Skip to main content
VA Rating Assistant

DC 7351 · 38 CFR 4.114

Liver Transplant C&P Exam Prep

To evaluate the current severity of residuals following liver transplant surgery under DC 7351, and to document any ongoing symptoms, complications, or recurrence of underlying liver disease for VA disability rating purposes. The exam also captures transplant surgery dates, hospitalization records, post-transplant treatment needs, and functional impact on daily living and employment.

Format:
Interview + Physical
Typical duration:
30-45 minutes
DBQ form:
liver-conditions (liver-conditions)
Examiner:
Gastroenterologist or Hepatologist

What the examiner evaluates

  • Date and details of liver transplant surgery and hospital admission/discharge
  • Underlying liver disease that necessitated the transplant (e.g., hepatitis C, cirrhosis, NASH, hepatocellular carcinoma)
  • Current signs and symptoms including fatigue, weakness, malaise, anorexia, abdominal pain, and pruritus
  • Presence of post-transplant complications: ascites, portal hypertension, hepatic encephalopathy, variceal hemorrhage, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary syndrome, splenomegaly, and coagulopathy
  • Current immunosuppressive and other medication requirements
  • Whether parenteral antiviral or immunomodulatory therapy is required
  • Relevant lab values: AST, ALT, bilirubin, alkaline phosphatase, INR/PT, creatinine
  • Imaging and procedure results: ultrasound, CT, MRI/MRCP, ERCP, liver biopsy, EUS
  • MELD score and functional status
  • Whether symptoms have resolved or persisted following transplant
  • Functional impact on occupational and daily activities
  • Whether any residuals or recurrence of underlying disease are present

Exam may be conducted in person at a VA medical facility or via telehealth. If conducted remotely, have your medication list, recent lab results, and imaging reports readily accessible. For in-person exams, a brief abdominal physical examination is likely. The exam may be conducted by a VA staff physician, a contract examiner (e.g., LHI, QTC, VES), or a specialist. Request that the exam be conducted by a gastroenterologist or hepatologist if possible, as they are best equipped to evaluate post-transplant residuals.

Measurements and tests

Liver Function Tests (AST, ALT, Alkaline Phosphatase, Bilirubin)

What it measures: Hepatocellular injury, cholestasis, and overall liver synthetic function. Elevated values indicate ongoing inflammation, rejection, recurrent disease, or bile duct complications post-transplant.

What to expect: Examiner will review your most recent lab results from your treating provider. Blood may or may not be drawn at the exam itself. Bring printed copies of your most recent labs (within the past 6-12 months).

Critical thresholds

  • AST/ALT > 2x upper limit of normal Supports ongoing liver disease activity; relevant to rating residuals above minimum 30%
  • Bilirubin elevated above normal range Indicates impaired liver function; may support higher residual disability rating
  • Alkaline phosphatase elevated Suggests bile duct complications or rejection; relevant to overall liver function assessment

Tips

  • Bring printed lab results from your transplant hepatologist or gastroenterologist dated within the past 6-12 months
  • If labs show normal values, ensure the examiner understands this may reflect medication compliance rather than full recovery
  • Note whether any labs have recently worsened or required treatment adjustments

Pain considerations: Not directly applicable; however, abdominal discomfort during blood draws or palpation should be reported accurately.

INR/PT (Prothrombin Time / International Normalized Ratio)

What it measures: Liver's ability to produce clotting factors. An elevated INR indicates impaired synthetic function and increased bleeding risk, relevant to coagulopathy as a post-transplant complication.

What to expect: Reviewed from existing records or drawn at exam. Elevated INR may contribute to a coagulopathy finding on the DBQ.

Critical thresholds

  • INR > 1.5 Suggests clinically significant coagulopathy; supports documentation of this complication
  • INR > 2.0 Indicates significant clotting impairment; strongly supports coagulopathy checkbox and related functional limitations

Tips

  • Bring the most recent INR result, especially if you are on anticoagulation therapy
  • Inform the examiner if you have had bleeding episodes, easy bruising, or prolonged bleeding from cuts

Pain considerations: Not directly applicable.

