Ingram Rating Guidance

Ingram v. Collins Interim Field Rating Guidance Compensation Service October 2025 Background The Court of Appeals for Veterans Claims (Court) held in Ingram v. Collins, 38 Vet.App. 130 (2025) that the Board of Veterans’ Appeals erred in failing to discount the ameliorative, or beneficial, effects of medication in evaluating the Veteran’s low back and ankle disabilities. The Court held that VA must discount the ameliorative effects of medication in evaluating those disabilities for rating purposes because the diagnostic codes under which those musculoskeletal disabilities are rated do not explicitly consider medication. Accordingly, when determining a disability evaluation for any musculoskeletal disability assigned a diagnostic code under 38 C.F.R. § 4.71a, the medical evidence must be reviewed to determine if: 1. the Veteran takes any medication, prescription or non-prescription, to treat the disability; 2. the medication relieves or reduces the severity of the disability’s symptoms; and 3. the medication relieves or reduces the disability’s severity, is it possible to evaluate the severity of the disability as if the Veteran were not taking the medication without resorting to speculation. Under the Ingram decision, if the medical evidence demonstrates that it is possible to discount the ameliorative effects of medication in determining the severity of the disability, VA must assign a disability rating that reflects the extent of disability that would be present if not for the ameliorative effects of medication. Example: Application of Ingram A Veteran’s service-connected lumbosacral strain exhibits flexion limited to 65 degrees. The Veteran reports constant pain in the lumbar region, which is treated daily with Motrin. Tramadol is occasionally used during episodes of heightened pain. The examiner indicates that the medication used for the treatment of lumbar pain lessens the severity of the pain and improves mobility. The examiner opines that without the medication, the Veteran’s lumbar mobility would be further limited, restricting flexion to 50 degrees. The examination report does not include any notation that the opinion was speculative. In view of this evidence, VA should assign a 20% disability evaluation for the lumbosacral strain rather than a 10%, which is predicated upon discounting the ameliorative effects of medication. Claim Guidance To facilitate medical opinion compliance with Ingram when evaluating musculoskeletal disabilities, the Examination Scheduling Request (ESR) document has been revised in the Examination Management System (EMS). Claim processors must consider the Page 1

ameliorative effects of medication when assigning a rating evaluation for a musculoskeletal condition. If the examiner indicates that an opinion regarding the severity of disability, absent the ameliorative effects of medication, cannot be rendered without resorting to speculation, then claim processors should assign a rating evaluation based upon the evidence of record demonstrating the severity of disability in accordance with the applicable musculoskeletal diagnostic code under § 4.71a. In this scenario, insert the following language into the rating narrative: “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.” As of October 13, 2025, the MDE vendors have been instructed to add the Ingram language to the respective DBQ results for Musculoskeletal Disability Benefit Questionnaire (DBQ). Claims processors must ensure that the Musculoskeletal DBQ addresses the potential medication impact under Ingram. This information will be in the Remarks section of the DBQ. 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 Ingram language, a new ESR may be required. Any musculoskeletal rating evaluation from October 13, 2025 forward, must consider the ameliorating effects of medication. The effective date of any evaluation awarded pursuant to Ingram and this guidance will be assigned in accordance with normal procedures in M21-1, Part V, Subpart ii.4.A.7. Exception: This guidance does not apply to evaluations assigned under or analogous to the following diagnostic codes (DCs), both of which consider the impact of medication: • DC 5012, malignant neoplasm of the bone • DC 5025, fibromyalgia VBMS-R Evaluation Builder and Rating Decision Narrative Claim processors should apply the impact to the range of motion under Ingram similarly to DeLuca and Mitchell. While system updates are pending, if an examiner provides additionally delimited range of motion readings under Ingram, claims processors must enter the set of values that result in the most advantageous disability rating into the VBMS-R evaluation builder. Regardless of whether the rating considers the ameliorative effects of medication, claim processors must insert the following language into the rating narrative: Page 2

