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Why would a VA rater deem a medical examination / private medical evidence as insufficient?

After going through the efforts of trying to gather competent evidence for your VA disability benefits claim, the VA can still deem your medical exam as insufficient. It's frustrating, confusing, and unfortunately all too common. We've seen it in a lot of cases and know how to avoid it as private medical evidence providers who know the VA well.


We'll cover the basics of why some veterans' medical examinations / private medical evidence are marked as insufficient, and also cover how to avoid this type of messy situation in the first place.


Why your medical evidence was deemed insufficient or given a lower weight

The VA outlines a few different criteria that are necessary for acceptance when it comes to the information in your VA disability benefits claim. According to the VA's M21-1 (Part IV, Subpart i, Chapter 3, Section C regarding Insufficient Examinations), evidence or exams are considered insufficient for the following reasons.


Medical examinations are insufficient if…

  • There is no doctor signature on the exam report.

  • The exam doesn't address all of the disabilities that it was requested for.

  • Required questions on the DBQ are unanswered.

  • The required review of the claims folder submitted to the VA was not accomplished.

  • The exam report is missing key information regarding the disability under review (the VA's example: impact of musculoskeletal pain on the functional loss of an affected joint)

  • The medical opinion isn't properly supported by valid rationale or evidence of record.

  • A requested medical opinion was not furnished.

  • The letter doesn't add the language "at least as likely" or "more likely" for positive opinions (Here's an example of an acceptable statement: "It is my professional medical opinion that it is at least as likely as not that the veterans sleep apnea is aggravated by his service connected PTSD.")


Medical evidence will have a lower weight if…

  • Conflicting statements made by the veteran in either medical visits or lay statements

  • Evidence or an opinion that lacks medical basis

  • If the opinion or evidence is too old and newer research proves it wrong

  • A medical opinion that is not backed up by current literature 

  • Inaccurately reflects the severity of a condition


So, as you can see above,  there are a lot of reasons (some of them vague) that the VA can label your medical exam as insufficient. If your exam came from a state, county, municipal, private, or contract hospital – the M21-1 states that they will "authorize a VA examination if a satisfactory corrected report cannot be obtained within a reasonable period of time." 


That means that you could be required to show up for a VA examination after you've already completed that examination elsewhere. We see a lot of veterans going in for C&P exams through the VA even though they've already received documentation elsewhere.


How working with a private medical evidence provider can help

Getting private medical evidence and/or exams can help to avoid this issue completely, as long as you're working with a trustworthy company.


Going this route can ensure that…

  • Your evidence will help you get the highest possible rating

  • Your diagnosis is from the right type of diagnosing provider

  • All of your medical exams are 100% sufficient by VA standards 


Picking the right medical evidence provider requires careful thought and consideration. We're not here to push salesy tactics on you – if you want to work with us, we're here to help. If you feel better going with another provider, we just hope you'll take your time to do your research to find an honest and trustworthy fit.


Read more about specific VA requirements for private medical evidence providers here.


Get sufficient medical documentation for the VA disability benefits you deserve

Navigating the VA's rules and regulations can be stressful and time consuming. Our goal is to make your claim experience easy and effective, with impactful results. Get in touch with us today to plan your Nexus Letter, DBQ, or chart review – or simply to talk about your options and learn more.



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