Creatinine (Renal Function)

What it measures: Kidney function. Post-transplant patients are at increased risk for renal impairment due to calcineurin inhibitor toxicity (tacrolimus, cyclosporine), and may develop hepatorenal syndrome.

What to expect: Reviewed from records. Elevated creatinine may support documentation of hepatorenal syndrome or renal complications as a secondary condition.

Critical thresholds

  • Creatinine > 1.5 mg/dL Suggests renal impairment that may support hepatorenal syndrome documentation or separate secondary claim

Tips

  • If you have been told your kidneys are affected by your anti-rejection medications, report this clearly
  • Consider whether a separate kidney condition claim may be warranted as secondary to liver transplant

Pain considerations: Not directly applicable.

MELD Score (Model for End-Stage Liver Disease)

What it measures: Composite score using bilirubin, INR, and creatinine to predict 90-day mortality in liver disease. Used pre-transplant to prioritize organ allocation; post-transplant MELD may reflect recurrent disease severity.

What to expect: Examiner will record the most recent MELD score if available. Pre-transplant MELD scores are important for establishing severity of the original condition and transplant necessity.

Critical thresholds

  • MELD - 15 pre-transplant Confirms severity of underlying disease necessitating transplant; relevant to nexus and original condition documentation
  • Elevated MELD post-transplant Indicates recurrent or ongoing liver disease; may support higher residual disability rating

Tips

  • Ask your transplant team for your pre-transplant MELD score if not in your records
  • Bring documentation of MELD score from transplant evaluation records

Pain considerations: Not directly applicable.

Liver Biopsy

What it measures: Histological assessment of liver tissue for rejection, recurrent hepatitis, fibrosis, steatohepatitis, or other pathology.

What to expect: Examiner will review biopsy results from your records if performed. Findings such as fibrosis staging, inflammation grade, or rejection patterns are highly relevant.

Critical thresholds

  • Fibrosis stage F2-F4 on biopsy Indicates significant recurrent liver disease; supports rating residuals under appropriate diagnostic code above minimum 30%
  • Evidence of rejection or recurrent hepatitis on biopsy Supports ongoing active disease documentation and may justify higher rating

Tips

  • Bring copies of any biopsy reports with pathology results
  • If biopsy showed recurrent hepatitis C, fibrosis, or NASH, ensure the examiner documents these findings explicitly

Pain considerations: If you experienced significant pain, recovery time, or complications from the biopsy procedure itself, report these accurately as they reflect your overall disease burden.

Abdominal Ultrasound / CT / MRI

What it measures: Structural assessment of the transplanted liver, biliary system, portal vasculature, and abdominal organs. Detects ascites, splenomegaly, portal hypertension, biliary strictures, and recurrent tumors.

What to expect: Examiner will review imaging reports from records. Imaging may not be performed at the exam itself.

Critical thresholds

  • Ascites on imaging Confirms ascites complication; supports documentation of this serious post-transplant finding
  • Splenomegaly on imaging Supports portal hypertension and hypersplenism documentation
  • Biliary stricture on imaging Indicates post-transplant biliary complication requiring ongoing treatment

Tips

  • Bring radiology reports from all imaging studies within the past 1-2 years
  • If you have had ERCP or other biliary procedures, bring those procedure reports as well

Pain considerations: Report any abdominal pain, bloating, or discomfort associated with ascites or organomegaly accurately.

Rating criteria by percentage

100%

Assigned for an indefinite period from the date of hospital admission for liver transplant surgery. This 100% rating continues until one year following hospital discharge, at which point a mandatory VA examination determines the appropriate post-transplant rating. The 100% rating reflects the severity of the transplant procedure itself and the recovery period.

Key symptoms

  • Active hospitalization for transplant surgery
  • Immediate post-operative recovery period
  • Immunosuppression management
  • Risk of acute rejection
  • Inability to work or perform normal activities during recovery
  • Dependence on continuous immunosuppressive medication
  • Ongoing monitoring and frequent medical appointments

From 38 CFR: 38 CFR 4.114, DC 7351: 'For an indefinite period from the date of hospital admission for transplant surgery: 100.' The 100% rating automatically applies from admission date through the first year post-discharge.

