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C&P Exam Prep: Acromegaly

DC 7908 endocrine 38 CFR 4.119

DBQ Overview

Interview + Physical
Form Name
Endocrine_Other_than_Thyroid_Parathyroid_and_Diabetes_Mellitus
Form Code
Endocrine_Other_than_Thyroid_Parathyroid_and_Diabetes_Mellitus
Page Count
9
Examiner Type
Endocrinologist or Physician
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of acromegaly and its associated complications - including evidence of increased intracranial pressure, arthropathy, glucose intolerance, hypertension, cardiomegaly, and enlargement of acral parts or long bones - for VA disability rating purposes under 38 CFR 4.119, Diagnostic Code 7908.

What the examiner evaluates:

  • Diagnosis confirmation and date of initial diagnosis
  • Whether acromegaly is active/progressive or in remission
  • Evidence of increased intracranial pressure (e.g., visual field defects, papilledema, headaches)
  • Presence and severity of acromegalic arthropathy affecting joints
  • Glucose intolerance or diabetes mellitus secondary to acromegaly
  • Hypertension attributed to or associated with acromegaly
  • Cardiomegaly (enlargement of the heart) associated with acromegaly
  • Enlargement of acral parts (hands, feet, jaw, nose, ears, soft tissue) and overgrowth of long bones
  • Treatment history including surgery (transsphenoidal or craniotomy), radiation therapy, and medications (somatostatin analogs, dopamine agonists, GH receptor antagonists)
  • Current laboratory values including IGF-1, growth hormone (GH) levels, and glucose tolerance test results
  • Imaging studies including pituitary MRI or CT findings
  • Associated comorbidities including hypopituitarism, sleep apnea, carpal tunnel syndrome, colon polyps
  • Functional impact on daily activities and ability to work
  • Mental and psychological symptoms related to acromegaly

The exam will typically be conducted in person at a VA medical facility, VAMC outpatient clinic, or contracted examination center. The examiner will review your claims file (C-file) prior to or during the exam. Bring all relevant medical records, especially endocrinology notes, lab results, MRI/CT reports, and operative reports. In most states you have the right to record the examination - confirm your state's law beforehand and notify the examiner at the start.

Typical duration: 30-45 minutes

Serum IGF-1 (Insulin-Like Growth Factor-1)

The primary biochemical marker for acromegaly activity; elevated IGF-1 confirms active disease or inadequate biochemical control after treatment.

What to expect:

The examiner will review your most recent IGF-1 lab results. They may order new labs if recent results are unavailable. Normal ranges are age- and sex-adjusted. Values above the age-adjusted upper limit of normal indicate active or uncontrolled acromegaly.

Key thresholds:

  • IGF-1 above age-adjusted upper limit of normal — Supports active disease; relevant to 30%, 60%, or 100% rating depending on accompanying findings
  • IGF-1 within normal range with no symptoms — May support remission classification; examiner should still document residual structural changes and complications

Tips:

  • Bring printed copies of all recent IGF-1 and GH lab results with dates
  • If labs were drawn at different facilities, consolidate them with a brief timeline
  • Note that IGF-1 can be within normal range yet structural changes and complications may persist
  • Ask your treating endocrinologist to write a letter summarizing your biochemical control status

Pain considerations: Lab draws themselves are minimally painful, but acromegalic arthropathy may make positioning for IV access uncomfortable - inform the examiner of any joint pain or limited mobility.

Glucose Tolerance Test (Oral Glucose Tolerance Test / fasting glucose)

Evaluates whether acromegaly-induced growth hormone excess has caused glucose intolerance or overt diabetes mellitus. GH normally suppresses after an oral glucose load; failure to suppress confirms active acromegaly.

What to expect:

The examiner will review existing OGTT results, fasting glucose, and HbA1c values. A new OGTT is unlikely during the C&P exam itself but existing results will be assessed. Impaired fasting glucose (100-125 mg/dL), impaired glucose tolerance (2-hour glucose 140-199 mg/dL), or diabetes (fasting -126 mg/dL or 2-hour -200 mg/dL) are all relevant findings.

