--- title: "Part VIII, Subpart ii, Chapter 1, Section C Rating Presumptive Service Connection (SC) Claims for Persian Gulf Veterans" document: "M-21-1" section: "Part VIII, Subpart ii, Chapter 1, Section C" canonical: "https://veteranai.co/va-regulations/m21-1/viii.ii.1.c-rating-presumptive-service-connection-sc-claims-for-persian" source: "https://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001018/content/554400000177440/M21-1-Part-VIII-Subpart-ii-Chapter-1-Section-C-Rating-Presumptive-Service-Connection-SC-Claims-for-Persian-Gulf-Veterans" updated: "2026-09-07T14:37:32.473574Z" --- June 6, 2025 ### VIII.ii.1.C.1.a. Deciding SC for an Undiagnosed Illness or MUCMI The following information is required to determine whether service connection (SC) under [38 U.S.C. 1117]() for an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) is in order: * if the Veteran’s service qualifies for Persian Gulf Veteran status, and * whether the disability chronically persisted for at least six months. **Important:** * _Public Law 117-168_ , Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022, added locations qualifying for presumptive SC and removed the requirement for qualifying disabilities that have onset after service to become manifest to a compensable degree. Under the PACT Act, an undiagnosed illness or MUCMI may manifest to a 0-percent disability level and still qualify for presumptive SC. * When deciding these claims, it is important that claims processors note which authority (pre-PACT Act or the PACT Act) applies to the claim and explain the basis of the decision, citing relevant favorable findings, regulations, and statutes, as required. **References:** For more information on * regulatory and statutory history regarding compensation for disabilities occurring in Persian Gulf Veterans, see [M21-1, Part VIII, Subpart ii, 1.A.1.a]() * the definition of qualifying chronic disability, see [M21-1, Part VIII, Subpart ii, 1.A.1.e]() * determining chronicity, see M21-1, Part VIII, Subpart ii, 1.C.1.b, and * requirement to provide adequate explanation of the decision, see M21-1, Part VIII, Subpart ii, 1.C.3.a. ### VIII.ii.1.C.1.b. Determining Chronicity for Qualifying Disabilities To establish SC for a disability under [38 U.S.C. 1117](), the claimed disability must be chronic, that is, it _must_ have persisted for a period of six months. Measure the six-month period of chronicity from the earliest date on which _all pertinent evidence_ establishes that the signs or symptoms of the disability first manifested. **Notes:** * If a disability is subject to intermittent episodes of improvement and worsening within a six-month period, consider the disability to be chronic. * Carefully review all evidence, not just the most recent evidence, prior to determining if a claimed disability is chronic. **Reference:** For a discussion on the types of evidence that may be accepted to establish objective indications of a chronic disability, see M21-1, Part VIII, Subpart ii, 1.C.1.c-e. ### VIII.ii.1.C.1.c. Role of the Veteran’s Testimony in Establishing Signs or Symptoms When considering disabilities under the provisions of [38 U.S.C. 1117](), a Veteran’s lay statement describing his or her own symptoms of a qualifying disability takes on a greater importance than when considering other claims under direct SC principles. First, as indicated in [M21-1, Part VIII, Subpart ii, 1.B.2.a](), the threshold for ordering an examination for an undiagnosed illness or MUCMI claim is low, as the claimant’s statement alone, describing symptoms, may be sufficient to trigger an examination. Second, lay evidence describing symptoms unsupported by clinical findings is sufficient to establish SC under [38 U.S.C. 1117]() as long as there is **_medical evidence showing that “no medical diagnosis” is present_**. **Important:** The Federal Circuit, in [_Joyner v. McDonald_](), 766 F.3d 1939 (Fed. Cir. 2014) held that “neck pain,” that was unsupported by physical examination findings or laboratory tests, may establish an undiagnosed illness that causes a qualifying chronic disability. This demonstrates the importance of the Veteran’s