60%

Minimum rating assigned when a veteran is eligible and awaiting transplant surgery. Also applicable post-transplant when residuals reflect significant ongoing disability including near-daily symptoms, requirement for continuous medication, and meaningful functional impairment, but not meeting criteria for 100%. Post-transplant, 60% may apply when symptoms such as daily fatigue, weakness, abdominal pain, anorexia, and malaise substantially impair daily functioning and employment, and/or when complications such as portal hypertension, coagulopathy, or recurrent hepatitis are present requiring active treatment.

Key symptoms

  • Listed as eligible and awaiting liver transplant (pre-transplant)
  • Daily fatigue significantly limiting activity
  • Generalized weakness affecting work capacity
  • Persistent anorexia with weight loss
  • Malaise occurring most days
  • Abdominal pain requiring regular medication
  • Portal hypertension with or without varices
  • Coagulopathy requiring monitoring and management
  • Recurrent hepatitis or fibrosis in transplanted liver
  • Continuous medication requirement including immunosuppressants with significant side effects
  • Frequent medical appointments limiting work

From 38 CFR: 38 CFR 4.114, DC 7351: 'Eligible and awaiting transplant surgery, minimum rating 60.' Post-transplant residuals at this level reflect substantial ongoing functional impairment consistent with 38 CFR 4.114 criteria for active liver disease.

30%

Minimum rating assigned following transplant surgery, applicable when the veteran has undergone transplant and post-transplant course shows improvement but ongoing residuals remain. This is the floor rating - it cannot be rated below 30% following a transplant even if largely asymptomatic. This level typically reflects intermittent symptoms, ongoing immunosuppressive medication requirements, and some functional limitation without the severity seen at higher levels. Note: Residuals of recurrent underlying liver disease should be rated separately under the appropriate diagnostic code and combined per 38 CFR 4.14.

Key symptoms

  • Intermittent fatigue that does not prevent daily activities
  • Mild or intermittent malaise
  • Continued immunosuppressive medication requirement (tacrolimus, mycophenolate, prednisone)
  • Periodic lab abnormalities requiring monitoring
  • Intermittent abdominal discomfort
  • Mild arthralgia or pruritus
  • Asymptomatic but with history of liver disease and transplant
  • Regular follow-up appointments with transplant hepatologist

From 38 CFR: 38 CFR 4.114, DC 7351: 'Following transplant surgery, minimum rating 30.' Even with successful transplant and good functional recovery, 30% is the lowest rating assignable. The Note directs that residuals of recurrent underlying disease be rated separately and potentially combined.

Describing your symptoms accurately

Fatigue and Energy Limitation

How to describe it: Describe fatigue in functional terms - how many hours per day you can be active before exhaustion sets in, whether you require daytime naps, and how fatigue affects your ability to work, complete household tasks, or engage in social activities. Distinguish between your average day and your worst day. Specify whether fatigue is daily, weekly, or episodic.

Example: On my worst days, I wake up already exhausted and cannot get out of bed until mid-morning. Even after resting, I feel a heavy, bone-deep tiredness that prevents me from doing more than basic self-care. I cannot work on these days. I have approximately 8-10 of these days per month.

Examiner listens for: Frequency (daily vs. intermittent), severity (mild inconvenience vs. prevents activity), functional impact (can you hold a job?), relationship to medication side effects versus underlying liver disease, whether fatigue affects sleep, cognition, or mood.

Avoid: Saying 'I get tired sometimes' or 'I manage okay' understates the impact. Do not minimize fatigue because you push through it - report how you actually feel, not how you cope.

Weakness and Physical Capacity

How to describe it: Describe muscle weakness specifically - can you lift groceries, climb stairs, stand for extended periods, or perform physical labor? Note whether weakness is generalized or localized. Describe how your physical capacity compares to before your liver disease and transplant. Quantify in terms of distance you can walk, weight you can lift, or time you can stand.