Key thresholds:

  • Glucose intolerance (pre-diabetes) present — Contributes to 60% or 100% rating criteria when combined with arthropathy and hypertension/cardiomegaly
  • Overt diabetes mellitus secondary to acromegaly — Satisfies the glucose intolerance criterion; diabetes mellitus may also warrant a separate rating under DC 7913

Tips:

  • Bring documentation of all glucose-related testing including HbA1c results
  • If you have been diagnosed with diabetes mellitus, clarify with your physician whether it is attributable to acromegaly
  • Disclose all diabetes medications including insulin, metformin, and GLP-1 agonists
  • Request a separate diabetes mellitus claim if GH-induced diabetes is confirmed

Pain considerations: Not directly painful, but hypoglycemic episodes or hyperglycemia can cause fatigue, weakness, and cognitive difficulties - document these functional effects accurately.

Blood Pressure Measurement

Documents the presence and severity of hypertension, which is a key criterion distinguishing 60% from 100% ratings under DC 7908.

What to expect:

The examiner should take blood pressure at least three times during the visit (BP x3 is specifically referenced in the DBQ). Hypertension is generally defined as systolic -130 mmHg or diastolic -80 mmHg on multiple readings, or current use of antihypertensive medications.

Key thresholds:

  • Confirmed hypertension (BP -130/80 mmHg on multiple readings or on antihypertensive therapy) — Required for 60% rating (arthropathy + glucose intolerance + hypertension) and 100% rating (adds cardiomegaly or intracranial pressure evidence)
  • Blood pressure within normal range without medication — Does not satisfy hypertension criterion; may limit rating to 30% if only acral enlargement present

Tips:

  • Disclose all antihypertensive medications you currently take - medically controlled hypertension still counts as hypertension
  • Mention if BP was higher on your worst days or before medication was optimized
  • Bring home blood pressure log if you monitor BP at home
  • Ask your cardiologist or primary care physician for a letter confirming hypertension diagnosis and treatment

Pain considerations: If acromegaly has caused carpal tunnel or peripheral neuropathy, inform the examiner that cuff placement on a specific arm may be uncomfortable.

Cardiac Evaluation / Echocardiogram Review

Detects cardiomegaly (enlarged heart), left ventricular hypertrophy, diastolic dysfunction, or other cardiac complications caused by chronic GH/IGF-1 excess, which is a criterion for the 100% rating.

What to expect:

The examiner will review any existing echocardiograms, cardiac MRI, chest X-ray findings, or cardiology notes documenting cardiomegaly. A physical cardiac exam may be performed. The DBQ specifically asks about cardiomegaly as an acromegaly finding.

Key thresholds:

  • Cardiomegaly confirmed by echo, cardiac MRI, or chest X-ray — Satisfies the cardiomegaly criterion for 100% rating when combined with arthropathy, glucose intolerance, and increased intracranial pressure
  • No cardiomegaly documented — 100% rating requires this OR confirmed hypertension along with other criteria; absence of cardiomegaly does not preclude 100% if hypertension and ICP evidence are present

Tips:

  • Bring most recent echocardiogram report with measurements (left ventricular mass index is key)
  • Request a cardiology note explicitly documenting acromegalic cardiomyopathy if present
  • Chest X-ray reports noting cardiomegaly are also useful supporting evidence
  • Do not assume the examiner has access to cardiology records - bring copies

Pain considerations: Cardiac symptoms such as exertional dyspnea, palpitations, reduced exercise tolerance, and peripheral edema should be described in detail - these are functional manifestations of cardiomegaly.

Visual Field Testing / Ophthalmologic Evaluation

Detects evidence of increased intracranial pressure or direct compression of the optic chiasm by a pituitary macroadenoma, including bitemporal hemianopia, visual field defects, decreased visual acuity, or papilledema.

What to expect:

The examiner will ask about visual symptoms and review any existing ophthalmology or neuro-ophthalmology records. Formal visual field testing (perimetry) is not typically performed during a C&P exam but existing results will be reviewed. The DBQ specifically asks about evidence of increased intracranial pressure such as visual field defects.

Key thresholds:

  • Documented visual field defect or papilledema attributable to acromegaly/pituitary tumor — Satisfies the 'evidence of increased intracranial pressure' criterion required for the 100% rating
  • No visual field defect or ICP evidence — 100% rating may still be achievable if cardiomegaly is present with other criteria; ICP evidence is one of two qualifying features for 100%

Tips:

  • Bring all ophthalmology and neuro-ophthalmology reports including Humphrey visual field test results
  • Describe any history of vision changes, blurring, tunnel vision, or loss of peripheral vision
  • Note whether visual symptoms predated or followed treatment
  • Headaches associated with pituitary mass effect are also relevant - describe location, frequency, and severity

Pain considerations: Headaches from increased intracranial pressure can be severe and debilitating - describe pain intensity on worst days using a 0-10 scale, location (typically frontal or retro-orbital), frequency, and any associated nausea or vomiting.

