DC 8212 · 38 CFR 4.124a
Twelfth (Hypoglossal) Cranial Nerve, Paralysis of C&P Exam Prep
To evaluate the nature, severity, and functional impact of hypoglossal (CN XII) nerve paralysis by documenting the degree of tongue motor dysfunction and its downstream effects on speech, swallowing, chewing, and daily activities.
- Format:
- Interview + Physical
- Typical duration:
- 30-45 minutes
- DBQ form:
- Cranial_Nerve_Conditions (Cranial_Nerve_Conditions)
- Examiner:
- Neurologist or Physician
What the examiner evaluates
- Degree of tongue paralysis (complete vs. incomplete) and laterality
- Tongue motor function including protrusion, lateral movement, elevation, and retraction
- Tongue atrophy and fasciculations on inspection
- Tongue deviation toward the affected side upon protrusion
- Articulation and speech intelligibility (dysarthria)
- Swallowing function (dysphagia) and aspiration risk
- Chewing difficulty and food manipulation
- Saliva management (increased or decreased salivation, drooling)
- Associated pain, paresthesias, or numbness of the tongue
- Nutritional impact and weight changes due to feeding difficulty
- Presence of concurrent cranial nerve involvement (CN IX, X, XI)
- EMG or nerve conduction study results if available
- History of etiology, onset, and course of the condition
- Functional impact on occupational and social activities
The exam will include a structured neurological interview followed by a physical examination of tongue function, oral motor testing, and review of relevant diagnostic studies. You will be asked to speak, move your tongue in specific directions, and swallow. Bring all prior imaging (MRI, CT), EMG reports, and medical records documenting your condition. In most states you have the right to record this examination - confirm your state's policy in advance.
Measurements and tests
Tongue Motor Function Assessment
What it measures: Evaluates the ability to protrude the tongue to midline, deviate laterally, elevate to the palate, and retract; identifies asymmetry, deviation toward affected side, and weakness
What to expect: The examiner will ask you to stick out your tongue, move it side to side, push it against your cheek, and lift it. They will observe for deviation, atrophy, and fasciculations.
Critical thresholds
- Complete loss of volitional tongue movement 50% - Complete paralysis under DC 8212
- Severe reduction in tongue movement with significant functional deficit (markedly impaired speech and swallowing) 30% - Incomplete, severe paralysis under DC 8212
- Moderate reduction in tongue movement with noticeable but manageable functional deficit 10% - Incomplete, moderate paralysis under DC 8212
Tips
- Perform the test as you normally function - do not try harder than usual
- If your tongue fatigues during repeated testing, tell the examiner immediately
- Mention if tongue function is worse at the end of the day or after eating
- Describe any visible wasting or twitching you have noticed in the mirror
Pain considerations: Describe any pain, burning, or discomfort in the tongue or jaw during movement. Note whether pain limits full effort.
Speech Intelligibility Assessment (Dysarthria Evaluation)
What it measures: Evaluates the impact of tongue motor impairment on articulation, word formation, and overall speech clarity
What to expect: The examiner may ask you to repeat words or phrases, count, or read aloud. They will assess the clarity of lingual consonants (l, t, d, n) which depend on tongue function.
Critical thresholds
- Unintelligible or severely dysarthric speech requiring alternative communication Supports complete or severe incomplete paralysis (50% or 30%)
- Noticeably impaired speech requiring listener accommodation or repetition Supports severe or moderate incomplete paralysis (30% or 10%)
Tips
- Speak at your natural pace - do not slow down artificially to appear more intelligible
- Note if speech worsens with fatigue, extended speaking, or at day's end
- Describe how others react to your speech difficulty (asking for repetition, avoiding phone calls)
- Mention any compensatory strategies you use such as writing or texting instead of speaking
Pain considerations: Note if speaking causes tongue fatigue, aching, or cramping that limits how long you can talk continuously.
Swallowing Function Assessment (Dysphagia Evaluation)
What it measures: Evaluates tongue's role in bolus formation and oral phase of swallowing; identifies risk of aspiration, choking, and nutritional compromise
What to expect: The examiner will ask about your ability to swallow liquids and solids, whether you cough or choke during meals, and how long it takes to eat. A bedside swallow observation may be performed.