Example: On my worst days, I cannot carry anything heavier than a few pounds without my arms giving out. Climbing one flight of stairs requires me to stop and rest. I used to be able to work a full physical job but now I cannot stand for more than 20 minutes without needing to sit down.

Examiner listens for: Specific functional limitations (not just 'I feel weak'), comparison to pre-transplant baseline, whether weakness limits employment type, whether physical therapy has been tried, and how weakness interacts with fatigue.

Avoid: Do not say 'I have some weakness' without providing specific examples of what you cannot do. Avoid saying you are 'doing okay' if you have had to change jobs, reduce hours, or stop working due to physical limitations.

Abdominal Symptoms

How to describe it: Describe abdominal pain location (right upper quadrant, diffuse), character (dull ache, sharp, cramping), frequency (daily, weekly, episodic), severity (scale of 1-10), duration of episodes, and what makes it better or worse. Also describe nausea, bloating, early satiety, and any changes in bowel habits. Note whether pain has required ER visits or hospitalizations.

Example: On my worst days, I have a constant dull ache in my right side that rates 7 out of 10. I feel so bloated I cannot eat more than a few bites before feeling full and nauseated. This happens about 4-5 times per month and has sent me to urgent care twice in the past year.

Examiner listens for: Pattern and frequency of pain, whether pain correlates with eating or activity, relationship to any documented complications (ascites, biliary stricture), impact on nutrition and weight, and whether over-the-counter or prescription medications are required for control.

Avoid: Do not say 'I have some discomfort' if the pain affects your diet, sleep, or daily function. Report episodes that required medical attention, even if you ultimately managed at home.

Post-Transplant Complications

How to describe it: For each complication (ascites, hepatic encephalopathy, variceal hemorrhage, spontaneous bacterial peritonitis, portal hypertension, hepatorenal syndrome, hepatopulmonary syndrome), describe specific episodes with dates, symptoms experienced, treatments received, and hospitalizations required. Be specific about how often complications occur and their impact on your life.

Example: I had an episode of hepatic encephalopathy last spring where my family noticed I was confused and could not remember where I was. My wife had to take me to the ER and I was admitted for three days. Since then I take lactulose daily to prevent recurrence, but I still have two to three 'foggy' days per month where I cannot drive or make decisions.

Examiner listens for: Dates and frequency of specific complication episodes, whether complications required hospitalization, current preventive treatments, ongoing risk of recurrence, functional impact of complications (cannot drive due to encephalopathy, diet restrictions due to ascites), and whether complications are documented in medical records.

Avoid: Do not omit complication episodes because they resolved. Past episodes of variceal hemorrhage, encephalopathy, or peritonitis are highly relevant even if currently controlled with medication. Report all hospitalizations related to liver complications.

Medication Burden and Side Effects

How to describe it: List all current medications including immunosuppressants (tacrolimus, cyclosporine, mycophenolate mofetil, prednisone), antivirals, diuretics, and other liver-related medications. Describe the side effects you experience: tremors from tacrolimus, infections due to immunosuppression, kidney problems, high blood pressure, diabetes, bone loss, and the frequency of required lab monitoring and clinic visits.

Example: I take tacrolimus twice daily and have developed hand tremors severe enough that I cannot type accurately or handle small objects. I also get infections 3-4 times per year because my immune system is suppressed. I have blood draws every two weeks to monitor my drug levels and kidney function, which requires taking time off work.

Examiner listens for: Whether treatment requires parenteral antiviral or immunomodulatory therapy (relevant to DBQ fields for higher ratings), frequency of medication monitoring requirements, side effects causing secondary conditions, and whether medications are continuous and long-term.

Avoid: Do not downplay medication side effects. The burden of immunosuppression - infections, organ toxicity, monitoring requirements - is a significant component of post-transplant disability. Report all secondary conditions caused by your immunosuppressive regimen.

