Ingram Job Aid

Medication Considerations for Musculoskeletal Conditions Job Aid Purpose The purpose of this job aid is to provide guidance on completing Musculoskeletal Disability Benefits Questionnaires (DBQ). As a result of the court decision Ingram v. Collins, VA must consider the severity of the disability in an unmedicated state when the relevant musculoskeletal rating criterion does not already account for medication use. Audience This job aid is for all Compensation and Pension examiners who complete musculoskeletal disability examinations and medical opinions for the VA. Guidance The following questions will be added to examination scheduling requests (ESR) by claims processors for all types of musculoskeletal DBQs. Examiners are expected to answer these additional questions and provide information on the ameliorative effects of only medication, prescription or non-prescription, if applicable. This information is to be documented in the Remarks section of the relevant musculoskeletal DBQ until these questions have been added to the affected DBQs. Important: Any other forms of treatment, which may have an ameliorative effect on the musculoskeletal condition being examined, should not be used or considered for the questions below. Some examples of other types of treatments that could provide ameliorative effects, but should not be considered for these additional questions, are TENS units, canes, acupuncture, physical therapy, etc. 1. 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.) 2. 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.) 3. 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. Medical Disability Examination Office (MDEO) Last Updated: October 10, 2025 Page 1 of 3

Medication Considerations for Musculoskeletal Conditions Job Aid 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 [ ] Flare-ups [ ] 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) ___________________________ Important: If the ESR does not contain this additional language when a musculoskeletal condition is examined, the examiner must still provide this information. A clarification request should not be sent to add this language to the ESR. To assist examiners with responses that require further clarification, please see the examples provided below. Examples to Answer Question 3 To assist examiners with responses that require further clarification or opinions, please see the examples below. Example 1 – No Response: At the time of the examination, Veteran XYZ was [taking ABC medication]. It is not possible to calculate the impact of the [medication] on the Veteran’s functioning, and it is medically contraindicated to discontinue or alter [medication] for the purposes of this examination; therefore, it is not possible to determine the severity of functional impact in the absence of [ABC medication] without resorting to mere speculation. Example 2 – Yes Response: A Veteran’s service-connected lumbosacral strain demonstrates forward flexion limited to 65 degrees. The Veteran reports he has constant lumbar pain, which he treats with Motrin twice daily and uses Tramadol approximately once weekly during periods of increased severity. The Veteran states that the Motrin mildly reduces the severity of pain and improves his mobility such that he is able to put his shoes on and bend over more easily. He can provide a description of the improvement with medication. The examiner finds that without the use of such medication, the Medical Disability Examination Office (MDEO) Last Updated: October 10, 2025 Page 2 of 3

Medication Considerations for Musculoskeletal Conditions Job Aid Veteran’s lumbar mobility would be more restricted, with flexion limited to 50 degrees. All other ROM findings were the same as reported above. Important Reminders  Examiners must ensure all applicable questions are answered thoroughly to avoid returned examinations based on inadequate information.  When providing a medical opinion, the rationale should be consistent and supportive.  Examiners should carefully read each question before answering, as a “No” response may not require further action. References Ingram v. Collins https://www.uscourts.cavc.gov/documents/IngramCH_23-1798.pdf Medical Disability Examination Office (MDEO) Last Updated: October 10, 2025 Page 3 of 3