Procedure Update Due to Ingram Court Decision 10-31-2025

October 31, 2025 Districts, Please share the following message with all offices under your jurisdiction, and request confirmation it is distributed to all impacted claims processors. What is changing? Three documents are attached to the email for review. • **UPDATE** Ingram Rating Guidance issued on October 10, 2025, has been modified to clarify that Ingram applies to muscle injuries under 38 C.F.R. § 4.73 and temporomandibular disorder (TMD) under 38 C.F.R. § 4.150. The prior rating guidance stipulated that only musculoskeletal conditions under 38 C.F.R. §4.71a were applicable. Please note, there is no change to the list of impacted DBQs; Muscle Injuries and TMD DBQs were included on the original list. Additionally, the document adds one diagnostic code exception and validates that claims processors includes Military Service Coordinators (MSCs) • **NEW** A summary of the Ingram processing guidance for all Pre-Discharge claims processors, to include MSCs. • **NEW** Frequently Asked Questions (FAQ) Document Who needs to know about this change? All Compensation and Appeals claims processors and quality review specialists, to include VSRs, RVSRs, DROs, QRSs, and MSCs. Questions related to rating procedures can be directed to 218VASRDPMO.VBACO@va.gov and 211_Policy.Vbavaco@va.gov. Questions related to examination procedures can be directed to VAVBAWAS/CO/Contract Examination Inquiries. Questions related to Pre-Discharge (IDES and BDD) policy can be directed to 219 Pre-Dis Mailbox.

All other questions can be directed to the OFO Mailbox. Thank you, Office of Field Operations From: VAVBAWAS/CO/OFO <OFO.VBACO@va.gov> Sent: Thursday, October 16, 2025 4:04 PM To: VAVBAWAS/CO/OFO <OFO.VBACO@va.gov>; VBACO_Area_Leads <VBACO Area Leads@va.gov> Cc: VAVBAWAS/OAR/OPS <OAROPS.VBAWAS@va.gov>; VAVBAWAS/OAR/ADMIN <OARADMIN.VBAWAS@va.gov>; VAVBAWAS/CO/218_VASRD <218VASRDPMO.VBACO@va.gov>; VAVBAWAS/CO/Contract Examination Inquiries <ContractExam.VBAVACO@va.gov>; VAVBAWAS/CO/211_Policy <211 Policy.Vbavaco@va.gov>; Glenn, Mary, VBAVACO <Mary.Glenn@va.gov>; Smith, James W. II, VBAVACO <James.W.Smith@va.gov>; Zybarth, Michael, VBAVACO <Michael.Zybarth@va.gov>; Shevory, Nicole M. (VBAVACO) <Nicole.Warren3@va.gov>; Skelly, Tina, VBAVACO <Tina.Skelly@va.gov>; Knopf, Linsay, VBAVACO <Linsay.Knopf@va.gov>; Detty, John R., VBAVACO <John.Detty@va.gov>; Souba, Miranda C. VBAVACO <Miranda.Souba@va.gov>; McBane, Crystal L., VBAVACO <crystal.mcbane@va.gov>; Piper, Jadine S., VBAVACO <Jadine.Piper@va.gov>; Kirkland, Angela L. VBAVACO <Angela.Kirkland@va.gov>; Flannery, (Gathercole) Jessica J. VBAVACO <Jessica.Flannery@va.gov>; VAVBAWAS/CO/21MDE <21MDE.VBACO@va.gov> Subject: RE: Procedure Update due to Ingram Court Decision October 16, 2025 Good afternoon Districts, Please share the following message with all offices under your jurisdiction. 1. Please see clarification below under “Who need to know about this change?” and ensure that all MSCs are aware of the change related to musculoskeletal exams. 2. Compensation Service is currently reviewing IDES related procedural questions, and will provide more information once available 3. MDEO has received reports that vendors may be requesting Ingram-related exams be rescheduled. Please note, guidance on Ingram v. Collins was distributed to all vendors on October 10, 2025, which provides the official VA guidance on these cases for implementation on October 13, 2025. Vendors are expected to process these exams in accordance with this guidance. Please direct any questions or concerns on this topic to 21MDE.VBACO@va.gov a. 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.”