Critical thresholds
- Inability to manage solids or liquids safely; requires tube feeding or modified-texture diet Supports complete or severe incomplete paralysis (50% or 30%)
- Frequent choking, extended meal times, dietary restrictions Supports severe or moderate incomplete paralysis (30% or 10%)
Tips
- Track and report actual meal duration - bring a log if possible
- Note specific food textures you have eliminated from your diet due to choking or difficulty
- Describe any episodes of aspiration pneumonia or choking requiring medical intervention
- Report unintentional weight loss linked to feeding difficulty
Pain considerations: Describe any pain or discomfort with swallowing (odynophagia) or in the tongue during eating.
Electromyography (EMG) and Nerve Conduction Studies
What it measures: Objective assessment of hypoglossal nerve and tongue muscle denervation, axonal loss, and reinnervation patterns
What to expect: If prior EMG is in your record, the examiner will review it. Per M21-1 guidance, repeat EMG is not required if existing studies reflect your current condition. Bring all prior EMG reports.
Critical thresholds
- Evidence of complete denervation of tongue musculature on EMG Supports complete paralysis finding (50%)
- Partial denervation or active/chronic neurogenic changes on EMG Supports incomplete paralysis finding (30% or 10%)
Tips
- Bring printed copies of any prior EMG or nerve conduction study results
- If no EMG has been performed, note this and ask whether one will be ordered
- Per M21-1, the VA rating activity - not the examiner - ultimately determines severity based on all evidence
- Understand that abnormal objective findings support higher rating levels regardless of examiner's verbal assessment
Pain considerations: EMG of tongue musculature can be uncomfortable; inform the examiner if you have difficulty with the procedure.
Tongue Atrophy and Fasciculation Assessment
What it measures: Visual inspection of tongue for hemiatrophy (unilateral wasting) or bilateral atrophy, and spontaneous fasciculations indicating lower motor neuron degeneration
What to expect: Examiner will visually inspect your tongue at rest in your open mouth for wasting or twitching before asking you to move it.
Critical thresholds
- Severe hemiatrophy with prominent fasciculations Supports severe or complete paralysis (30%-50%)
- Mild visible atrophy without prominent fasciculations Supports moderate incomplete paralysis (10%)
Tips
- Do not pre-stretch or forcefully exercise your tongue before the exam
- If you have noticed tongue twitching at rest, report this verbally even if not observed during the exam
- Photographs or video of resting tongue fasciculations taken at home can be submitted as lay evidence
Pain considerations: Describe any chronic tongue soreness, burning, or sensitivity that may accompany atrophic changes.
Rating criteria by percentage
50%
Complete paralysis of the hypoglossal nerve with total loss of motor function of the tongue. The tongue is completely flaccid, cannot be protruded or moved volitionally, and there is total loss of tongue motor function.
Key symptoms
- Total inability to protrude tongue
- Complete absence of voluntary tongue movement in all directions
- Severe bilateral or complete unilateral atrophy of tongue musculature
- Profound dysarthria rendering speech unintelligible
- Inability to manage oral phase of swallowing safely
- Requirement for tube feeding or severely modified diet
- Profuse drooling due to inability to manage oral secretions
- Marked tongue deviation at rest toward affected side
From 38 CFR: DC 8212: Complete paralysis - 50%. Rating is dependent upon loss of motor function of tongue. Complete paralysis means total loss of volitional tongue movement as defined under 38 CFR 4.124a.
30%
Incomplete, severe paralysis of the hypoglossal nerve. Substantially impaired tongue motor function that is significantly less than complete paralysis but causes marked functional deficits in speech, swallowing, and oral motor activities.
Key symptoms
- Severely limited tongue protrusion and lateral movement
- Pronounced tongue deviation toward affected side on attempted protrusion
- Moderate to severe tongue atrophy with possible fasciculations
- Significantly dysarthric speech with reduced intelligibility affecting communication
- Marked difficulty swallowing requiring dietary texture modification
- Frequent choking episodes with liquids or solids
- Significant drooling or difficulty managing oral secretions
- Notably prolonged meal times with functional impact on nutrition
- Significant chewing difficulty
From 38 CFR: DC 8212: Incomplete, severe - 30%. Per 38 CFR 4.124a, incomplete paralysis indicates a degree of lost or impaired function substantially less than complete paralysis. Severe incomplete paralysis represents marked functional deficit approaching but not reaching complete loss.