Cognitive and Neurological Effects (Hepatic Encephalopathy)

How to describe it: Describe cognitive changes including confusion, memory lapses, difficulty concentrating, slow thinking, or personality changes. Specify frequency, duration, and triggers. Note whether you have been restricted from driving, operating machinery, or handling finances due to cognitive symptoms. Describe the impact on work and relationships.

Example: During encephalopathy episodes, I cannot follow conversations, I forget where I am going, and I become irritable and confused. My family has to manage my medications during these episodes. I have had to stop driving because of unpredictable mental fog. I miss work 1-2 days per month because of cognitive symptoms.

Examiner listens for: History of diagnosed hepatic encephalopathy, current preventive treatment (lactulose, rifaximin), frequency of cognitive episodes, whether cognitive symptoms are documented by treating providers or family, and functional impact on employment and daily living.

Avoid: Do not normalize cognitive symptoms as 'just getting older' or 'stress.' If you or your family have noticed mental changes since your transplant or liver disease, report them as potential hepatic encephalopathy manifestations.

Common mistakes to avoid

Reporting only how you feel on the day of the exam rather than your typical or worst-day symptoms

Why: Veterans often feel anxious about the exam and either overperform physically or underreport symptoms, giving the examiner an unrepresentative snapshot. VA rating is based on the overall picture of disability, not just one good day.

Do this instead: Explicitly tell the examiner: 'Today may be a relatively good day for me. My typical experience is...' and describe your average week and your worst days separately. Bring a symptom diary or written notes covering the past 30-90 days.

Impact: 60% vs 30%

Failing to report all post-transplant complications because they are 'controlled' with medication

Why: Controlled complications (ascites managed with diuretics, encephalopathy managed with lactulose, portal hypertension managed with beta-blockers) still represent significant disability. The need for medication to control these conditions is itself a rating consideration.

Do this instead: Report all diagnosed complications regardless of current control status. State: 'I have portal hypertension that is currently managed with carvedilol, but without this medication I would have...' Document all complications in your written statement.

Impact: 100% and 60%

Not bringing documentation of the transplant hospitalization dates

Why: The 100% rating is anchored to the date of hospital admission for transplant surgery. Without documentation, the examiner cannot accurately complete the DBQ fields for transplant dates, which are critical for establishing the rating start date.

Do this instead: Bring hospital admission and discharge records for the transplant surgery, including the transplant surgery date, hospital name, and discharge date. These establish the entitlement period for the 100% rating.

Impact: 100%

Failing to claim residuals of the underlying liver disease separately

Why: DC 7351 Note explicitly states that residuals of recurrent underlying liver disease should be rated under the appropriate diagnostic code and combined per 38 CFR 4.14. Veterans who only claim 'liver transplant' may miss additional rating for recurrent hepatitis C (DC 7354), cirrhosis (DC 7312), or other conditions.

Do this instead: If your underlying liver disease has recurred in the transplanted liver (e.g., recurrent hepatitis C, NASH, or cirrhosis), ensure you have separate service-connected claims for those conditions. Ask your attorney or VSO to evaluate whether combined ratings are appropriate.

Impact: Combined rating above DC 7351 minimum

Not reporting the functional impact on employment and daily activities

Why: The DBQ has a specific field (field 324) for functional impact. Examiners must document how each condition affects occupational and daily functioning. Without this information, the examiner may leave this section incomplete or understate the impact.

Do this instead: Prepare specific examples of how your liver transplant and its residuals affect your ability to work, commute, perform job duties, care for yourself, maintain relationships, and engage in activities you previously enjoyed. Be specific: 'I can only work 4 hours before fatigue forces me to stop' rather than 'I get tired at work.'

Impact: 60% vs 30%

Omitting secondary conditions caused by immunosuppressive medications

Why: Long-term immunosuppression causes diabetes, hypertension, renal impairment, osteoporosis, opportunistic infections, and increased cancer risk. These conditions may be separately ratable as secondary to the service-connected liver transplant.

