Ingram FAQ

Last Updated: October 31, 2025 FAQ: Ingram Implementation Q1: If a musculoskeletal DBQ is received and indicates a negative medical opinion for service connection, are new or rework examinations required due to the missing Ingram language? A1: Ingram v. Collins is focused on assigning an evaluation for a service-connected disability based on evidence if/when the Veteran is not taking medication. If an evaluation cannot be assigned (i.e. service-connection is being denied), additional information related to the Ingram court case would not be required. ____________________________________________________________________________ Q2: If the contention is at the code sheet maximum evaluation with the existing evaluation, are new or rework examinations required due to the missing Ingram language? A2: No. You do not need to send the claim for a new or rework exam in this case. ____________________________________________________________________________ Q3: If an examination provider indicates that they have not received Ingram related guidance, and requests the claims processor to cancel or reschedule an examination, what is the appropriate process? A3: Claims processors should return these ESRs to the vendors and state the following: “Guidance on processing Ingram-related examination requests was distributed to all medical disability examination vendors on October 10, 2025 with an expected implementation date of October 13, 2025.” ____________________________________________________________________________ Q4: Would Ingram apply to radiculopathy since radiculopathy is addressed on the Back and Neck DBQs? A4: No, Ingram is not applicable to radiculopathy and ESR language has been updated accordingly as follows: Note: There is no requirement for VA to consider the severity of neurological abnormalities of the spine (e.g. radiculopathy) in an unmedicated state. When completing the Neck (Cervical Spine) or Back (Thoracolumbar Spine) DBQ, do not respond to the Ingram questions for neurological abnormalities. ____________________________________________________________________________ Q5: If a claimed MUSC condition has the auto Ingram language, do we also add the GW language as well?

Last Updated: October 31, 2025 A5: Yes, all additional required language should be added. Only the Ingram language is auto- populated. ____________________________________________________________________________ Q6: When submitting Medical Opinion only exams (for example, Higher Level Review Medical Opinions requests), the Ingram language populates on the exam. Several contract vendors return the exam requesting clarification and even asking to remove the language for them to accept the request. A6: If requesting a Medical Opinion only, the Ingram language will generate in the ESR if the contention classification is musculoskeletal. Please reference A3, regarding vendor clarifications and requests for Ingram language removals. ____________________________________________________________________________ Q7: The following DBQs have been identified as requiring Ingram language: • Amputations • Ankle Conditions • Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline and Infectious) and Decompression Illness • Back (Thoracolumbar Spine) Conditions • Bones and Other Skeletal Conditions • Elbow & Forearm Conditions • Foot Conditions Including Flatfoot (Pes Planus) • Hand and Fingers • Hip and Thigh Conditions • Knee and Lower Leg • Muscle Injuries • Neck (Cervical Spine) Conditions • Osteomyelitis • Shoulder and/or Arm Conditions • Temporomandibular Disorders (TMDs) • Wrist Conditions Are we only adding this to these conditions? ESRs submitted prior to October 13, 2025, for which an examination has not been completed as of that date, will not have the necessary Ingram language. A7: The Ingram language will auto populate for any DBQs requested on or after October 13. Please see Ingram Rating Guidance (initially issued on October 10, 2025, and clarified on October 31, 2025). 1. For ESRs requested prior to October 13, 2025, where the Ingram language was not included as part of the examination request: and appointments have been scheduled, MDE