10%
Incomplete, moderate paralysis of the hypoglossal nerve. Measurable but less severe tongue motor impairment causing noticeable but manageable functional deficits in speech, swallowing, and chewing.
Key symptoms
- Reduced tongue range of motion with partial protrusion possible
- Mild to moderate tongue deviation on protrusion
- Mild tongue atrophy, possibly with rare fasciculations
- Mildly dysarthric speech noticeable to listeners but generally intelligible
- Occasional difficulty swallowing certain food textures
- Some dietary modifications required for safety or comfort
- Mild chewing difficulty particularly with tough or chewy foods
- Mild saliva management difficulty or intermittent drooling
- Symptoms may worsen with fatigue or extended use
From 38 CFR: DC 8212: Incomplete, moderate - 10%. Per 38 CFR 4.124a, moderate incomplete paralysis reflects partial loss of tongue motor function with functional impact that is clearly present but substantially less than severe. Per M21-1, the rating activity considers the complete evidentiary record and may assign a higher rating than suggested by examiner's verbal assessment if objective findings warrant it.
Describing your symptoms accurately
Speech and Communication
How to describe it: Describe the specific sounds and words you struggle with, how often listeners ask you to repeat yourself, and any situations you avoid because of speech difficulty. Use concrete examples: 'I can no longer speak clearly on the phone,' 'my coworkers frequently misunderstand me,' or 'I have stopped making presentations at work.'
Example: On my worst days, my speech becomes so slurred that even my family cannot understand me. I cannot clearly say my own name, I avoid phone calls entirely, and I feel socially isolated because conversations are exhausting and embarrassing. Speaking for more than a few minutes causes my tongue to fatigue and my words to become even less clear.
Examiner listens for: Specific lingual consonant errors (l, t, d, n, th), reduced speech rate, slurring, functional communication restrictions, avoidance behaviors, and emotional or occupational impact of dysarthria.
Avoid: Do not say 'my speech is fine' if others struggle to understand you. Do not minimize slurring because you have adapted to it. The examiner needs to hear your worst-day reality, not your compensated best-day performance.
Swallowing and Dysphagia
How to describe it: Be specific about what foods and liquids cause problems, how often you choke or cough during meals, whether you have had aspiration pneumonia, and how long meals take. Describe dietary changes you have made and any weight loss.
Example: On my worst days I choke on thin liquids multiple times during a meal. I have largely eliminated meats, raw vegetables, and crusty bread from my diet. Meals that used to take 15 minutes now take 45 minutes or longer. I have lost weight because eating is so difficult and frustrating that I sometimes skip meals. I have had two emergency room visits for aspiration.
Examiner listens for: Frequency and severity of choking episodes, dietary restrictions adopted, aspiration events, meal duration, weight changes, and any speech-language pathology or modified barium swallow study results.
Avoid: Do not say 'I just eat slowly' if you have changed your diet or choked. Do not fail to mention episodes of aspiration pneumonia or choking requiring medical attention. These are critical severity markers.
Tongue Motor Function and Physical Symptoms
How to describe it: Describe exactly what movements you can and cannot perform, whether your tongue deviates, any visible wasting you have noticed, and any twitching. Use directional language: 'my tongue pulls to the left when I stick it out,' 'I cannot reach my upper lip with my tongue.'
Example: On my worst days I have no control over my tongue and it lies flat in my mouth. I cannot move food around to chew properly, I cannot clear food from my cheeks, and my tongue visibly pulls to one side. I have noticed significant shrinking of the left side of my tongue compared to the right.
Examiner listens for: Degree of restriction in tongue protrusion and lateral range of motion, presence and direction of deviation, evidence of atrophy or fasciculations, and correlation between functional deficits and physical findings.
