VA HIGHER-LEVEL REVIEW REQUEST

De Novo Review by Senior Reviewer

DEPARTMENT OF VETERANS AFFAIRS
Veterans Benefits Administration

SECTION 1: VETERAN IDENTIFICATION

Veteran's Full Legal Name: _______________________________________________

VA File Number: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Current Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

SECTION 2: DECISION BEING REVIEWED

Date of VA Decision: _______________________________________________

Type of Decision:
☐ Initial Rating Decision
☐ Supplemental Claim Decision
☐ Decision on Claim for Increase
☐ Effective Date Decision
☐ Severance/Reduction Decision
☐ Other: _______________________________________________

VA Regional Office that Issued Decision: _______________________________________________

Letter Date on Decision Notice: _______________________________________________

SECTION 3: ISSUES FOR HIGHER-LEVEL REVIEW

IMPORTANT: Higher-Level Review is a review of the same evidence - you cannot submit new evidence. The senior reviewer will determine if VA made an error.

Issue 1:

Issue Description: _______________________________________________

VA's Decision on This Issue: _______________________________________________

Rating/Benefit Assigned: _______________________________________________

Effective Date Assigned: _______________________________________________

Type of Error Alleged:
☐ Clear and unmistakable error (CUE)
☐ Misapplication of law or regulation
☐ Failure to apply benefit of the doubt
☐ Incorrect interpretation of evidence
☐ Failure to consider evidence of record
☐ Incorrect rating criteria applied
☐ Mathematical/calculation error
☐ Effective date error
☐ Other: _______________________________________________

Issue 2:

Issue Description: _______________________________________________

VA's Decision on This Issue: _______________________________________________

Rating/Benefit Assigned: _______________________________________________

Effective Date Assigned: _______________________________________________

Type of Error Alleged:
☐ Clear and unmistakable error (CUE)
☐ Misapplication of law or regulation
☐ Failure to apply benefit of the doubt
☐ Incorrect interpretation of evidence
☐ Failure to consider evidence of record
☐ Incorrect rating criteria applied
☐ Mathematical/calculation error
☐ Effective date error
☐ Other: _______________________________________________

Issue 3:

Issue Description: _______________________________________________

VA's Decision on This Issue: _______________________________________________

Rating/Benefit Assigned: _______________________________________________

Effective Date Assigned: _______________________________________________

Type of Error Alleged:
☐ Clear and unmistakable error (CUE)
☐ Misapplication of law or regulation
☐ Failure to apply benefit of the doubt
☐ Incorrect interpretation of evidence
☐ Failure to consider evidence of record
☐ Incorrect rating criteria applied
☐ Mathematical/calculation error
☐ Effective date error
☐ Other: _______________________________________________

(Attach additional pages if requesting review of more issues)

SECTION 4: INFORMAL CONFERENCE REQUEST

You have the right to request an informal conference with the Higher-Level Reviewer. This is a phone call to discuss why you believe VA made an error - it is NOT a formal hearing and new evidence cannot be submitted.

☐ YES, I request an informal conference
☐ NO, I do not want an informal conference

If requesting informal conference:

Preferred Time for Call:
☐ Morning (8:00 AM - 12:00 PM)
☐ Afternoon (12:00 PM - 4:30 PM)
☐ No preference

Phone Number for Conference: _______________________________________________

Alternative Phone Number: _______________________________________________

Time Zone: _______________________________________________

Who Will Participate in Conference:
☐ Veteran only
☐ Veteran and representative
☐ Representative only (Veteran authorizes representative to speak on their behalf)

SECTION 5: DETAILED ERROR IDENTIFICATION

For each issue, explain specifically what error VA made. The reviewer will conduct a de novo (fresh) review of the existing evidence.

Error Analysis for Issue 1:

The Specific Error:
_______________________________________________
_______________________________________________
_______________________________________________

Evidence in the Record that Supports Your Position:
_______________________________________________
_______________________________________________
_______________________________________________

Correct Outcome Based on Evidence:
_______________________________________________
_______________________________________________

Applicable Law/Regulation Misapplied:
_______________________________________________

Error Analysis for Issue 2:

The Specific Error:
_______________________________________________
_______________________________________________
_______________________________________________

Evidence in the Record that Supports Your Position:
_______________________________________________
_______________________________________________
_______________________________________________

Correct Outcome Based on Evidence:
_______________________________________________
_______________________________________________

Applicable Law/Regulation Misapplied:
_______________________________________________

Error Analysis for Issue 3:

The Specific Error:
_______________________________________________
_______________________________________________
_______________________________________________

Evidence in the Record that Supports Your Position:
_______________________________________________
_______________________________________________
_______________________________________________

Correct Outcome Based on Evidence:
_______________________________________________
_______________________________________________

Applicable Law/Regulation Misapplied:
_______________________________________________

SECTION 6: LEGAL ARGUMENTS

Benefit of the Doubt (38 USC § 5107(b)):

☐ VA failed to apply the benefit of the doubt doctrine

Explanation: When there is an approximate balance of positive and negative evidence, the benefit of the doubt must be given to the veteran. The evidence shows:
_______________________________________________
_______________________________________________
_______________________________________________

Rating Criteria Errors (38 CFR Part 4):

☐ VA applied incorrect diagnostic code
☐ VA failed to consider all applicable diagnostic codes
☐ VA failed to apply most favorable diagnostic code
☐ VA failed to consider functional impairment

Correct Diagnostic Code: _______________________________________________

Correct Rating Percentage: _______________________________________________

Explanation:
_______________________________________________
_______________________________________________

Effective Date Errors (38 CFR § 3.400):

