A common question we receive at Wingman Med is, “What sort of medical records do I need for my VA claim?” This question has numerous implied components. This article will unpack and explore this question.
Medical Evidence
For a VA claim, medical evidence refers to any documentation or records that establish the existence of a veteran’s medical condition. This evidence is crucial for substantiating claims for disability benefits and must come from credible medical sources. Medical evidence typically includes records from healthcare providers, such as doctors, hospitals, or clinics.
These records usually detail diagnoses, treatments, and prognoses. Common types of medical evidence include service treatment records (STRs) and post-service medical records showing ongoing or newly developed conditions. Additionally, diagnostic test results, such as imaging studies or lab reports, can provide objective support for the claim.
Other Types of Medical Evidence
Medical evidence can also include independent medical evaluations (IMEs) or disability benefit questionnaires (DBQs) completed by qualified healthcare professionals. The VA also considers lay evidence, such as statements from the veteran or family members, but medical evidence carries more weight in proving a claim.
Individual Veteran Needs
What you will need specifically for your application for VA disability benefits will vary depending on your claim. There are a lot of things that are true for everybody, but many other veteran situations require unique information.
Elements of Quality
When grading the quality of medical evidence for an application for VA disability benefits, I look at three criteria: Diagnosis, Chronicity, and VA Disability Benefits Questionnaires.
Diagnosis
First, I look for a bona fide diagnosis in the health record. I try to find proof that the veteran was formally diagnosed. A diagnosis made by a board-certified physician using established diagnostic criteria is the best. Diagnoses from Nurse Practitioners and Physician Assistants are also acceptable.
Other categories of providers, such as dentists and chiropractors, can also diagnose within the limits of their scope of practice. Often, aviators avoid medical care and self-diagnose. Self-diagnosis is not a bona fide diagnosis and, therefore, is weaker evidence of diagnosis.
Chronicity
I also consider the chronicity of the diagnosis. Let’s look at some examples of strong and weak evidence of chronicity. If a veteran was seen monthly or quarterly for ankle pain from 2003-2023, that is strong evidence of chronicity.
That level of periodic re-evaluation suggests the ankle pain was not a one-time event. On the other hand, if a veteran was seen once in 2003 for ankle pain, then never again, this is weaker evidence.
It does not mean the veteran hasn’t had ankle pain continuously since 2003; it just means you lack objective proof for the chronic ankle pain. Medical records signed by a board-certified physician dated numerous times throughout active duty are the most substantial evidence of chronicity.
Disability Benefit Questionnaires
Finally, I look at DBQs. Wingman Med produces the highest quality DBQs possible through a painstaking process. Active participation from the aviator over months is required to get all the details onto the forms.
DBQs produced at Compensation and Pension (C&P) Exams are typically low quality. The VA contract examiner has hours to summarize the impact of 20 years of medical care. This is inadequate in most cases.
Quality Tiers
I break the tiers of quality into three groups based on how many quality elements are present. Remember, I’ve seen applications for VA disability benefits come back rated at 100% for all three quality tiers. However, the lower quality tiers do invite additional questions from the VA.
Tier 1 – Highest Quality Tier
Tier 1 quality means the veteran’s application for VA disability benefits meets or exceeds all of my criteria. They have evidence of a bona fide diagnosis made by a board-certified physician who used established guidelines for diagnosis or evidence-based medicine protocols.
The diagnosis is chronic, as it is shown multiple times in the veteran’s medical records across many years of service. The Veteran has Wingman Med’s DBQs.
Tier 2 – Middle Quality Tier
Tier 2 means missing something from the list of 3 possible quality elements. Since all of our clients get Wingman Med’s DBQs, you are missing either a quality diagnosis or evidence of chronicity.
Tier 2 can mean you have a bona fide diagnosis but no evidence of chronicity. An example of this would be a single visit for eczema in 2003, but no follow-up visits were documented anywhere in your record. We can fill out DBQs for you, but we can’t go back in time and get your eczema documented when it occurred over the last 20 years.
Tier 2 may also mean you have evidence of chronicity, but your diagnosis was of lower quality. Maybe you saw a non-board-certified physician (General Duty Medical Officer or GMO), or the board-certified physician you did see did not follow established guidelines or protocols for diagnosis. Alternatively, you may have only enlisted medical personnel’s documentation or documentation from other medical professionals who are not legally empowered to diagnose, such as pharmacists or nurses. Finally, you may have a diagnosis from a provider practicing outside their scope of practice – a chiropractor who diagnoses your eczema.
Tier 3 – Lowest Quality Tier
Tier 3 means all you have are Wingman Med’s DBQs. A board-certified physician has never diagnosed you; you can’t show chronicity without that diagnosis. While we will help veterans route this level of claim, we don’t advise it. At the very least, we recommend that you have an independent 3rd party provider verify the diagnoses listed on our application for VA disability benefits. Having two sources of evidence will get you back to the Tier 2 – Middle-Quality Level.
However, Tier 3 Claims have been successful in the past. They have succeeded because of the outstanding quality Wingman Med does on the DBQs. Even if all you have are Wingman Med DBQs, this is frequently enough for the VA to accurately award a disability rating.
Late In The Game Documentation
Active Duty Military Aviators typically avoid medical at all costs. Many pilots are concerned that medical visits may discover problems that would interfere with the ability to operate aircraft continuously. So, at the end of many military aviators’ careers, a new stack of diagnoses appears in their health records. This is fine.
As I discussed above, I prefer both a bona fide diagnosis and chronicity. In most circumstances, we’re stuck with just a bona fide diagnosis. Most aviators’ next question is, “What do I get my doctor to write in my chart?”
Documentation, Not Treatment
To get that late-in-the-game diagnosis, you should be frank with your provider. I prefer that you see a board-certified physician, but any category of diagnosing provider is acceptable. Tell them you want several diagnoses documented but are not looking for many therapeutics. Tell them the product you want is the note – the medical documentation. Be honest – “I want an ICD-10 diagnosis code, a couple of sentences that say why I have the diagnosis, and it’s chronic. I’d like it if there were easy workups like a blood test or x-rays.” And that’s it. You don’t need specialty consults, advanced imaging, or invasive testing. You don’t need a detailed clinical progress note to the same level we like for the FAA. At least, not yet. For most things, veterans want to claim a visit or two to the PCM, which should be all it takes. If your assigned provider won’t help you, shop around until you find someone willing to do this essential work. It may be worth looking into a Direct Primary Care physician if needed.
What You Need to Do
As I said above, individual cases need individual plans. This is why Wingman Med’s VA FAA service writes up VA Recommendations (VAR) for each client. The VAR looks at what is in your medical record and then tells you what you need to do next. Suppose you are a military aviator getting ready to retire or a military member interested in civilian aviation. In that case, you should sign up for Wingman Med VA FAA service. Our service will help you get your highest possible true VA Disability Rating while protecting your FAA medical.