Avoid: Do not perform the tongue movements to the maximum of your ability if that requires unusual effort. Move naturally as you do in daily life. Do not fail to mention tongue twitching you have observed at home even if not currently visible during the exam.
Chewing Difficulty
How to describe it: Describe which food textures you cannot manage, whether food falls out of your mouth during chewing, and how this affects your nutrition and social eating. Note if you have changed to a softer diet.
Example: I cannot chew meat, hard vegetables, or crusty bread without food collecting in my cheeks because my tongue cannot move it back for proper chewing. Food falls from my mouth, which is humiliating in social settings. I now eat primarily soft foods and liquid meals.
Examiner listens for: Specific food avoidances, signs of inadequate nutrition, impact on social functioning, and whether chewing difficulty is independent of or additive to swallowing difficulty.
Avoid: Do not omit chewing difficulty simply because swallowing is your primary complaint. Chewing difficulty is independently relevant to the rating under DC 8212 and supports field PUBLICDBQNEUROCRANIALNERVES_215_FDIFFICULTYCHEWINGIFCHECKEDINDICATESEVERITY.
Pain and Sensory Symptoms
How to describe it: Describe any tongue pain, burning, numbness, tingling, or unusual sensations. Note their location, frequency, severity on a 0-10 scale, and triggers. Distinguish between resting pain and pain with movement or use.
Example: On my worst days I have a constant deep aching pain in my tongue rated 7 out of 10 that spikes to 9 when I try to speak for extended periods. There is also a persistent burning sensation along the left side of my tongue that never fully goes away and makes eating uncomfortable even when I am not choking.
Examiner listens for: Pain characteristics (constant vs. intermittent, dull vs. sharp), sensory symptom location and distribution, severity ratings, and functional impact of pain on eating, speaking, and daily activities.
Avoid: Do not dismiss pain as unimportant. Pain and sensory symptoms are captured in DBQ checkboxes including constant pain, intermittent pain, dull pain, paresthesias, and numbness fields. These support a complete clinical picture.
Saliva Management
How to describe it: Describe whether you experience drooling, increased saliva production you cannot control, or conversely reduced saliva causing dry mouth and difficulty chewing. Note frequency, social impact, and whether it disrupts sleep or activities.
Example: I drool constantly and must carry a cloth to manage saliva. This happens at rest, while eating, and when I try to speak. The social embarrassment has caused me to withdraw from gatherings and avoid eating in public. At night I wake up with saliva pooling uncomfortably.
Examiner listens for: Presence of increased or decreased salivation, drooling, social restriction due to saliva management difficulty, and sleep impact.
Avoid: Do not minimize drooling as 'just embarrassing.' It is a direct functional indicator of tongue motor paralysis captured in specific DBQ checkboxes and supports higher severity ratings.
Functional and Occupational Impact
How to describe it: Describe how your condition affects your ability to work, maintain relationships, perform daily activities, and participate in social events. Be specific about job duties you can no longer perform and activities you have given up.
Example: I was employed as a sales representative and my job required constant phone and in-person communication. I was let go because my speech became unintelligible to customers. I can no longer attend family dinners because eating in public is embarrassing and unsafe. I have lost over 20 pounds because of feeding difficulty. I experience depression and social isolation directly attributable to these physical limitations.
Examiner listens for: Specific occupational restrictions, social withdrawal, activities of daily living affected, and any documented functional impairment in medical or vocational records.
Avoid: Do not fail to connect your physical symptoms to concrete life impacts. The DBQ has a dedicated field (PUBLICDBQNEUROCRANIALNERVES_427_IFYESDESCRIBETHEFUNCTIONALIMPACTOFEACHCONDITIONPRO) specifically for functional impact - the examiner must complete it and your testimony drives its content.
Common mistakes to avoid
Performing tongue movements to maximum ability during examination
Why: Veterans sometimes try their hardest during the physical examination even though their normal daily function is much more limited, leading the examiner to underestimate the true degree of paralysis.
Do this instead: Move your tongue as you naturally would during ordinary daily activities. If a movement requires unusual concentration or effort that you do not normally apply, say so. Tell the examiner: 'I am working much harder to do this than I normally would.'
