Exceptions to Ordering TERA Examinations

Exceptions to Ordering TERA Examinations 38 U.S.C. § 1168(b) provides that TERA examination requirements do not apply if the Secretary determines there is no indication of an association between the disability claimed by the Veteran and participation in the TERA. Review the job aid below for situations in which TERA examination requirements may or may not apply. Exception Scenario Correct Action Physical Trauma The Veteran claims service By definition, patellofemoral connection for left knee pain syndrome is a disorder of patellofemoral pain syndrome. the knee caused by overuse, The Veteran submits medical injury, or muscle weakness. In evidence of a diagnosis of left the absence of competent knee patellofemoral pain medical or scientific evidence to syndrome but submits no other suggest a link between this evidence regarding the etiology condition and a toxic exposure of the condition. Exposure to risk activity, this condition is burn pits is conceded for this exempt from the TERA Veteran. examination requirements, and the claims processor would not order a TERA examination with medical opinion. Physical Trauma The Veteran claims service Follow the guidelines in M21-1, connection for a left elbow Part IV, subpart i,1,B,1,c to condition. The Veteran submits evaluate the submitted private medical evidence evidence. The threshold for showing a diagnosis of left determining whether an elbow arthritis and submits a association may be present is peer reviewed medical journal low. Medical assessments that article indicating a potential link do not support a decision on between arthritis and exposure the merits can still be sufficient to air pollution. Exposure to to establish an indication of an burn pits is conceded for this association for the purposes of Veteran. requesting an examination. If after reviewing the evidence, it is determined to have probative value that the Veteran’s arthritis could be due to burn pit exposure, then a TERA examination with medical opinion should be requested. Mental Disorders or disabilities The Veteran claims service Follow the guidance under that Manifested During Military connection for major depressive M21-1, Part V, Subpart ii, 2, A Service. disorder. The Veteran submits a and M21-1, Part IV, subpart i, 1, statement on VA Form 21-4138 B, 1, a-c to determine whether a indicating that he started mental health examination feeling depressed while on should be ordered with a direct

active duty and has felt opinion. This condition is depressed ever since. The exempt from the TERA Individual Longitudinal Exposure examination requirements, as Record (ILER) report shows the claimed condition is a participation in a TERA. Service mental disorder. It is also treatment records show the exempt from the TERA Veteran visited a counselor on examination as the disability one occasion for depression in manifested during military service. A review of VAMC service. records show the Veteran has a current diagnosis of depression and receives counseling on a regular basis. Mental Disorders The Veteran claims service Follow the guidelines in M21-1, connection for a cognitive Part V, Subpart ii, 1, A to disorder. The Veteran submits a evaluate the credibility and statement on VA Form 21-4138 competence of the submitted indicating symptoms of evidence. If after weighing the forgetfulness and issues with evidence, it is determined to processing information. An have probative value that the Individual Longitudinal Exposure Veteran’s cognitive disorder Record (ILER) report shows could be due to the verified participation in a TERA. The TERA, then a mental health Veteran also submits a examination with TERA medical statement from his private opinion should be requested. physician who states that the Toxic exposure can result in Veteran’s exposure to symptoms of neurobehavioral environmental hazards while on decline. active duty resulted in severe neurobehavioral decline. Conditions Determined to Have The Veteran submits a claim for Review the records to No Positive Association with a stomach cancer and provides determine if the stomach Herbicide Exposure current medical evidence of a cancer can be granted on a biopsy. The Veteran served in a direct basis. The Secretary has location that exposed him to determined that a positive herbicides, but has no other association does not exist documented TERA exposure. between herbicide exposure and digestive cancers, including stomach cancer. This condition is exempt from the TERA examination requirements, and the claims processor would not order a TERA examination with medical opinion. Reference Toxic Exposure Risk Activity (TERA) Exception Job Aid. Claims for Disabilities that The Veteran submits a claim for Follow the guidance under Manifested During Military low back pain. A statement on M21-1, Part V, Subpart ii, 2, A

Service or With an Etiology Not VA Form 21-4138 indicates that and M21-1, Part IV, subpart i, 1, Associated to Toxic Exposure his low back pain is due to B, 1, a-c to determine whether a multiple landings as a lumbar spine examination parachutist. DD form 214 should be ordered. This shows the Veteran received a condition is exempt from the Parachutist Badge with Combat TERA examination Jump Device. Service treatment requirements, and the claims records show multiple visits for processor would not order a back pain and stiffness. TERA examination with medical opinion. Claims for Disabilities that The Veteran files a claim for This condition is exempt from Manifested During Military cirrhosis. The TERA exposure the TERA examination Service or With an Etiology Not memorandum documents requirements, as the evidence Associated to Toxic Exposure exposure to asbestos. VAMC of record indicates the treatment records document a condition is related to an long history of treatment for etiology that is not associated cirrhosis, with several with toxic exposures (post- indications in the treatment service alcohol use). Per M21-1, records that his cirrhosis was Part X, Subpart iv, 1, D, 1, h, due to 20 years of chronic service connection for alcohol abuse post-service. secondary disabilities resulting There is no evidence that the from alcohol abuse is alcohol abuse is secondary to a prohibited. No examination or service-connected disability. opinion should be ordered.