All other questions can be directed to the OFO Mailbox. Thank you, Office of Field Operations From: VAVBAWAS/CO/OFO Sent: Friday, October 10, 2025 5:32 PM To: VBACO_Area_Leads <VBACO Area Leads@va.gov> Cc: VAVBAWAS/OAR/OPS <OAROPS.VBAWAS@va.gov>; VAVBAWAS/OAR/ADMIN <OARADMIN.VBAWAS@va.gov>; VAVBAWAS/CO/218_VASRD <218VASRDPMO.VBACO@va.gov>; VAVBAWAS/CO/Contract Examination Inquiries <ContractExam.VBAVACO@va.gov>; VAVBAWAS/CO/211_Policy <211 Policy.Vbavaco@va.gov>; Glenn, Mary, VBAVACO <Mary.Glenn@va.gov>; Smith, James W. II, VBAVACO <James.W.Smith@va.gov>; Zybarth, Michael, VBAVACO <Michael.Zybarth@va.gov>; Shevory, Nicole M. (VBAVACO) <Nicole.Warren3@va.gov>; Skelly, Tina, VBAVACO <Tina.Skelly@va.gov>; Knopf, Linsay, VBAVACO <Linsay.Knopf@va.gov>; Detty, John R., VBAVACO <John.Detty@va.gov>; Souba, Miranda C. VBAVACO <Miranda.Souba@va.gov>; McBane, Crystal L., VBAVACO <crystal.mcbane@va.gov> Subject: Procedure Update due to Ingram Court Decision October 10, 2025 Good afternoon Districts, Please share the following message with all offices under your jurisdiction. Background: In a recent court decision, Ingram v. Collins, the Court of Appeals for Veterans Claims (CAVC) held that VA must consider the severity of the claimed disability in an unmedicated state, because the musculoskeletal disabilities diagnostic codes do not explicitly consider medication. Essentially, VA must compensate a Veteran for the level of disability that would be present but for the ameliorative effects of medication for these musculoskeletal disabilities. What is changing? • Claims processors will order musculoskeletal exams with Ingram language, starting October 13, 2025 (this will require no special action by field personnel). • Claims processors must review the remarks section of every musculoskeletal DBQ, to confirm if the responses to the Ingram language have been provided (see page 4 of the attachment). o If the responses to the Ingram language are not provided, claims processors will need to order new or rework musculoskeletal exam(s). • Rating personnel must: o Consider if the medical evidence demonstrates that it is possible to discount the ameliorative effects of medication in determining the severity of the disability, in the final rating decision.

o Potentially insert required language into the rating narrative and/or enter values into the VBMS-R evaluation builder manually. The attached document outlines the rating procedures, along with the appendix which outlines exam ordering procedures. Who needs to know about this change? All Compensation and Appeals claims processors and quality review specialists, to include VSRs, RVSRs, DROs, QRSs, and MSCs. Where is it changing? • Responses to Ingram language will be entered into the remarks section of the musculoskeletal DBQs • Ingram language will automatically populate within any new or rework musculoskeletal Exam Scheduling Request (ESR) is ordered, starting on October 13 Note: There are no other system updates in progress due to the government shutdown. OFO will provide notification when/if these procedures are superseded by system updates. What else do I need to know? • Compensation Service (CS) and the Office of Field Operations (OFO) approves a 30-calendar day grace period (from October 13, 2025 to November 12, 2025) on critical errors related to issuance of this guidance. • At this time, the field should not take corrective action on claims completed between September 19, 2025 and October 13, 2025, where a musculoskeletal condition was at issue. Additional guidance will be provided at a later date. Questions related to rating procedures can be directed to 218VASRDPMO.VBACO@va.gov and 211_Policy.Vbavaco@va.gov. Questions related to examination procedures can be directed to VAVBAWAS/CO/Contract Examination Inquiries. All other questions can be directed to the OFO Mailbox. Thank you, Office of Field Operations