Impact: Can cause misclassification from severe incomplete (30%) to moderate incomplete (10%)
Failing to describe symptom variability and worst-day experience
Why: The examiner sees you on one day which may not represent your worst functioning. Per M21-1 guidance, the rating is based on the overall disability picture including your worst-day experience.
Do this instead: Proactively describe how your condition fluctuates. State clearly: 'Today is not my worst day. On my worst days...' and provide specific worst-day examples for each symptom category.
Impact: Can cause underrating at any level (10%, 30%, or 50%)
Not connecting tongue paralysis to downstream functional consequences
Why: Veterans may describe the physical deficit (tongue does not move well) but fail to articulate the cascading functional impacts on speech, swallowing, chewing, nutrition, and social participation that drive the severity rating.
Do this instead: For every physical finding, explicitly state its functional consequence. Example: 'Because my tongue cannot move food properly, I choke frequently, have restricted my diet to soft foods, and have lost 15 pounds over six months.'
Impact: Primarily affects distinction between 30% and 50%, and between 10% and 30%
Minimizing saliva management difficulty
Why: Drooling and salivation problems are direct objective markers of CN XII dysfunction severity but veterans often minimize them due to embarrassment.
Do this instead: Describe drooling and saliva management difficulty accurately and specifically. Note frequency, social impact, and any adaptive measures such as carrying cloths or towels. This directly supports the examiner checking specific DBQ severity checkboxes.
Impact: Affects distinction between moderate (10%) and severe incomplete (30%) paralysis
Not bringing prior diagnostic studies to the examination
Why: EMG studies, MRI findings, CT scans, and prior speech-language pathology evaluations are critical objective evidence. Per M21-1, EMG results are required unless previously documented. Without prior records, the examiner may request repeat testing or render an incomplete opinion.
Do this instead: Compile and bring printed copies of all prior EMG reports, imaging studies, modified barium swallow studies, speech-language pathology evaluations, and neurology consultation notes.
Impact: Can affect any rating level by leaving objective evidence gaps
Failing to report concurrent cranial nerve involvement
Why: Hypoglossal nerve paralysis can occur alongside injury to CN IX (glossopharyngeal), CN X (vagus), or CN XI (spinal accessory). Failing to report concurrent symptoms may result in incomplete documentation of the full neurological picture.
Do this instead: Report all neurological symptoms including difficulty with gag reflex, voice hoarseness, shoulder weakness, or autonomic symptoms. These may be separately ratable and may also contextualize the severity of your CN XII condition.
Impact: Affects overall rating picture and potential for separate ratings under DC 8210, 8209, 8211
Not describing the impact of fatigue on tongue function
Why: Tongue motor weakness from CN XII paralysis typically worsens with sustained use (fatigue), meaning speech and swallowing are worse at the end of the day or after extended use. This fatigue factor is critical but often omitted.
Do this instead: Explicitly describe how your tongue function deteriorates with sustained use: 'After talking for 10 minutes my speech becomes much more slurred,' or 'By evening my swallowing is significantly worse than in the morning.'
Impact: Supports upgrade from moderate (10%) to severe incomplete (30%) or from severe incomplete (30%) to complete (50%)
Prep checklist
- critical
Compile all prior diagnostic studies
Gather all EMG and nerve conduction study reports, MRI and CT scan reports showing hypoglossal canal or nerve pathology, modified barium swallow study reports, and clinical neurology notes documenting tongue paralysis diagnosis and severity.
before exam
- critical
Prepare a written symptom summary for the worst day
Write a one-page description of your worst-day experience covering: tongue movement limitations, speech intelligibility, swallowing difficulty and choking frequency, chewing restrictions, dietary changes and weight loss, saliva management problems, pain and sensory symptoms, and functional/occupational impact. Bring this document to the exam.
before exam
- critical
Document dietary changes and weight history
Record your current diet modifications (soft diet, liquid diet, food avoidances), any dietary supplements or nutritional support required, and any documented weight loss since symptom onset. If your VA or treating physician has nutrition records, obtain them.
before exam
- critical
Obtain speech-language pathology records
If you have seen a speech-language pathologist (SLP) for dysarthria or dysphagia therapy, obtain all evaluation and treatment notes. SLP formal assessments of speech intelligibility and swallowing function are highly probative evidence.