Joint Examination / Arthropathy Assessment

Documents the presence and severity of acromegalic arthropathy - a direct complication of chronic GH/IGF-1 excess causing cartilage hypertrophy, joint space widening followed by narrowing, osteophyte formation, and functional joint impairment.

What to expect:

The examiner will assess joint range of motion, tenderness, swelling, deformity, and functional limitation. Commonly affected joints include the spine (particularly lumbar), hips, knees, shoulders, and hands. The examiner may note muscle wasting in proximal upper and lower extremities, which the DBQ specifically addresses.

Key thresholds:

  • Arthropathy documented clinically or radiographically — Required criterion for both 60% and 100% ratings under DC 7908; must be present along with glucose intolerance and hypertension/cardiomegaly/ICP evidence
  • Proximal muscle wasting causing inability to rise without assistance — Specifically listed on the DBQ as a finding - documents functional severity and may support higher ratings or secondary musculoskeletal claims

Tips:

  • Describe joint pain at its worst, including during flare-ups, not just on the day of the exam
  • Mention fatigue and weakness during repetitive joint use - these are DeLuca factors
  • Report all joints affected, including spine, hips, knees, shoulders, wrists, and ankles
  • Bring X-ray or MRI reports documenting joint space changes, osteophytes, or cartilage loss
  • Note whether you use assistive devices such as braces, canes, or orthopedic shoe inserts

Pain considerations: Acromegalic arthropathy pain may be worse with weight-bearing, after prolonged activity, or during weather changes. Describe pain at rest versus with activity, morning stiffness duration, and whether pain disrupts sleep. These are all DeLuca factors critical to documenting true functional impairment.

Estimate

Rating Criteria Breakdown

100% Evidence of increased intracranial pressure (such as visual ...

Evidence of increased intracranial pressure (such as visual field defect), PLUS arthropathy, PLUS glucose intolerance, PLUS EITHER hypertension OR cardiomegaly. All four categories of findings must be present.

Key Symptoms

  • Visual field defects (e.g., bitemporal hemianopia from optic chiasm compression)
  • Papilledema or other signs of raised intracranial pressure
  • Severe headaches consistent with increased ICP
  • Acromegalic arthropathy with documented joint disease
  • Glucose intolerance or overt diabetes mellitus
  • Hypertension requiring medication or documented on multiple readings
  • Cardiomegaly confirmed by echocardiogram, cardiac MRI, or chest X-ray
  • Functional limitation from multiple organ system involvement

CFR: 38 CFR 4.119, DC 7908: 'Evidence of increased intracranial pressure (such as visual field defect), arthropathy, glucose intolerance, and either hypertension or cardiomegaly - 100%'

60% Arthropathy, PLUS glucose intolerance, PLUS hypertension. Al ...

Arthropathy, PLUS glucose intolerance, PLUS hypertension. All three must be present. Cardiomegaly and evidence of increased intracranial pressure are NOT required at this level, distinguishing 60% from 100%.

Key Symptoms

  • Acromegalic arthropathy with joint pain, stiffness, or reduced range of motion
  • Glucose intolerance (pre-diabetes or overt diabetes secondary to acromegaly)
  • Hypertension attributable to or associated with acromegaly
  • Significant functional limitations affecting daily living and employment
  • Fatigue and weakness from multi-system involvement

CFR: 38 CFR 4.119, DC 7908: 'Arthropathy, glucose intolerance, and hypertension - 60%'

30% Enlargement of acral parts (hands, feet, jaw, facial feature ...

Enlargement of acral parts (hands, feet, jaw, facial features, soft tissue) OR overgrowth of long bones. This is the minimum compensable rating and reflects structural changes without the full constellation of organ system complications required for higher ratings.

Key Symptoms

  • Enlarged hands or feet requiring larger shoe or glove sizes
  • Coarsening of facial features including jaw (prognathism), brow, nose
  • Increased hat size or ring size documented over time
  • Overgrowth of long bones (may cause height increase or limb length changes)
  • Soft tissue swelling or thickening
  • Skin changes including thickening, increased sweating, skin tags

CFR: 38 CFR 4.119, DC 7908: 'Enlargement of acral parts or overgrowth of long bones - 30%'

How to Describe Your Symptoms

Joint Pain and Arthropathy

How to describe:

Describe each affected joint specifically - location, character of pain (aching, sharp, grinding), what makes it worse (walking, climbing stairs, prolonged standing, repetitive use), what provides partial relief, and how it limits your function. Use specific examples such as 'I cannot stand for more than 20 minutes without knee pain forcing me to sit down' or 'I wake up with hip stiffness that takes 45 minutes to improve every morning.'

