Evidence Review - Sample Veteran

VBMS Reviewer | Public sample | 05/01/2026

Factual evidence organization. Attorney review required before relying on procedural posture, filing decisions, date calculations, or legal conclusions. Not legal advice or strategy.

Veteran

Sample Veteran

Report Date

05/01/2026

Documents Reviewed

Review Type

Evidence Review

Disabilities Reviewed

Compact Case Posture Summary

Known from reviewed records

Most recent VA decision

03/18/2024 - S-014 Rating Decision Narrative

Rating Decision

Current service-connected count

Count extracted from current rating records

Documents reviewed

Sample Evidence Review metadata

Needs verification

Complete code sheet

S-014 Rating Decision Codesheet

Current-rating source identified in sample set

Current combined rating

80%

03/18/2024

True combined rating

82%

Calculated from extracted current ratings

Issue Overview

Issues found

Granted / service connected

Denied

Needs attorney verification

Current Ratings

Condition	Rating	Effective Date	Source	Confidence
Posttraumatic stress disorder with TBI Service connected	70%	07/15/2020	S-004 Rating Decision Codesheet · Document-level source · High	High
Migraine headaches Service connected	50%	09/02/2023	S-006 Rating Decision Narrative · Document-level source · High	High
Right knee strain with limitation of flexion Service connected	20%	03/18/2024	S-014 Rating Decision Codesheet · Document-level source · High	Medium
Tinnitus Service connected	10%	05/10/2018	S-002 Rating Decision Narrative · Document-level source · High	High
Left ankle sprain residuals Service connected	10%	07/15/2020	S-004 Rating Decision Codesheet · Document-level source · High	Medium

Disability Evidence Board

PTSD with traumatic brain injury

Granted70%Attorney verification

Continued / 03/18/2024 · 18 evidence facts · 1 gap

Latest Decision

Decision date	03/18/2024	Decision document	S-014 Rating Decision Narrative
Outcome	Continued	Rating assigned	70%
Effective date assigned	07/15/2020	Source citation	S-014 Rating Decision Narrative · Document-level source · High

Medical Evidence

02/12/2024 VA treatment summary notes ongoing sleep disturbance, irritability, and hypervigilance, with medication management listed as active.

S-021 VA Treatment Summary · Document-level source · High

Highmedical evidence

02/20/2024 C&P mental health examination recorded occupational and social impairment with deficiencies in most areas.

S-017 C&P Mental Health DBQ · Document-level source · High

Highmedical evidence

Functional Impact

02/20/2024 Veteran reported missed workdays and difficulty maintaining concentration during flare-ups of anxiety and sleep disruption.

S-017 C&P Mental Health DBQ · Document-level source · High

Highfunctional impact

03/01/2024 Supervisor statement references reduced reliability during periods of sleep impairment and irritability.

S-030 Lay / Employer Statement · Document-level source · High

Highfunctional impact

Rating Facts

03/18/2024 Decision continued 70 percent evaluation and did not identify total occupational and social impairment.

S-014 Rating Decision Narrative · Document-level source · High

Highrating facts

Evidence Gaps

Employment evidence

The file summarizes work impairment, but no wage history or attendance records were included in the reviewed sample.

May affect TDIU/employment-development review.

S-030 Lay / Employer Statement · Document-level source · High

MediumAttorney verification

Migraine headaches

Granted50%Attorney verification

Increased / 09/02/2023 · 14 evidence facts · 1 gap

Latest Decision

Decision date	09/02/2023	Decision document	S-006 Rating Decision Narrative
Outcome	Increased	Rating assigned	50%
Effective date assigned	09/02/2023	Source citation	S-006 Rating Decision Narrative · Document-level source · High

Medical Evidence

08/17/2023 Headache DBQ records characteristic prostrating attacks occurring more than once per month.

S-011 Headaches DBQ · Document-level source · High

Highmedical evidence

08/20/2023 Medication list includes migraine abortive therapy and preventive medication.

S-019 VA Treatment Summary · Document-level source · High

Highmedical evidence

Functional Impact

08/17/2023 Veteran reported leaving work early during severe migraine episodes and needing a dark room for several hours.

S-011 Headaches DBQ · Document-level source · High

Highfunctional impact

Rating Facts

09/02/2023 Decision assigned 50 percent based on very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

S-006 Rating Decision Narrative · Document-level source · High

Highrating facts

Evidence Gaps

Headache log / work records

The reviewed sample does not include a headache diary, employer attendance records, or wage-loss documentation.

Would support verification of frequency and occupational impact.

S-011 Headaches DBQ · Document-level source · High

MediumAttorney verification

Right knee strain with limitation of flexion

Granted20%Attorney verification

Reduced / 03/18/2024 · 21 evidence facts · 2 gaps

Latest Decision

Decision date	03/18/2024	Decision document	S-014 Rating Decision Narrative
Outcome	Reduced	Rating assigned	20%
Effective date assigned	03/18/2024	Source citation	S-014 Rating Decision Narrative · Document-level source · High

Medical Evidence

02/14/2024 Knee DBQ measured flexion limited to 45 degrees during flare-ups and documented painful motion.

S-016 Knee DBQ · Document-level source · High

Highmedical evidence

01/29/2024 VA treatment note references a right knee brace and physical therapy referral.

S-022 VA Treatment Note · Document-level source · High

Highmedical evidence

Functional Impact

02/14/2024 Veteran reported difficulty standing longer than 20 minutes and avoiding stairs during flare-ups.