Last Updated: October 31, 2025 vendors have been instructed to add the responses to the questions above to the respective DBQ results, in the remarks section. This will require no additional action by field personnel. a. If the examination was completed by the vendor and submitted to VBA but is missing the required responses to questions, proceed to Scenario 2. 2. For ESRs requested prior to October 13, 2025, where the examination was completed by the vendor and submitted to VBA but is missing the required responses to questions: a NEW ESR may be required. a. Review the DBQ to determine if it is sufficient for rating purposes. i. If sufficient, proceed with rating the contention. ii. If insufficient due to missing responses to questions, a new exam request should be submitted. 1. A rework ESR should not be submitted for missing Ingram language as the necessary language was not originally requested. 2. The claims processor should then request the new ESR using the appropriate DBQ and adding the following language: a. “The Veteran does not need to be seen again unless deemed necessary by the examiner” Note: The Ingram language will automatically populate with the new ESR. ____________________________________________________________________________ Q8: The guidance provided is not clear. How can we include the required language (“Although the evidence of record shows that medication is taken for the disability, the medical evidence indicates that it is not possible to determine the severity of disability as if you were not taking the medication without resorting to speculation.”), if the examiners are advised not to answer the remaining questions when Question 1 is answered "YES", and Question 2 is answered "NO"? 1. Is the required language to be incorporated in every musculoskeletal rating decision? 2. Is the provision language to be incorporated in every musculoskeletal rating decision? A8: If the response to Question 2 is No, the Veteran is being examined without the ameliorative effects of medication. No additional information is needed. Within the ESR, examiners are asked whether the Veteran reported taking medication. If they answer Yes, then they must state whether the medication relieves or reduces the severity of the symptoms being evaluated. If the examiner, answers No, there is no need to answer the next questions regarding whether an opinion on the impact of medication and the associated functional losses can be rendered without speculation. Within the second question, the examiner has already stated that the medication does not relieve or reduce the severity of the disability. The rating narrative language fragment prescribed in the interim rating guidance is reserved for use in instances in which the examiner responds Yes to the first and second Ingram ESR questions, but responds No to the third, indicating that an opinion on the extent of the disability’s severity in an unmedicated state cannot be rendered without resorting to mere

Last Updated: October 31, 2025 speculation. If those criteria are not met, inclusion of the language is not necessary or situationally appropriate. ___________________________________________________________________________ Q9: When generating a Gen Med or GW Gen Med for Fibromyalgia, the Ingram language generates. How can we remove the language? A9: Please ensure the correct contention classification is added for Fibromyalgia. It would either be “Gulf War unexplained chronic multi-symptom" or “Neurological other” classification. If the correct classification is associated with Fibromyalgia, the language will not generate. ____________________________________________________________________________ Q10: Are we only using Ingram language when range of motion is a question or when for “DBQ Musc Foot” is used for Gout? A10: Ingram language should automatically be added to musculoskeletal ESRs. Ingram is applicable in the scenario above. ____________________________________________________________________________ Q11: VBA sent Exam request Tuesday (10/14/25) which contained the new Ingram verbiage. Yesterday (10/15), the examiner returned the exam request stating they have not received guidance, and VA should resubmit once guidance has been released. Should we re-submit again, hold on to the case, or something else? A11: Please reference A3. ___________________________________________________________________________ Q12: Per the attached guidance, I assume it will be more for the RVSRs to determine if the DBQs are sufficient for rating purposes and if not will request for new exams to be scheduled. Just need some clarification as an MSC to ensure we are not receiving quality errors for requesting and not requesting new exams to cover the Ingram language? A12: Claims processors, including MSCs, must review the remarks section of every musculoskeletal DBQ, to confirm if the responses to the Ingram language have been provided. Compensation Service (CS) and the Office of Field Operations (OFO) approved a 30-calendar day grace period (from October 13, 2025 to November 12, 2025) on critical errors related to issuance of the Ingram guidance. ____________________________________________________________________________ Q13: How should claims processors handle Private Provider DBQ’s regarding Ingram Language? I had a Veteran state “that he did not want to go to the scheduled examination the initial vendor scheduled because he sent the Private Provider DBQ. That should be enough”.