Worst-day example:

“On my worst days, the joint pain in my knees and lower back is so severe that I cannot get out of bed without assistance. My hands are so stiff and swollen in the morning that I cannot grip a coffee cup for the first hour. Walking more than half a block causes me to limp and forces me to stop. The pain is a 7-8 out of 10 and does not fully resolve with my pain medications.”

What the examiner listens for:

Frequency and duration of joint pain episodes, which joints are affected, degree of functional limitation, use of pain medications or assistive devices, effect on employment and activities of daily living, and whether symptoms have worsened over time.

Understatements to avoid:

Do not describe only your average or good days. Do not minimize joint stiffness by saying 'it loosens up after a while' without explaining the duration and functional impact of that stiffness. Do not omit joints that are less severely affected - document all affected joints.

Visual Symptoms and Headaches (Increased Intracranial Pressure)

How to describe:

Describe any changes in peripheral vision, episodes of visual blurring, double vision, or loss of visual field. Characterize headaches by location (frontal, behind the eyes, top of head), severity on a 0-10 scale, frequency (daily, weekly), duration, associated symptoms (nausea, vomiting, light sensitivity), and what treatments provide partial relief. Note whether headaches were present before diagnosis or have changed after treatment.

Worst-day example:

“My worst headaches occur several times per week. They feel like intense pressure behind my eyes and across my forehead, reaching 8 out of 10 in severity. They last 4-6 hours and force me to lie down in a dark room. I have noticed that my peripheral vision on the right side seems narrower than it used to be, and my eye doctor noted changes on my visual field test last year.”

What the examiner listens for:

Documented visual field defects, papilledema on fundoscopic exam, history of symptoms consistent with raised intracranial pressure such as positional headache or morning headache, and correlation between pituitary tumor size and neurological symptoms.

Understatements to avoid:

Do not dismiss headaches as 'just stress' or 'typical migraines' without noting their association with your acromegaly diagnosis. Do not omit visual changes even if they seem minor - even subtle peripheral vision changes are clinically significant under DC 7908.

Glucose Intolerance and Metabolic Symptoms

How to describe:

Describe symptoms of high blood sugar including excessive thirst, frequent urination, fatigue, blurred vision, difficulty healing cuts or bruises, and numbness or tingling in extremities. Specify all medications used to manage blood sugar. If you have a glucometer, describe your typical fasting and post-meal glucose readings. Note dietary restrictions required due to glucose intolerance.

Worst-day example:

“When my blood sugar runs high, I feel exhausted no matter how much sleep I get, my vision blurs, and I am constantly thirsty and urinating every hour. On my worst days the fatigue is so severe that I cannot work a full day or concentrate on tasks. My fasting glucose has been as high as 160 mg/dL and my HbA1c was 7.2% at my last test.”

What the examiner listens for:

Laboratory confirmation of impaired fasting glucose, OGTT results, HbA1c values, current glucose-lowering medications, and whether diabetes is secondary to acromegaly versus pre-existing or independently caused.

Understatements to avoid:

Do not say 'I manage it fine with diet' without also describing the significant dietary restrictions and lifestyle modifications required. Do not fail to mention if you have been prescribed any diabetes medications, even if they are considered mild or low-dose.

Hypertension and Cardiovascular Symptoms

How to describe:

State your diagnosis of hypertension, all antihypertensive medications, typical blood pressure readings, and any cardiovascular symptoms including exertional chest pain, shortness of breath, palpitations, reduced exercise tolerance, or ankle swelling. If you have cardiomegaly, describe how it limits your physical activity and daily function.

Worst-day example:

“Even on my blood pressure medications, my BP frequently reads 145/92 at home. When I try to walk up a flight of stairs, I become short of breath and my heart races. I used to be able to walk a mile without stopping; now I am winded after a block. My cardiologist told me my heart is enlarged due to the acromegaly and I have diastolic dysfunction.”

What the examiner listens for:

Documented hypertension on three readings or confirmed on antihypertensive therapy, echocardiographic evidence of cardiomegaly or cardiomyopathy, cardiology records, and functional cardiac limitations.