testimony, which is essentially all that is needed for the examiner to characterize the symptoms as an “undiagnosed illness” and for SC to be granted, if all other SC requirements are otherwise met. **References:** For more information on * requesting examinations, see [M21-1, Part IV, Subpart i, 2.A](), and * the need for an adequate characterization of the disability, see [M21-1, Part VIII, Subpart ii, 1.B.2.p](). ### VIII.ii.1.C.1.d. Role of Third Party Lay Evidence in Establishing Signs or Symptoms Lay statements from third party lay witnesses that are competent and credible may help establish the presence of objective indications of a chronic disability. Such statements may cover * what the Veteran complained of * when complaints began * how long complaints lasted, and * nature/severity of witnessed signs or symptoms. **Reference:** For more information on when evidence is competent and credible, see [M21-1, Part V, Subpart ii, 1.A](). ### VIII.ii.1.C.1.e. Role of Non-Medical Indicators in Establishing Signs and Symptoms Non-medical indicators may help establish signs and symptoms of a qualifying disability. Non-medical indicators may include * time lost from work * evidence that the Veteran sought medical treatment for their symptoms, and * relevant observations, such as changes in the Veteran’s * appearance * physical abilities, and/or * mental or emotional status. ### VIII.ii.1.C.1.f. Considering VHA Persian Gulf Health Registry Examinations In all cases when the Veteran has been examined as part of the Veterans Heath Administration (VHA) Persian Gulf Health Registry, ensure those results have been obtained and considered when rating the Gulf War-related issues. **Reference:** For more information on developing for the Gulf War Registry examination, see [M21-1, Part VIII, Subpart ii, 1.B.1.f](). ### VIII.ii.1.C.1.g. Rating Action to Take Based on Disability Pattern Determination The table below shows the rating action to take based on the Department of Veterans Affairs (VA) examiner’s determination of disability pattern._**Important**_ : * Benefits should only be awarded after taking into consideration the overall evidence of record. * Ensure the determination of disability pattern contains the examiner’s supporting rationale. | ** If the examiner determined the Veteran’s disability pattern to be …**| **Then …** * an undiagnosed illness, or * a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology | award SC under [38 U.S.C. 1117]() if the Veteran meets all [38 U.S.C. 1117]() criteria. **Reference:** For more information on awarding SC for qualifying disabilities under [38 U.S.C. 1117](), see M21-1, Part VIII, Subpart ii, 1.C.3. * a diagnosable chronic multi-symptom illness with a partially explained etiology, such as diabetes or multiple sclerosis, or * a disease with a clear and specific etiology | SC * cannot be awarded under [38 CFR 3.317](), and * may be awarded only if the medical evidence is sufficient to establish SC on a direct or other basis. _**Important**_ : In this claim scenario, the examiner must provide a medical opinion regarding toxic exposure risk activity (TERA) participation. _**Reference**_ : For more information on deciding claims based on TERA participation, see the _[PACT Act Implementation Standard Operating Procedure]()_. **Important:** As held in [_Gutierrez v. Principi_](), 19 Vet.App. 1 (2004) the Veteran is not required to provide nexus evidence linking a qualifying chronic disability to events in service, as long as the Veteran meets all other requirements in [38 U.S.C. 1117](). _**Reference**_ : For more information on handling examination reports that do not contain the required determination of disability pattern, see [M21-1, Part VIII, Subpart ii, 1.B.2.p](). ### VIII.ii.1.C.1.h. Evaluating Symptoms of Undiagnosed Illness and MUCMI as a Single or Multiple Issues The decision to evaluate multiple symptoms or signs of an undiagnosed illness or MUCMI together as a single issue or separately as multiple issues depends on the outcome most favorable to the Veteran. Although evaluating multiple manifestations under a single body system will in most cases