Last Updated: October 31, 2025 A13: Please see M21-1 IV.i.2.C.1.e; M21-1 IV.i.3.A.1.e.; and M21-1 IV.i.3.C.1.i. If the DBQ is missing information relevant to the rating activity, then attempt to contact the provider to resolve insufficiencies. Any request for clarification to a private examiner or claimant should clearly indicate what further action needs to be taken to make the insufficient private examination report acceptable for VA consideration. If no response is received from the private examiner or claimant, continue adjudicating the claim and, if necessary, request a VA examination, instructing the examiner to furnish only responses to the Ingram questions. ____________________________________________________________________________ Q14: As the MSC, I received this case file assigned to me on 10/16/25 under EP689-IDES case file-Pre-discharge claim. It was a BDD-Pre-discharge case file, filed on 8/27/25 and all conditions the service member, exams are good within the year, but this claim was Pcan and not completed fully with an award. Service member did not claim any new conditions under EP689- pre-discharge claim. Exams were completed as follows: SHA 10/14/25, Mental Health 10/9/25 and Audio 10/1/25. Am I able to move case file forward with these completed exams or am I to resend them up to the same QTC vendor, to review the musculoskeletal conditions again, with the verbiage? Please advise. A14: Per the guidance, since the claim had not been previously rated, and the exams were requested prior to Oct. 13, 2025, and likely does not include the Ingram language, a new ESR would be required for Ingram language only. Please review A7, as well as the “Summary of Ingram Guidance for Pre-D Claims Processors_MSCs.” ____________________________________________________________________________ Q15: Veteran had exam completed 9/16/2025. The exam needed clarification. A new medical opinion was requested as the vendors tend to insist on a new request if the clarification was not requested in the original examination. The vendor sent it back wanting a new exam request w/ Ingram language. I sent it back w/ the verbiage provided to us: “Guidance on processing Ingram-related examination requests was distributed to all medical disability examination vendors on October 10, 2025, with an expected implementation date of October 13, 2025.” Vendor returned the request again stating that the required Ingram language was not included on the original request. A15: Please use the appropriate musculoskeletal DBQ and not the Medical Opinion DBQ. Per the field guidance:

Last Updated: October 31, 2025 For ESRs requested prior to October 13, 2025, where the examination was completed by the vendor and submitted to VBA but is missing the required responses to questions: a NEW ESR may be required. b. Review the DBQ to determine if it is sufficient for rating purposes. i. If sufficient, proceed with rating the contention. ii. If insufficient due to missing responses to questions, a new exam request should be submitted. 1. A rework ESR should not be submitted for missing Ingram language as the necessary language was not originally requested. 2. The claims processor should then request the new ESR using the appropriate DBQ and adding the following language: a. “The Veteran does not need to be seen again unless deemed necessary by the examiner” Note: The Ingram language will automatically populate with the new ESR. ____________________________________________________________________________ Q16: Question about Ingram and IDES. SM previously filed a BDD claim and exams were complete in May. Now IDES, would I need to request all musculoskeletal conditions again or because they were completed prior to sept date (no rating ever done) I wouldn't need to request again? A16: For any musculoskeletal conditions where a decision has not been reached by September 19, 2025, the Ingram ruling must be applied. This can include examinations that were conducted several months ago. Please review A7, as well as the “Summary of Ingram Guidance for Pre-D Claims Processors_MSCs.” ____________________________________________________________________________ Q17: Guidance is missing one important word which is causing confusion. Claims processors should return these ESRs to the SAME vendor and state the following. I received several calls from service members concerning additional exams. They were under the impression that they had to go through all the examinations all over again. I explained the court decision of Ingram vs Collins and that DRAS had to request exams for all muscular conditions based on the court decision. I requested the exam from QTC. Then DRAS VSR requested an exam with the muscular conditions from VES. When QTC, VES or LHI get the request it’s super important for those folks reaching out to our active-duty soldiers to emphasize that service member may not need to be seen in person. If there’s sufficient evidence of record for the provider to answer the Ingram questionnaire then no face to face is needed. But that’s the decision from the provider. No one has mentioned that to our active-duty soldiers during this exam schedules and now they’re confused. A17: Please see Ingram Rating Guidance (initially issued on October 10, 2025, and clarified on October 31, 2025).

Last Updated: October 31, 2025 The claims processor should then request the new ESR using the appropriate DBQ and adding the following language: “The Veteran does not need to be seen again unless deemed necessary by the examiner”. Claims processors must ensure this new ESR is routed to the same vendor that completed the original examination request. If the correct vendor is not populated when submitting the ESR, the field should use the “View Alternate Destinations” option and select the original vendor. In the “Reason” block, the field should include “Ingram Language Required”. This guidance applies to both Veteran and Service Member’s claims.