Understatements to avoid:

Do not omit hypertension because it is 'controlled' with medication - controlled hypertension still counts as hypertension under VA rating criteria. Do not fail to bring echocardiogram results showing cardiomegaly.

Acral Enlargement and Physical Changes

How to describe:

Describe measurable, concrete examples of physical changes caused by acromegaly: shoe size increase (e.g., went from size 9 to size 13), ring size increase, hat size change, jaw growth requiring dental work or difficulty chewing, changes in facial appearance noted by others. Describe any functional problems caused by enlarged hands or feet such as difficulty with fine motor tasks, fitting in standard equipment, or shoe-related skin problems.

Worst-day example:

“My hands have grown so large that I can no longer use standard work gloves and need custom-fitted gloves. My shoe size increased three sizes over five years and my feet are constantly painful from the structural changes. My jaw has grown to the point that my teeth no longer align properly and I have had to undergo dental work twice because of it. My wife and colleagues have commented on the visible changes in my facial features.”

What the examiner listens for:

Physical examination findings documenting prognathism, frontal bossing, enlarged hands and feet, coarse facial features, and skin changes. Patient-reported functional limitations from structural changes. Comparison to pre-illness photographs or shoe/clothing records if available.

Understatements to avoid:

Do not minimize physical changes by focusing only on cosmetic impact - emphasize functional limitations. Do not fail to bring before-and-after photographs if available, as these provide compelling objective evidence of acral enlargement.

Fatigue, Weakness, and Functional Impact

How to describe:

Acromegaly causes profound fatigue through multiple mechanisms including sleep apnea, metabolic disruption, cardiac dysfunction, and muscle changes. Describe fatigue severity using concrete functional terms: how many hours per day you can be productive, whether you require rest periods, how fatigue affects your employment, and whether it is worse on certain days or after activity.

Worst-day example:

“On my worst days, which occur at least 3-4 times per week, the fatigue is so overwhelming that I cannot function after noon. I require 1-2 hours of rest in the afternoon just to manage basic self-care. I have been unable to maintain full-time employment because of unpredictable fatigue crashes. Even after 9 hours of sleep, I wake feeling exhausted due to my sleep apnea which is a direct result of my acromegaly.”

What the examiner listens for:

Impact of fatigue on employment and daily activities, relationship between acromegaly and sleep apnea, proximal muscle weakness documented on physical exam, and whether the veteran requires accommodations or assistance with activities of daily living.

Understatements to avoid:

Do not describe fatigue only as 'feeling tired' - use functional terms that quantify the impact. Do not omit sleep apnea if present, as it is a recognized complication of acromegaly and contributes to fatigue severity.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to request an in-person examination - you do not have to accept a records-only review if you believe your condition requires physical evaluation.
  • You have the right to request a new C&P examination if you believe the original exam was inadequate, the examiner lacked relevant expertise, or key symptoms were not documented.
  • You have the right to submit a buddy statement, personal statement, and lay evidence describing your symptoms and their impact - this evidence cannot be ignored by the rater.
  • You have the right to request a copy of the completed DBQ after the examination through your VBMS portal or VSO, and to review it for accuracy before a rating decision is issued.
  • You have the right to record your C&P examination in most states - check your state's consent laws, notify the examiner, and bring a recording device.
  • You have the right to bring a support person (caregiver, family member, VSO representative) to observe the examination - they may not participate in medical questioning but can provide support and take notes.
  • You have the right to submit a Notice of Disagreement (NOA) if you believe the rating decision is incorrect, within one year of the decision date under the legacy appeals process or within one year under the Modernized Appeals System.
  • You have the right to a higher-level review, a supplemental claim with new and relevant evidence, or a Board of Veterans Appeals hearing if you disagree with a rating decision.
  • Under the PACT Act and Benefit of the Doubt standard (38 CFR 3.102), when there is an approximate balance of positive and negative evidence, the benefit of the doubt is given to the veteran.
  • You have the right to request a Fully Developed Claim (FDC) to potentially expedite processing if you have gathered all relevant evidence prior to submission.
  • You have the right to free assistance from an accredited VSO, VA-accredited claims agent, or VA-accredited attorney in preparing your claim - these services do not charge for initial claims assistance.
  • If your acromegaly is diagnosed as being in remission but you have permanent residual structural changes and complications, you retain the right to a rating based on those residuals - remission does not mean zero percent.

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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.