Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) brought changes to the way that the Department of Veterans Affairs (VA) determines presumptive conditions. A presumptive condition is a medical condition that VA presumes to be incurred or aggravated by military service when specific service requirements are met. If a presumed condition is diagnosed in a Veteran, disability compensation can be awarded as long as service requirements, typically defined by dates and locations of service, are met. Prior to the PACT Act, Congress directed VA to contract with the National Academy of Sciences, Engineering and Medicine (NASEM) to evaluate all the available scientific evidence pertaining to Veterans’ health issues. NASEM would provide recommendations for presumptive conditions based on their review of the scientific literature. This process took a long time and did not allow for Veterans to provide any input on the health conditions that were of concern to them. Additionally, the types of literature that NASEM reviewed was often observational in nature, as almost all human studies that examine environmental exposures and adverse health outcomes are observational. Observational studies are considered to carry a risk of bias and more limitations as subjects are not randomized, data is self-reported, and exposure is frequently not measured precisely. As a result, NASEM considers the findings from these types of studies to have less value. Section 202 of the PACT Act, entitled, “Improvements to Ability of Veterans Affairs to Establish Presumptions of Service Connection Based on Toxic Exposure” describes the new requirements to determine presumptive conditions. Every year the VA is required to consider a new exposure-disease relationship for presumptive status. Several different sources of information are used to determine what condition to consider, and includes healthcare data, claims data, and feedback from Veterans, Veterans Service Organizations, and other stakeholders. A Federal Register Notice (FRN) is published annually to notify the public on which exposure-disease relationship VA will assess for presumption, and that a listening session will be held to get feedback on the planned assessment. Once the FRN is published, an assessment of the scientific literature examining the exposure-disease relationship is conducted. VA uses a PECOTS framework (Population, Exposure, Comparator, Outcome, Timing, Setting) to guide a comprehensive literature search performed by medical librarians. Relevant literature is critically reviewed and graded by a committee of experts that include physicians and scientists in VA and other federal agencies with specialized expertise in either the exposure or the medical condition (or both). The totality of the literature is considered and scored, and an algorithm is applied to determine if there is sufficient evidence to conclude that an association is at least as likely as not, this is referred to as equipoise and is the threshold that VA uses to make a determination for a presumptive condition. A final report is written with recommendations to the VA Secretary on whether the evidence supports the establishment of a presumptive condition. VA’s new presumptive decision process offers a Veteran-centric, evidence based, expedited method to deliver benefits to Veterans. Since its inception in 2022, this process has been used to examine genitourinary cancers, and leukemia and multiple myelomas for presumptive status among those exposed to particulate matter pollution in the Southwest Theatre of Operations. It demonstrates cross-administration collaboration to implement evidence-based policy to deliver more benefits to Veterans.