In January 2025 the VA made changes to the guidance related to ordering PTSD C&P examinations. For example, here is the word document file from their website outlining changes to the ordering guidance related to PTSD:
Here are the current rules: M21-1, Part VIII, Subpart iv, Chapter 1, Section C – Examinations and Medical Opinions for Posttraumatic Stress Disorder (PTSD) Claims
Some thoughts and things I find interesting:
- I have seen a lot of talk online about the recent December 2024 law where the VA could choose to not have some DBQ’s publicly online. One thing that is interesting is that after they took the DBQ’s down a few years ago and then were forced to put them back up, they never put all the DBQ’s back up, just some of them. One of the DBQ’s they did not put back online for the public was the Initial PTSD DBQ. The VA basically insisted that the Initial PTSD DBQ had to be done by one of their employees or contractors. In practice it also tended to seem like an Initial PTSD DBQ was needed for all first time PTSD filings regardless of how much evidence was in the records or if a private provider had completed the review DBQ and had provided ample evidence related to stressors and markers (which is frankly a waste of taxpayer money). Amusingly, with the edits to the rules noted above it reads like technically an Initial PTSD DBQ “may” not be required in all instances (though I won’t hold my breath in practice). An Initial PTSD DBQ would be required “unless medical evidence adequate for rating purposes is already of record.”
- Here is another fun reference where the VA wants nothing to do with your treatment provider’s opinion despite the fact that other policies and even how they draft their DBQ’s would suggest otherwise. Quoting directly from their rules: “Note: When requesting a PTSD examination, specify that, if possible, the Veteran’s treating mental health professional should not perform the examination” (see VIII.iv.1.C.1.b. Requesting Initial PTSD Examinations Other Than Personal Trauma). Certainly, forensic practice and clinical practice/ treatment should be separate, but it is hilarious how inconsistent the VA often is with this.
- Generally, in practice from my perspective in the past the VA wanted an initial PTSD DBQ in PTSD cases that met the VA’s duty to assist- even when this was a waste of time and money. Perhaps that may change in the future if there is “medical evidence adequate for rating purposes” even without an Initial PTSD DBQ (or perhaps the VA will let the public complete Initial PTSD DBQ’s) but we’ll just have to wait and see on that.
- There is still lots of room for interpretation on the part of the rater in relation to whether the VA’s duty to assist is met and an exam should be ordered. The rules often ask raters to function much like medical professionals. Unfortunately, this will likely continue to generate many duty to assist errors.
I find the following quoted changes interesting from the VA’s rules in relation to C&P exams as well:
When a PTSD examination or medical opinion report is insufficient for rating purposes, follow procedures in M21-1, Part IV, Subpart i, 3.C.
Reasons that a PTSD examination or medical opinion report may be insufficient for VA purposes include
- the assessment does not conform to current Diagnostic and Statistical Manual of Mental Disorders (DSM) standards
- it does not identify or adequately describe the claimed stressor(s)
- it does not sufficiently describe symptomatology, social and occupational functional impairment, or other facts required by the regulatory diagnostic criteria
- the examiner did not discuss the significance of, and reconcile, any differential diagnoses or changes in diagnosis
- the claims folder was not provided or the examiner did not review provided claims folder material
- the examiner did not
offerprovide a requested comment or opinion - the examiner was not sufficiently qualified to
render an initial diagnosisconduct a psychological examination as specified in M21-1, Part IV, Subpart i, 3.A.1.hi - the examiner did not justify a conclusion that an opinion could not be provided without resorting to mere speculation, or
the examination was not conducted by a properly-qualified examiner.a provided medical opinion is not properly supported by a valid rationale and/or by the evidence of record.
Notes:
- The diagnosis of PTSD must be made by a competent (properly qualified) medical professional and should be unequivocal.
- The examining psychiatrist or psychologist should comment on whether the Veteran has experienced other traumatic events and, if so, indicate the relevance of these events to the current symptoms.
Important: The Federal Circuit held in AZ and AY v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013), that the absence of a service record documenting an unreported sexual assault or a Veteran’s failure to report a claimed assault in service may not be treated as pertinent evidence that the assault did not occur. Accordingly, if an examiner provides a negative medical opinion in response to a request for clinical interpretation of behavioral changes and the examiner uses the absence of a report or documentation of the event in the service records to support the negative opinion, then the medical opinion should be returned as insufficient. A VA examiner cannot use the absence of in-service documentation as evidence that the personal traumatic event did not occur.