Do this instead: List all conditions diagnosed after your transplant that your treating providers have linked to immunosuppression. Discuss with your VSO whether secondary service connection claims are appropriate for tacrolimus-induced nephrotoxicity, steroid-induced diabetes, or other medication-related conditions.

Impact: Combined overall rating

Saying 'I'm doing well' or 'the transplant went fine' in response to general questions

Why: These statements, recorded in the DBQ narrative, can be used to justify a lower rating. They do not accurately convey the ongoing burden of immunosuppression, monitoring, lifestyle restrictions, and residual symptoms.

Do this instead: Reframe accurate positive information: 'The transplant was medically successful, but I still require lifelong immunosuppressive medication with significant side effects, regular monitoring, and I continue to experience [specific symptoms] that affect my daily life and work capacity.'

Impact: 60% vs 30%

Not reporting variceal hemorrhage episodes or portal gastropathy because they occurred 'a while ago'

Why: The DBQ specifically asks for dates of variceal hemorrhage and portal gastropathy episodes in the past 24 months. These are critical findings for higher ratings. Omitting past episodes removes important clinical evidence from the record.

Do this instead: Review your medical records before the exam and compile dates of all variceal hemorrhage episodes, GI bleeds, and portal gastropathy-related events within the past two years. Report all episodes to the examiner.

Impact: 100% and 60%

Prep checklist

  • critical

    Gather transplant surgery and hospitalization records

    Obtain hospital records confirming the date of admission for transplant surgery, the transplant surgery date, and the date of hospital discharge. These are essential for establishing the 100% rating period under DC 7351. Contact the transplant hospital's medical records department if you do not have these documents.

    before exam

  • critical

    Collect current and recent laboratory results

    Gather the most recent results for AST, ALT, bilirubin, alkaline phosphatase, INR/PT, creatinine, and complete metabolic panel from your transplant hepatologist or gastroenterologist. Results within the past 6-12 months are ideal. Include any abnormal results and note what treatment changes, if any, resulted.

    before exam

  • critical

    Compile complete medication list with dosages and start dates

    List all current medications including immunosuppressants (tacrolimus/Prograf, mycophenolate mofetil/CellCept, prednisone, cyclosporine), antiviral medications, diuretics (furosemide, spironolactone for ascites), beta-blockers (propranolol/carvedilol for portal hypertension), lactulose/rifaximin (for encephalopathy), and any other liver-related medications. Include dosage, frequency, and how long you have been taking each medication.

    before exam

  • critical

    Write a detailed symptom diary covering the past 30-90 days

    Document daily symptoms including fatigue levels (scale 1-10), energy limitations, abdominal pain episodes, nausea, weakness, cognitive symptoms, and any complications. Note which days were your worst days, what you could not do, and how symptoms affected work, family life, and self-care. This diary will help you provide accurate information during the exam.

    before exam

  • critical

    Document all post-transplant complications with dates

    List all episodes of hepatic encephalopathy, variceal hemorrhage, ascites requiring treatment, spontaneous bacterial peritonitis, portal hypertension episodes, and any hospitalizations related to liver complications. Include dates, treating facility, treatments received, and outcomes. The DBQ specifically asks about episodes in the past 24 months.

    before exam

  • recommended

    Gather imaging and procedure reports

    Collect reports from liver ultrasounds, CT scans, MRIs, MRCP, ERCP, liver biopsies, and EUS performed in the past 1-2 years. These document objective findings including ascites, splenomegaly, biliary strictures, portal hypertension, and recurrent liver disease.

    before exam

  • recommended

    Obtain a buddy statement from a family member or caregiver

    Ask a spouse, family member, or close friend who witnesses your daily limitations to write a statement (VA Form 21-10210 or informal letter) describing specific ways your liver condition affects your daily life. Focus on concrete examples: 'He cannot drive on days when he has mental fog,' 'She cannot attend family events due to fatigue,' 'He was hospitalized twice this year for complications.'

    before exam

  • recommended

    Request records from your transplant hepatologist confirming diagnosis and treatment

    Obtain a letter or treatment notes from your transplant team confirming the diagnosis, transplant date, current treatment plan, and your ongoing medical needs. A letter that mentions specific complications, medications, and functional limitations is particularly valuable.