S-016 Knee DBQ · Document-level source · High

Highfunctional impact

02/03/2024 Lay statement reports intermittent swelling after prolonged walking.

S-025 Statement in Support of Claim · Document-level source · High

Highfunctional impact

Rating Facts

03/18/2024 Prior rating history shows 30 percent evaluation before the March 2024 reduction; current rating listed as 20 percent.

S-014 Rating Decision Codesheet · Document-level source · High

Highrating facts

Evidence Gaps

Underlying imaging

The DBQ references recent imaging, but the underlying imaging report was not included in the reviewed sample.

Could affect restoration/rating-change review.

S-016 Knee DBQ · Document-level source · High

MediumAttorney verification

Employment impact

Work restrictions are described, but no employer statement or accommodation record was provided.

Could affect functional-impact review.

S-025 Statement in Support of Claim · Document-level source · High

MediumAttorney verification

Lumbar strain claimed secondary to knee condition

DeniedAttorney verification

Denied / 03/18/2024 · 9 evidence facts · 2 gaps

Latest Decision

Decision date	03/18/2024	Decision document	S-014 Rating Decision Narrative
Outcome	Denied	Rating assigned	Not assigned
Effective date assigned	Not assigned	Source citation	S-014 Rating Decision Narrative · Document-level source · High

Medical Evidence

02/22/2024 VA examiner acknowledged lumbar strain diagnosis but provided a negative secondary relationship opinion.

S-018 Back Medical Opinion · Document-level source · High

Highmedical evidence

01/18/2024 Treatment record notes intermittent low back pain after prolonged standing.

S-020 VA Treatment Summary · Document-level source · High

Highmedical evidence

Functional Impact

02/22/2024 Veteran reported avoiding lifting and prolonged standing due to back and knee pain.

S-018 Back DBQ · Document-level source · High

Highfunctional impact

Rating Facts

03/18/2024 Decision denied secondary service connection, stating the evidence did not establish causation by the service-connected knee condition.

S-014 Rating Decision Narrative · Document-level source · High

Highrating facts

Evidence Gaps

Medical nexus development

The reviewed sample contains a negative opinion but no private or treating-clinician nexus opinion.

May affect evidence development review.

S-018 Back Medical Opinion · Document-level source · High

MediumAttorney verification

Aggravation rationale

The decision summary does not clearly discuss whether aggravation was addressed separately from causation.

Attorney verification required.

S-014 Rating Decision Narrative · Document-level source · High

MediumAttorney verification

Procedural Signals for Attorney Review

Intent to File

Reviewed records identify a source-backed Intent to File received on 04/15/2026. The candidate expiration date is 04/15/2027. Attorney verification required before relying on this date.

ITF expiration candidateCandidate due date: 04/15/2027HighAttorney verification required

S-001 Intent to File Letter · Document-level source · High

Right knee strain

Review-window candidate date derived from the 03/18/2024 decision notice. This is a candidate date only, not a legal deadline calculation.

Review-window candidate date: 03/18/2025Past candidate dateMediumAttorney verification required

S-014 Rating Decision Narrative · Document-level source · High

Lumbar strain

No current challenge document was identified in the reviewed sample for the 03/18/2024 denial.

No current challenge signal foundMediumAttorney verification required

S-014 Rating Decision Narrative · Document-level source · High

Evidence Gaps

Employment evidence

The reviewed sample contains functional-impact statements but no wage history, attendance records, or employer accommodation records.

Would support review of work-impact evidence.

S-030 Lay / Employer Statement · Document-level source · High

MediumAttorney verification

Knee imaging

The knee DBQ references imaging, but the underlying radiology report is not included in the sample record set.

May affect rating-change/restoration review.

S-016 Knee DBQ · Document-level source · High

MediumAttorney verification

Back nexus evidence

The reviewed sample contains a negative secondary opinion but no alternate treating-source or private medical opinion.

May affect evidence development review.

S-018 Back Medical Opinion · Document-level source · High

MediumAttorney verification

Confidence Warnings

4 verification warnings

Several citations are document-level sources because this public sample does not include underlying source PDFs.

Procedural dates are candidate dates for attorney verification, not legal deadline calculations.

Source documents are not included in this public landing-page sample.

This sample uses fictional veteran and document information.

Source Index

S-014 Rating Decision Narrative

Rating Decision Narrative - 03/18/2024

Document-level sourceFacts: 12Used in: posture, current ratings, issue decisions

S-014 Rating Decision Codesheet

Rating Decision Codesheet - 03/18/2024

Document-level sourceFacts: 8Used in: current ratings

S-016 Knee DBQ

C&P Exam - 02/14/2024

Document-level sourceFacts: 9Used in: knee issue, rating facts

S-017 Mental Health DBQ

C&P Exam - 02/20/2024

Document-level sourceFacts: 10Used in: PTSD/TBI issue

S-011 Headaches DBQ

C&P Exam - 08/17/2023

Document-level sourceFacts: 8Used in: migraine issue

S-018 Back DBQ / Opinion

C&P Exam and Medical Opinion - 02/22/2024

Document-level sourceFacts: 7Used in: lumbar issue

S-021 VA Treatment Summary

VA Treatment Summary - 02/12/2024

Document-level sourceFacts: 11Used in: medical evidence

S-030 Lay / Employer Statement

Lay / Employer Statement - 03/01/2024

Document-level sourceFacts: 5Used in: functional impact