provide the maximum benefit, be alert to symptoms affecting fundamentally different body systems that may clearly warrant separate consideration. **Notes:** * If SC for several symptoms or signs is denied for the same reason, consider such symptoms and signs as a single issue. * Assign one hyphenated diagnostic code (DC) on the _Codesheet_ to each issue that is separately considered, whether SC is awarded or denied. _**Reference**_ : For more information on assigning a disability evaluation, see [M21-1, Part V, Subpart ii, 3.D](). ## 2. General Information About Rating Decisions for Undiagnosed Illness and MUCMI Claims This topic contains general information about rating decisions for undiagnosed illness and MUCMI claims, including * proper coding for undiagnosed illnesses and MUCMIs * using hyphenated DCs for undiagnosed illnesses and MUCMIs * list of appropriate DCs for undiagnosed disabilities and MUCMIs * examples of hyphenated codes for undiagnosed disabilities and MUCMIs * termination or reduction of benefits previously awarded, and * Persian Gulf Veterans’ participation in VA-sponsored research projects. January 29, 2024 ### VIII.ii.1.C.2.a. Proper Coding for Undiagnosed Illnesses and MUCMIs In order to properly identify and track disabilities for which SC is awarded or denied, regional offices (ROs) must properly code the undiagnosed disabilities and MUCMIs in the Veterans Benefits Management System - Ratings (VBMS-R) by assigning the * 88 DC modifier, and * _Environmental Hazard in Gulf War_ special issue. **Reference:** For more information on assigning a special issue in VBMS-R, see the _VBMS-R User Guide_. ### VIII.ii.1.C.2.b. Using Hyphenated DCs for Undiagnosed Illnesses and MUCMIs Use of the hyphenated DC with the 88 DC modifier is required for all awards and denials of undiagnosed illnesses and MUCMIs under [38 U.S.C. 1117](). The table below describes each of the codes that comprise a complete hyphenated DC.| **Code**| **Description**| **Example** First DC| A 4-digit code created with the 88 modifier as the first two digits. The second two digits are assigned according to the relevant body system.| 8863, for disabilities awarded or denied under the infectious diseases, immune disorders, and nutritional deficiencies body system Second DC| Use the DC that most closely fits the evaluating criteria.| 6354, for the applicable evaluation criteria ### VIII.ii.1.C.2.c. List of Appropriate DCs for Undiagnosed Disabilities and MUCMIs The table below lists the first element in a hyphenated code and the type of undiagnosed condition to which each code refers.| **If the condition is being evaluated as …**| **And the body system code begins with …**| **Then the first DC of the hyphenated code is …** musculoskeletal diseases| 50| 8850 amputations| 51| 8851 joints, skull, and ribs| 52| 8852 muscle injuries| 53| 8853 diseases of the eye| 60| 8860 hearing loss| 61| 8861 ear and other sense organs| 62| 8862 systemic diseases| 63| 8863 nose and throat| 65| 8865 trachea and bronchi| 66| 8866 tuberculosis| 67| 8867 lungs and pleura| 68| 8868 heart diseases| 70| 8870 arteries and veins| 71| 8871 upper digestive system| 72| 8872 lower digestive system| 73| 8873 genitourinary system| 75| 8875 gynecological system| 76| 8876 hemic and lymphatic system| 77| 8877 skin| 78| 8878 endocrine system| 79| 8879 central nervous system| 80| 8880 miscellaneous neurological| 81| 8881 cranial nerve paralysis| 82| 8882 cranial nerve neuritis| 83| 8883 cranial nerve neuralgia| 84| 8884 peripheral nerve paralysis| 85| 8885 peripheral nerve neuritis| 86| 8886 peripheral nerve neuralgia| 87| 8887 epilepsies| 89| 8889 psychotic disorders| 92| 8892 organic mental| 93| 8893 psychoneurotic| 94| 8894 psychophysiologic| 95| 8895 dental and oral| 99| 8899 ### VIII.ii.1.C.2.d. Examples of Hyphenated Codes for Undiagnosed Disabilities and MUCMIs The table below contains examples of hyphenated codes that may be used when awarding or denying undiagnosed illnesses manifest by the 13 signs or symptoms or a MUCMI found in [38 CFR 3.317](). For the second code, use a DC with rating criteria that most accurately evaluates manifestations of the disability.