    before exam

  • recommended

    Research whether secondary conditions are ratable

    Consult with a VSO (Veterans Service Organization) or accredited claims agent to evaluate whether conditions caused by your immunosuppressive medications (diabetes, hypertension, renal disease, osteoporosis) or by the underlying liver disease are separately ratable as secondary to your service-connected liver transplant.

    before exam

  • recommended

    Review your claim file to understand what evidence the examiner has access to

    Request a copy of your claims file (C-file) or review your electronic records through the VA's MyHealtheVet or VA.gov portal. Understand what medical evidence VA already has so you can identify and fill any gaps. If important records are missing, submit them before the exam using VA Form 21-4142/4142a.

    before exam

  • recommended

    Prepare a written statement summarizing your condition

    Write a concise, factual personal statement (VA Form 21-4138 or informal letter) that describes your transplant history, current symptoms on a typical day and on your worst days, specific limitations on work and daily activities, all complications you have experienced, and all medications you currently require. Submit this before or bring it to the exam.

    before exam

  • critical

    Attend the exam reflecting your typical health status - do not specially prepare to feel better

    Do not schedule strenuous activity the day before or try to appear healthier than usual. The exam should reflect your typical daily condition. If you have a bad day on the exam day, inform the examiner this is consistent with your typical experience.

    day of

  • critical

    Bring all documentation in an organized folder

    Organize your records by category: (1) transplant records, (2) lab results, (3) imaging reports, (4) medication list, (5) buddy statement, (6) personal symptom diary, (7) personal statement. Having organized records demonstrates credibility and helps the examiner complete the DBQ accurately.

    day of

  • critical

    Arrive prepared to describe your worst days as well as your average days

    When asked how you are doing, resist the instinct to say 'fine' or 'okay.' Provide a nuanced answer: describe your average week, your worst days, and the percentage of days that fall into each category. This gives the examiner the full picture needed for an accurate rating.

    day of

  • critical

    Inform the examiner of all symptoms - do not wait to be asked

    If the examiner does not ask about specific symptoms (fatigue, cognitive issues, abdominal pain, complications), volunteer that information. You may say: 'I also want to make sure you have documented my [symptom]' or 'An important part of my condition that I want to make sure is noted is...'

    day of

  • recommended

    Clarify if you are describing a typical day versus your best or worst day

    Proactively clarify context when describing symptoms. Say 'On a typical day...' or 'On my worst days, which happen about X times per month...' This prevents the examiner from assuming your best-day description represents your overall condition.

    day of

  • optional

    Request recording of the exam if you wish (check state law)

    Veterans have the right to request that C&P exams be recorded. Check whether your state law permits recording and whether VA policy allows it for your exam type. If recording, inform the examiner at the start of the exam. A recording provides an accurate record if the DBQ does not reflect what was discussed.

    day of

  • critical

    Ensure the examiner documents all symptoms on the DBQ

    The DBQ has checkboxes for fatigue, weakness, generalized weakness, malaise, anorexia, abdominal pain, pruritus, arthralgia, hepatomegaly, and splenomegaly. If you have any of these symptoms and the examiner does not ask about them, proactively report them. These checkboxes directly influence the rating.

    during exam

  • critical

    Confirm the examiner documents all complications

    Ensure the examiner checks the appropriate boxes for any complications you have had: ascites, portal hypertension, portal gastropathy, hepatic encephalopathy, variceal hemorrhage, spontaneous bacterial peritonitis, coagulopathy, hepatorenal syndrome, hepatopulmonary syndrome, and splenomegaly. These significantly affect the rating.

    during exam

  • critical

    Report functional impact on work and daily life explicitly

    The DBQ field for functional impact (field 324) asks how the condition affects occupational and daily activities. When prompted, give specific, concrete examples: 'I cannot work more than 4 hours at a time,' 'I have missed X days of work in the past year,' 'I can no longer perform [specific job tasks],' 'I cannot drive on days with cognitive symptoms.'

