Evidence Checklist for a Spicer-Based Secondary Claim
1. Current diagnosis and functional impairment
A diagnosis alone is not a disability for compensation purposes. The record should show what the condition prevents or limits today — , endurance, mobility, concentration, sleep, or the activities of daily living. Examination findings and treatment notes that describe function carry more weight than a problem list.
2. The service-connected disability and its treatment history
Include the or code sheet establishing , and the treatment record for that condition: medications with dates, dosing changes, laboratory values where relevant, and any clinician notes describing risks associated with the treatment.
3. Documentation of the barrier
Contemporaneous documentation — written at the time, by the clinician involved — is generally the most useful form of this evidence.
- A cancelled, deferred, or declined procedure, with the reason recorded.
- A pre-operative or anesthesia clearance note identifying the contraindication.
- A pharmacy or clinician note documenting a medication interaction.
- A specialist note recommending treatment that cannot proceed, and explaining why.
- Records of a delayed referral, or of an inability to participate in rehabilitation.
4. Evidence that the blocked treatment was clinically appropriate
The record should indicate that the care at issue was recommended or indicated, not merely requested. A surgeon's note stating that replacement would ordinarily be offered at this stage of disease is an example of what this looks like in practice.
5. A medical opinion that reasons through the counterfactual
This is the element most often missing. The opinion should identify the service-connected condition and its treatment, identify the claimed condition and its present impairment, describe the barrier, and then address whether the claimed condition would be less severe, more treatable, or more functional had the care proceeded.
An opinion that says only that two conditions are 'associated with' or 'related to' each other does not answer that question. Oakridge Claims does not write medical opinions; we review what has been submitted and identify what a decision-maker will be looking for.
6. The decision itself
Bring the and, where available, the code sheet and the examination report it relied on. The reasoning in the decision often determines which post-decision route fits better than the medical evidence does.
Gap check
Where records most often fall short on this theory.
| If your record shows this | What it means |
|---|---|
| The barrier is only described by the veteran | Lay evidence counts and is admissible, but clinical documentation of the same barrier is generally what carries the analysis. |
| The medical opinion has a conclusion but no reasoning | Conclusory opinions tend to be given little weight regardless of who wrote them. |
| No document states the blocked treatment was indicated | Without that, the counterfactual has nothing to rest on. |
| The claimed condition has no current functional description | Present-day functional impairment is the subject of the compensation statute. |
| Everything is in private records VA never received | Evidence not before the decision-maker cannot support the decision. What is missing shapes which lane fits. |
Educational only. This is not a template and not legal advice.
Frequently Asked Questions
References & sources
Useful Tools & Topics
Have questions about your specific case?
Every veteran's facts are different. A free initial consultation with a VA-Accredited Claims Agent can tell you whether your matter is a fit for representation — and what the right next step looks like either way.
Disclaimer: This page is for educational purposes only and does not constitute legal advice. Oakridge Claims is a private business and is not affiliated with, endorsed by, or operated by the U.S. Department of Veterans Affairs. No guarantees of outcomes are made. Each claim is decided on its individual facts.
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