“The provisions of 38 CFR §§ 4.40 and 4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca v. Brown, Mitchell v. Shinseki and Ingram v. Collins, as well as the provisions of 38 CFR § 4.59, have been considered and applied.” Utilizing Ingram Language with Musculoskeletal Disability Benefits Questionnaires (DBQs) Ingram applies when a musculoskeletal rating evaluation is at issue. If a musculoskeletal condition was denied, the DBQ does not require an exam rework, and the denied condition does not require readjudication. For completed but unprocessed musculoskeletal DBQs (no final rating) that do not contain the revised ESR with the Ingram language, claim processors must return the exam so that the examiner can address the ameliorative effects of medication consistent with the revised ESR. This guidance only applies to evaluating musculoskeletal disabilities rated under diagnostic codes contained within § 4.71a. Ingram’s requirement to discount the ameliorative effects of medication is not mandated for any disability rated under a diagnostic code outside of the musculoskeletal system under § 4.71a. See the Appendix for more details Decisions Made on a Musculoskeletal Evaluation Between September 19, 2025, and October 13, 2025 This guidance applies to any decision rendered on or after September 19, 2025. Thus, any rating decision made on a musculoskeletal disability as of September 19, 2025, must have addressed the ameliorative effects of medication. If a decision made between September 19, 2025, and October 13, 2025, did not address Ingram, then VA must readjudicate it for compliance with the Court’s holding. Any musculoskeletal examination used to assign a rating evaluation on or after September 19, 2025, must address the ameliorative effects of medication as contained in the revised ESR. If the examiner determined that the Veteran uses medication that produces ameliorative effects for the disability but did not render an opinion addressing the additional functional loss of the disability after discounting the ameliorative effects, then the examination must be returned for the required opinion contained in the revised ESR. Questions Contact Compensation Service for questions on policy regarding exams at 211_Policy.Vbavaco@va.gov and rating evaluations at 218VASRDPMO.VBACO@va.gov. Page 3

Appendix: Field Guidance for Utilizing Ingram Language with Musculoskeletal DBQs In a recent court decision, Ingram v. Collins, the Veterans Court held that the VA must consider the severity of the claimed disability in an unmedicated state when the relevant musculoskeletal rating criteria does not specifically contemplate medication use. Ingram language will become available for use beginning October 13, 2025. For Examination Scheduling Requests (ESR) received on or after October 13, 2025, any Ingram language will be included within the Exam Scheduling Request (ESR) itself. Ingram language is defined as the following questions, which will be added to ESRs for musculoskeletal DBQs: At the time of the examination, does the Veteran report taking any medication(s), prescription or non-prescription, to treat the disability being evaluated? [ ] Yes [ ] No If No, do not answer the remaining questions. If Yes, does the medication(s) relieve or reduce the severity of the disability symptoms being evaluated? [ ] Yes [ ] No If no, do not answer the remaining questions. Is it possible to evaluate the severity of the Veteran’s disability as if not taking medication(s) (i.e. in an unmedicated state), without resorting to mere speculation? [ ] Yes [ ] No If No, the examiner should explain why it is not possible to do so without resorting to mere speculation in the Remarks Section. The explanation should not be based on an examiner’s shortcomings or a general aversion to offering an estimate on issues not directly observed. If Yes, check all functional losses that apply. For each item checked below, provide the estimated additional functional loss of the disability. If possible, provide this estimate as additional loss of motion of the disability in the Remarks section. [ ] Pain [ ] Active ROM [ ] Passive ROM [ ] Repetitive use [ ] Repeated use over time Page 4

[ ] Flareups [ ] Additional factors contributing to disability (e.g. interfering with standing or sitting, disturbance of locomotion, more or less movement than normal, weakened movement, instability of station, swelling, deformity, atrophy of disuse) [ ] Ankylosis [ ] Flail joints [ ] Other (specify) ___________________________ 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. 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 The following scenarios have been identified: 1. For ESR’s 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 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 ESR’s 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. Page 5

a. An RVSR should 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. b. 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”. 3. For ESR’s requested after October 13, 2025, the Ingram language will automatically be included as part of the examination request. This will require no additional action by field personnel. 4. For ESR’s requested after October 13, 2025, where the examination was completed by the vendor and submitted to VBA but is missing the required Ingram language: a Rework ESR may be required. a. An RVSR should 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 rework exam request should be submitted. 1. The claims processor should then request the rework 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 rework ESR. Questions pertaining to this Appendix may be directed to the Contract Examination mailbox, VAVBAWAS/CO/Contract Examination Inquiries. Page 6