegation receives the response under A.2.c; 'my date is wrong' alone is not a valid CUE pleading.