**_N_** _ote_** : This list does not contain all possible hyphenated codes. | **If the symptom or MUCMI is …**| **Then the hyphenated DC is …** abnormal weight loss| 8873-7328, (resection of intestine). cardiovascular signs or symptoms| 8870-7013, (tachycardia). cardiovascular signs or symptoms| 8870-7005, (arteriosclerotic heart disease (ASHD)). chronic fatigue syndrome| 8863-6354. fatigue| 8863-6354, (chronic fatigue syndrome). fatigue| 8877-7700, (anemia). fibromyalgia| 8850-5025. * gastrointestinal signs or symptoms, or * a functional gastrointestinal disorder (FGID) * 8873-7305, (ulcer) * 8873-7346 (hernia hiatal), or * 8873-7319, (irritable bowel syndrome). headache| 8881-8100, (migraine headaches). joint pain| 8850-5002, (rheumatoid arthritis). menstrual disorders| 8876-7622, (uterus displacement). muscle pain| 8850-5021, (myositis). neurologic signs or symptoms| 8885-85__, (peripheral neuropathy). neuropsychological signs or symptoms| 8893-9300, (organic mental disorder). signs or symptoms involving the respiratory system (upper or lower)| * 8865-65__, (respiratory system) * 8866-66__, (respiratory system), or * 8868-68__, (respiratory system). signs or symptoms involving the skin| 8878-7806, (eczema). sleep disturbances| 8894-9400, (generalized anxiety). **Reference:** For more information on the 13 signs or symptoms of an undiagnosed illness or MUCMI, see * [38 CFR 3.317(b)](), and * [M21-1, Part VIII, Subpart ii, 1.A.1.j](). ### VIII.ii.1.C.2.e. Termination or Reduction of Benefits Previously Awarded Situations may arise that will require termination or reduction of payments previously awarded for undiagnosed illness or MUCMI. Follow the normal procedures for reduction of benefits or severance of SC outlined in [M21-1, Part X, Subpart ii, 5.B](). **Notes:** * Termination or reduction of benefits paid under [38 U.S.C. 1117]() does not preclude continuation of payments if entitlement can be established for SC based on incurrence or aggravation under the provisions of [38 CFR 3.303]() and [38 CFR 3.306](), respectively, or based on presumption under the provisions of [38 CFR 3.307](). * The last day of the month 60 days after issuance of the final notice of the adverse action is the **_last_** date benefits are payable at the prior rate or, in cases of severance, for the disability. For rating purposes in VBMS-R, enter the first day of the following month as the date of the reduction or severance. **Example:** A physician indicates that the Veteran’s condition, which had previously been characterized as an undiagnosed illness and compensated under [38 U.S.C. 1117](), is now a clinically diagnosed condition with a clear etiology, and the RO is unable to establish continued entitlement under any other SC provision. After following the due process procedures, a final rating effectuating the severance is prepared on October 10, 2023. As final notice of the adverse action will be sent that same month, the Rating Veterans Service Representative enters January 1, 2024, as the date of severance of compensation for that disability.**Reference:** For more information on effective dates for reductions of discontinuance of benefits for certain disabilities due to undiagnosed illnesses, see [38 CFR 3.500(y)](). ### VIII.ii.1.C.2.f. Persian Gulf Veterans’ Participation in VA-Sponsored Research Projects Effective December 27, 2001, [38 U.S.C. 1117 ]()enacted protection of SC for disabilities awarded under [38 U.S.C. 1117]() or [38 U.S.C. 1118]() for Persian Gulf Veterans who participate in certain VA-sponsored medical research projects. **Exception:** SC is not protected if the original award was based on fraud, or military records clearly show that the Veteran did not have the requisite service or character of discharge. **Note:** A list of the relevant VA-sponsored medical research projects for which SC is protected is published in the Federal Register. ## 3. Requirements for Providing Adequate Explanation of Decisions on Undiagnosed Illness and MUCMI Claims June 6, 2025 ### VIII.ii.1.C.3.a. Requirement to Provide Adequate Explanation of Decisions When awarding or denying SC for a