before exam
- critical
Gather records of aspiration or choking events
Collect any emergency room or urgent care records related to aspiration events, choking episodes, or aspiration pneumonia. These are objective markers of dysphagia severity.
before exam
- recommended
Prepare a lay statement or buddy letters
Ask family members, caregivers, or coworkers who have witnessed your speech difficulty, drooling, choking episodes, or feeding problems to write buddy statements describing what they have observed. These corroborate your reported symptoms.
before exam
- recommended
Research your right to record the examination
Veterans have the right to record C&P examinations in most states. Confirm your state's applicable law and the VA facility's policy in advance. Notify the examiner at the start of the appointment if you intend to record.
before exam
- recommended
Document occupational impact
If your condition has affected your employment, gather documentation such as termination letters, accommodation requests, physician notes restricting work duties, or vocational rehabilitation referrals that substantiate your functional limitations.
before exam
- optional
Record video of tongue function at home
Consider recording video of your tongue at rest showing atrophy or fasciculations, and during movement attempts showing limited range, deviation, and fatigue. This provides evidence of your typical daily function rather than a one-time exam performance.
before exam
- critical
Do not modify your presentation
Do not exercise your tongue before the exam to temporarily improve function, and do not take extra medication solely to suppress symptoms on exam day. The exam should reflect your typical day-to-day condition.
day of
- critical
Arrive with written symptom document in hand
Bring your pre-written worst-day symptom summary and offer it to the examiner. If they decline to accept it, read key points aloud and ask that they be documented in the examination report.
day of
- critical
Bring all medical records and study reports
Bring physical copies of all EMG reports, imaging, SLP evaluations, and treatment notes in case they are not in the examiner's file. Organize them chronologically and by category.
day of
- recommended
Bring a trusted person for support
Consider bringing a spouse, caregiver, or VSO representative who has witnessed your symptoms. Their presence can support lay testimony and ensure accurate information is communicated, especially if your speech difficulty makes communication challenging.
day of
- critical
Correct any inaccuracies immediately
If the examiner documents something inaccurately during the examination, politely correct it in the moment. Do not assume errors will be fixed later. Say: 'I want to make sure that is accurately captured - I said X, not Y.'
during exam
- critical
Proactively state your worst-day experience
Do not wait to be asked. At the start of the functional history portion say: 'I want to make sure you have my worst-day experience documented, not just how I am today.' Then describe your worst-day symptoms systematically.
during exam
- critical
Describe functional impact for every physical finding
For each physical examination finding the examiner comments on, verbally connect it to a functional consequence. If they note tongue deviation, say: 'That deviation is why I cannot keep food on the center of my tongue to chew properly and why it falls into my cheeks.'
during exam
- recommended
Report fatigue effects on tongue function
Tell the examiner explicitly that your tongue function worsens with sustained use. Say: 'My speech and swallowing are significantly worse after speaking for more than [X] minutes, or by the end of the day.' This is directly relevant to functional severity.
during exam
- recommended
Request that the examiner note all symptoms in the report
After describing your symptoms, ask: 'Will all of the symptoms I have described today be included in your examination report?' If the examiner says certain items are outside scope, note this for your records.
during exam
- critical
Write a detailed post-exam note immediately
As soon as the exam ends, write down everything that was discussed, what the examiner observed, any questions asked and your answers, and any symptoms that were not addressed. This creates a contemporaneous record in case you need to challenge an inadequate examination.
after exam
- critical
Request a copy of the completed DBQ
You have the right to obtain a copy of your completed DBQ. Submit a request through MyHealtheVet, the VA Records office, or your VSO. Review it carefully for accuracy once received.
after exam
- recommended
Submit a supplemental statement if the DBQ is inaccurate
If you receive your DBQ and find inaccuracies or missing symptoms, submit a written statement to your Regional Office identifying the specific errors and providing corrected information. Do this before a rating decision is issued if possible.
after exam
- recommended
Consult your VSO or accredited claims agent
Share the DBQ and any post-exam notes with your Veterans Service Organization representative or accredited claims agent. They can advise whether the examination was adequate or whether a request for a new examination (inadequate examination claim) is warranted.
after exam
Your rights during a C&P exam
- You have the right to a thorough, adequate, and accurate C&P examination. An examination that fails to address all claimed symptoms or provides a conclusory opinion without rationale may be challenged as inadequate.