☐ VA assigned incorrect effective date

Effective Date Received: _______________________________________________

Correct Effective Date: _______________________________________________

Basis for Correct Effective Date:
☐ Date of claim (38 CFR § 3.400(b)(2))
☐ Date entitlement arose
☐ One year prior to claim (for increased rating)
☐ Date of liberalizing law (38 CFR § 3.114)
☐ Other: _______________________________________________

Explanation:
_______________________________________________
_______________________________________________

SECTION 7: PACT ACT CONSIDERATIONS

☐ This Higher-Level Review involves PACT Act issues

PACT Act Errors Alleged:

☐ VA failed to apply PACT Act presumption (38 CFR § 3.320)
☐ VA failed to apply correct effective date for PACT Act presumption
☐ VA failed to consider toxic exposure risk activity
☐ VA incorrectly determined PACT Act presumption did not apply

Explanation:
_______________________________________________
_______________________________________________
_______________________________________________

Relevant PACT Act Provision:
_______________________________________________

SECTION 8: EVIDENCE CURRENTLY OF RECORD

List the key evidence already in your VA file that supports your position. Remember: You cannot submit new evidence with a Higher-Level Review.

Medical Evidence of Record:

C&P Examination Reports:

Lay Evidence of Record:

Service Records of Record:

SECTION 9: DIFFERENCE OF OPINION NOTIFICATION

If the Higher-Level Reviewer identifies a "difference of opinion" (where a different conclusion could be reached based on the same evidence), the reviewer may grant a higher rating or earlier effective date.

☐ I believe a difference of opinion analysis should result in a favorable decision because:
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 10: DUTY TO ASSIST ERROR IDENTIFICATION

The Higher-Level Reviewer can identify duty to assist errors that require correction. If VA failed to fulfill its duty to assist, the claim may be returned for correction.

☐ VA failed to obtain relevant VA medical records
☐ VA failed to obtain relevant service treatment records
☐ VA failed to provide adequate C&P examination
☐ VA failed to obtain relevant private records (with authorization)
☐ VA failed to obtain federal records
☐ VA failed to provide proper notice
☐ Other duty to assist error: _______________________________________________

Explanation of Duty to Assist Error:
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 11: SAME OFFICE REVIEW OPT-OUT

Generally, a Higher-Level Review is conducted at a different VA office than the one that made the original decision. However, you may opt into same-office review.

☐ I request same-office Higher-Level Review
☐ I do NOT request same-office review (default - different office will review)

SECTION 12: OPT-IN FROM LEGACY APPEALS SYSTEM

If you have a legacy appeal (Statement of the Case issued before February 19, 2019), you may opt into the AMA system:

☐ I am opting into AMA from a legacy appeal

Legacy Appeal Information:
- SOC Date: _______________________________________________
- Issues in Legacy Appeal: _______________________________________________
- Current Status: _______________________________________________

I understand:
☐ My legacy appeal will be withdrawn
☐ A new decision will be issued under AMA
☐ Effective date protections generally apply

SECTION 13: REPRESENTATIVE INFORMATION

☐ Veteran is self-represented (pro se)
☐ Veteran is represented

Representative Name: _______________________________________________

Type:
☐ Veterans Service Organization (VSO)
☐ Accredited Attorney
☐ Accredited Claims Agent

Organization (if VSO): _______________________________________________

Phone Number: _______________________________________________

Email: _______________________________________________

VA Form 21-22 or 21-22a on File: ☐ Yes ☐ No

SECTION 14: ATTACHMENTS CHECKLIST

Required:
☐ VA Form 20-0996 (Decision Review Request: Higher-Level Review)
☐ Copy of VA decision being reviewed

Optional:
☐ Written argument/brief explaining errors (recommended)
☐ VA Form 21-22 or 21-22a (if appointing new representative)

DO NOT INCLUDE:
☐ New medical records (will not be considered)
☐ New nexus letters (will not be considered)
☐ New buddy statements (will not be considered)
☐ Any evidence not already in VA's possession

SECTION 15: CERTIFICATION AND SIGNATURE

I certify that:
1. I understand that Higher-Level Review is a review of existing evidence only
2. I am not submitting new evidence with this request
3. The information provided is true and correct to the best of my knowledge
4. I understand that I have one year from the date of the decision to file this request

Veteran's Signature: _______________________________________________

Date: _______________________________________________

Representative's Signature (if applicable): _______________________________________________

Date: _______________________________________________

SUBMISSION INSTRUCTIONS

DEADLINE: This request must be received within ONE YEAR from the date of the decision being reviewed.

Submit to:

Online: www.va.gov

Mail:
Department of Veterans Affairs
Claims Intake Center
PO Box 4444
Janesville, WI 53547-4444

Fax: 1-844-531-7818

IMPORTANT LEGAL REFERENCES

• 38 USC § 5104B - Higher-Level Review
• 38 USC § 5107(b) - Benefit of the doubt
• 38 CFR § 3.2601 - Higher-Level Review procedures
• 38 CFR § 3.2602 - Informal conference
• 38 CFR § 3.2603 - Duty to assist errors
• 38 CFR § 3.105 - Revision of decisions
• 38 CFR Part 4 - Schedule for Rating Disabilities

HIGHER-LEVEL REVIEW VS. OTHER OPTIONS

POSSIBLE OUTCOMES

1. Grant - Higher-Level Reviewer agrees with you and grants benefit
2. Denial - Higher-Level Reviewer finds no error
3. Return for Correction - Duty to assist error identified; claim returned to Regional Office
4. Difference of Opinion - Reviewer reaches different conclusion on same evidence

This template is designed to assist in preparing a VA Higher-Level Review request. Individual circumstances vary, and this document should be reviewed by an accredited representative before submission.