The West Virginia Distinguished Service Medal was created by the legislature in 1939. It can be awarded to former governors in their capacity as commander-in-chief of the national guard; to officers and enlisted men of the national guard for conspicuous or distinguished service in the line of duty; to West Virginians in the U.S. armed forces who distinguish themselves in the line of duty; and to any citizen for conspicuous or distinguished service to the state.

The first medals were given to West Virginians who distinguished themselves in combat through World War I. Included were Capt. Sayers L. Milliken, assistant superintendent of the Army Nurse Corps, for service during World War I, and Col. Andrew S. Rowan for delivering the famous "message to Garcia" during the Spanish-American War.

Among those honored later were Gen. Charles "Chuck" Yeager, who received his medal for being the first pilot to fly faster than the speed of sound; Louis Arthur Johnson, who served as an infantry officer in World War I, and as assistant secretary of war in the Roosevelt administration and secretary of defense during the Truman administration; Col. Florence A. Blanchfield, who served as chief nurse with the American Expeditionary Force in France during World War I and chief of the Army Nurse Corps during World War II; and Col. Ruby Bradley, one of the Army's most decorated nurses, who was captured in the Philippines after the Pearl Harbor attack, and spent 37 months as a prisoner of war.

Numerous other Distinguished Service Medals were awarded for service in the two world wars. In 1980, the 116th West Virginia Distinguished Service Medal was posthumously awarded to all deceased veterans of West Virginia who were honorably discharged from service. Sen. Robert C. Byrd was awarded the medal in 1997, for his devotion to the West Virginia National Guard. Among the most recent recipients was Major General James A. Hoyer, in 2021, for his 36 years in the national guard (1984-2020), including nine as adjutant general (2011-2020); his award specifically noted his leadership role during the 2016 flood recovery efforts and the COVID-19 pandemic.

A total of 225 medals were made. Of these, about 137 have been awarded, and five have been used as replacements for lost medals or for display purposes.