- You have the right to record your C&P examination in most states. Check your state's applicable recording laws and the VA facility's policy before your appointment and notify the examiner at the start if you intend to record.
- You have the right to obtain a copy of your completed DBQ and all C&P examination reports through a records request via MyHealtheVet, the VA Records office, or your VSO.
- You have the right to submit lay statements (your own or from others) describing your symptoms and their functional impact. Lay evidence regarding observable symptoms such as drooling, choking, and speech difficulty carries evidentiary weight.
- Per M21-1, the VA rating activity - not the examining physician - makes the final determination of severity level. If the examiner's verbal assessment differs from what the objective findings support, the rating activity must consider the full evidentiary record.
- You have the right to request a new C&P examination if the original examination is inadequate. An examination may be inadequate if it is based on an inaccurate history, fails to address all symptom areas, lacks sufficient rationale, or does not reflect your current condition.
- Under the PACT Act and applicable regulations, you are entitled to the benefit of the doubt when the evidence is approximately in equipoise. If the evidence is nearly equal for and against a higher rating, the higher rating must be assigned.
- You have the right to bring a representative, caregiver, or VSO to your examination for support. While the representative typically cannot answer questions for you, their presence is permitted and can assist with communication if your speech difficulty makes communication challenging.
- If your condition has worsened since a prior rating, you have the right to request an increased rating based on worsening of symptoms. A new C&P examination will typically be scheduled.
- You have the right to request that the examiner review specific medical records or diagnostic studies before completing the DBQ opinion. If relevant records are not in your VA file, bring copies to the appointment.
Related conditions
- Twelfth (Hypoglossal) Cranial Nerve, Neuralgia of DC 8411 under 38 CFR 4.124a covers neuralgia of the same nerve. If pain or sensory symptoms predominate without significant motor loss, rating under 8411 may be applicable or concurrent. Per 38 CFR 4.124a, purely sensory involvement is rated no higher than moderate.
- Ninth (Glossopharyngeal) Cranial Nerve, Paralysis of CN IX and CN XII injuries frequently co-occur due to proximity in the skull base region (jugular foramen area). CN IX involvement contributes to pharyngeal dysphagia and taste disturbance. Separate ratings under DC 8209 may be assignable if CN IX is independently involved.
- Tenth (Vagus) Cranial Nerve, Paralysis of CN X travels in close proximity to CN XII and is often co-injured. Vagus nerve involvement causes hoarseness, dysphonia, dysphagia, and autonomic symptoms. Separate rating under DC 8210 may apply. Concurrent CN X and CN XII injury significantly worsens swallowing and speech outcomes.
- Eleventh (Spinal Accessory) Cranial Nerve, Paralysis of CN XI is anatomically adjacent to CN XII and may be co-injured in neck surgery, trauma, or skull base pathology. Spinal accessory nerve involvement causes trapezius and sternocleidomastoid weakness. Separately ratable under DC 8211.
- Dysphagia (Secondary to Cranial Nerve Injury) Swallowing dysfunction is a primary functional consequence of CN XII paralysis and is documented directly on the cranial nerve DBQ. It may also be ratable as a secondary condition if it causes nutritional deficiency, aspiration pneumonia, or weight loss requiring separate treatment.
- Dysarthria (Secondary to Cranial Nerve Injury) Tongue-based dysarthria is a direct functional manifestation of CN XII paralysis. Speech intelligibility impairment contributes to occupational and social disability and is documented in the functional impact section of the cranial nerve DBQ.
- Traumatic Brain Injury (TBI) TBI is a common cause of hypoglossal nerve injury, particularly in cases involving skull base fractures or penetrating head trauma. If CN XII paralysis resulted from or is associated with a TBI, secondary service connection or pyramiding considerations may apply. Per M21-1, TBI secondary conditions have specific evaluation guidance.
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.
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.