The examination in a TBI claim is usually the single most influential document in the file, because it is where the facet levels in the rating table get filled in.
This guide is part of our series on VA claims for traumatic brain injury.
What the VA says about claim exams
The VA's claim exam page explains that the exam helps the VA gather more information about a claimed condition, that it is not a treatment appointment, and that not every claim requires one. 38 CFR 3.159 sets out the VA's duty to assist, which includes providing an examination when the evidence is not sufficient to decide the claim.
Why the facets shape the exam
Because Diagnostic Code 8045 assigns levels to specific facets, the examination is structured around those same areas - memory and concentration, judgment, social interaction, orientation, motor activity, visual spatial orientation, subjective symptoms, neurobehavioral effects, communication, and consciousness.
Each facet has defined descriptions in the regulation, and the examination findings are what the rating decision maps onto them.
Where veterans start
Every case is different, and there is no obligation at any step. When veterans want to understand what their records actually support, these are the two most common starting points:
- Medical records review
A licensed physician reviews your records for a $250 flat fee and identifies which conditions the available evidence may support. The fee is refunded in full if nothing supportable is identified.
- Nexus letter
When the records support one, a licensed provider writes the medical opinion that addresses the link between your condition and your service.
Describing a typical period, not a best day
The rating criteria describe how the residuals affect work, family, and other daily activities over time. An accurate description of a typical period - including the difficult days - gives the decision maker the picture the criteria ask about. Treatment records covering the same period support what is reported.
After the exam
The VA's page on how disability ratings are assigned explains the next steps. Our claim process guides cover what happens between the exam and the decision.
This guide is educational. It summarizes the VA's own published rules and links to the exact sources it relies on. It is not legal or claims advice, and it is not a substitute for an accredited representative, who can advise you about your specific claim. Accredited help is free - search the VA's accreditation database to find a Veterans Service Organization, accredited agent, or attorney.
Frequently asked questions
What happens at a VA claim exam for TBI?
The VA describes the claim exam as an appointment with a health care provider to gather information about a claimed condition. For TBI, the examination is organized around the residual areas described in Diagnostic Code 8045.
Is the claim exam a treatment appointment?
No. The VA states that the claim exam is for gathering evidence about the claimed condition, not for providing treatment.
What if I miss the exam?
The VA's claim exam page explains the importance of attending and how to reschedule. 38 CFR 3.159 describes the VA's duty to assist in developing the claim, including obtaining an examination when one is needed.