    during exam

  • recommended

    Report medication names, dosages, and why each is prescribed

    When listing medications, explain the reason for each medication to establish the relationship to your liver condition. For example: 'I take tacrolimus twice daily as my anti-rejection medication,' 'I take lactulose three times daily to prevent hepatic encephalopathy,' 'I take furosemide and spironolactone for ascites management.'

    during exam

  • recommended

    Mention the frequency of medical monitoring and its impact on daily life

    Post-transplant monitoring (frequent blood draws, clinic visits, imaging) is itself a burden of disability. Mention how often you see your transplant team, how often you have blood drawn, and how this monitoring requirement affects your ability to work and live normally.

    during exam

  • critical

    Request a copy of the completed DBQ

    Under the PACT Act and VA transparency policies, you may request a copy of your completed C&P exam report (DBQ). Submit a written request to the VA Regional Office or check VA.gov for the exam results. Review the DBQ carefully for accuracy and completeness.

    after exam

  • critical

    Submit a rebuttal if the DBQ contains errors or omissions

    If the completed DBQ fails to document symptoms you reported, omits complications you described, or contains inaccurate statements, you have the right to submit a rebuttal. Write a clear, factual statement identifying each error with specific corrections. Submit via your VSO or directly to the VA Regional Office.

    after exam

  • recommended

    Consider requesting an Inadequate Examination determination if the exam was incomplete

    If the examiner did not ask about all your symptoms, did not review your submitted records, spent less than 15 minutes with you, or did not conduct a physical examination when one was appropriate, you can request that the VA order a new, adequate examination. Document specific deficiencies in writing.

    after exam

  • recommended

    Continue documenting symptoms and treatment for ongoing claims

    Post-transplant, your condition may change. Keep a continuing symptom diary, maintain all lab results and imaging reports, and document any new complications, hospitalizations, or changes in medication. This documentation supports future re-evaluations or requests for increased ratings.

    after exam

Your rights during a C&P exam

  • You have the right to have your C&P exam conducted by a qualified examiner with appropriate expertise - a gastroenterologist or hepatologist is the appropriate specialist for a liver transplant claim.
  • You have the right to request a copy of your completed DBQ/C&P exam report and to review it for accuracy and completeness.
  • You have the right to submit additional evidence (buddy statements, private medical opinions, supplemental records) to correct or supplement an inadequate or inaccurate examination.
  • You have the right to request a new C&P examination if the original exam was inadequate - for example, if the examiner did not review your submitted evidence, did not conduct an appropriate physical examination, or if significant time has passed and your condition has worsened.
  • You have the right to record your C&P examination in most states, provided you notify the examiner at the start of the exam. Check your state's recording consent laws and current VA policy before recording.
  • You have the right under 38 CFR 3.159 to a thorough, contemporaneous medical examination that accurately reflects your current level of disability - including worst-day symptoms and functional impact.
  • You have the right to have the VA apply the benefit of the doubt in your favor when the evidence is in approximate balance, per 38 U.S.C. 5107(b).
  • You have the right to have the 100% rating applied from the date of hospital admission for transplant surgery, and to have the one-year post-discharge mandatory examination trigger applied correctly.
  • You have the right to have residuals of recurrent underlying liver disease rated separately under the appropriate diagnostic code and combined with your DC 7351 rating, per the Note to DC 7351.
  • You have the right to protection under 38 CFR 3.105(e) - any reduction in your rating based on a post-transplant examination requires advance notice and the opportunity to respond before the reduction takes effect.
  • You have the right to have secondary conditions (those caused or aggravated by your liver transplant or its treatment) evaluated for separate service connection.
  • You have the right to representation by an accredited Veterans Service Organization (VSO), claims agent, or attorney at no charge for VSO representation, throughout the claims process.

Related conditions

Get a personalized prep packet

This guide covers what to expect for any veteran with this condition. If you have already uploaded your medical records, sign in to generate a packet that maps your specific symptoms to the DBQ fields your examiner will fill out.

Get personalized prep

This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.