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The Department of Veterans Affairs (VA) provides health care and other benefits to eligible veterans with physical and mental injuries or illnesses (conditions) related to their military service. When the scientific information needed to connect a veterans service or a particular military exposure with their diagnosed condition is nonexistent, impossible to obtain, or incomplete, VA may make a presumption of service connection using a formalized decision process. In 2022, VA instituted a series of changes intended to ensure the presumption decision process was more scientifically based, fair, consistent, transparent, timely, and veteran-centric. The PACT Act of 2022 called for a National Academies committee to review the VA revised process document used to identify medical conditions to evaluate for presumption status, the factors that such an evaluation entails, and the governance process for the review and approval of a presumption recommendation. This resulting report, Review of the Department of Veterans Affairs Presumption Decision Process, contains the committee findings, conclusions, and recommendations.