condition under [38 U.S.C. 1117](), the decision and decision notice must provide adequate reasons for the decision as described in [M21-1, Part V, Subpart iv, 1.A.5.a](). _**Important**_ : * When denying SC, include * a discussion of the specific provisions that were not met under both the presumptive provisions of [38 U.S.C. 1117](), as well as any theories of SC raised by the claimant or the evidence, as discussed in [M21-1, Part II, Subpart iii, 1.A.2.e](), and * favorable findings, if applicable, specific to the facts of the case. * If the system-generated text options do not adequately cover the reason a claim is being awarded or denied, decision makers must use glossary text or free text to supplement the explanation of the decision. **References:** For more information on * system-generated text and glossary fragments, see the _VBMS-R User Guide_ , and * the required elements of decision notice, see * [38 CFR 3.103(f)](), and * [M21-1, Part VI, Subpart i, 1.B](). ## 4. Effective Date Determinations in Undiagnosed Illness and MUCMI Claims This topic contains information about effective date determinations, including * establishing an effective date for undiagnosed illness and MUCMI claims, and * examples of 38 U.S.C. 1117 and 38 CFR 3.317 effective dates. June 6, 2025 ### VIII.ii.1.C.4.a. Establishing an Effective Date for Undiagnosed Illness and MUCMI Claims When assigning an effective date, follow the guidance in[ M21-1, Part V, Subpart ii, 4.A]() relevant to the facts of the claim.In addition to the general principles governing the assignment of effective dates, consider the following relevant factors when awarding SC for an undiagnosed illness or MUCMI: * Did the Veteran’s service qualify under [38 CFR 3.317(e)(2)]() or under a location added in [38 U.S.C. 1117]()? * Was the qualifying disability manifest to a compensable degree? Use the table below to determine which effective date provisions apply.| **If the award involves a(n) …**| **And the condition …**| **Then ...** * undiagnosed illness or MUCMI, and * current [38 CFR 3.317]() location | manifest to a compensable degree| normal effective date rules applybased on existing [38 CFR 3.317]() authority. did not manifest to a compensable degree| the effective date cannot be prior to August 10, 2022, the date the law was changed to allow for the award of benefits under [38 U.S.C. 1117]().**Note:** If warranted by the facts of the case, apply [38 CFR 3.114(a)](). * undiagnosed illness or MUCMI, and * location added in [38 U.S.C. 1117]() | N/A| the effective date cannot be prior to August 10, 2022, the date the law was changed to allow for the award of benefits under [38 U.S.C. 1117]().**Note:** If warranted by the facts of the case, award retroactive benefits under [38 CFR 3.114(a)](). **Reference:** For more information on assigning an effective date, see * [38 CFR 3.400]() * [38 CFR 3.114](), and * [38 CFR 3.156(c)](). ### VIII.ii.1.C.4.b. Examples: 38 U.S.C. 1117 and 38 CFR 3.317 Effective Dates ** _Example 1_** : A Veteran filed a claim for gastrointestinal symptoms on June 2, 2022. Military records show service in a Southwest Asia theater of operations location under [38 CFR 3.317(e)(2)](). Medical records show a chronic functional gastrointestinal disorder. As the claim could be processed prior to the PACT Act under existing [38 CFR 3.317]() authority, the effective date would be the date of claim.**Example 2:** A Veteran had a previously denied claim for chronic fatigue syndrome in 2019, because even though there were chronic symptoms, they did not meet the minimum compensable criteria under [38 CFR 4.88b, DC 6354](). Military records show service in a Southwest Asia theater of operations location under [38 CFR 3.317(e)(2)](). The Veteran files a supplemental claim on October 2, 2022. Medical records and VA examination continue to show chronic symptoms that would only qualify for a 0-percent evaluation. The claim now qualifies for non-compensable SC because of the new authority in the PACT Act, i.e., removal of the compensability requirement. Therefore, effective date cannot be earlier than the date of the law, August 10, 2022.