**Veterans Benefits Administration Program Guide 21-2**

**Department of Veterans Affairs**

**Washington, DC 20420**

The Veterans Benefits Administration Program Guide 21-2 has been
updated.

We added Regulatory Amendment Explanations 4-02-1 to 4-03-2 to bring
current the Part 4 guide since 2002. We also updated the corresponding
Index to Transmittal Sheets for Compensation and Pension Regulations for
Part 4.

> By Direction of the Under Secretary for Benefits
>
> Renée Szybala, Director
>
> Compensation and Pension Service

Distribution: RPC: 2068

FD: EX: ASO and AR (included in RPC 2068)

**Veterans Benefits Administration**

**Department of Veterans Affairs**

**Washington, DC 20420**

PART II

INDEX TO TRANSMITTAL SHEETS FOR

COMPENSATION AND PENSION REGULATIONS

38 CFR PART 4

Includes All 38 CFR Part 4 Transmittal

or Extension Sheets Through 4-03-2

**INDEX TO TRANSMITTAL AND EXTENSION SHEETS**

CFR \# Transmittal or Extension Sheet \# and Diagnostic Code

4.1 17

4.2 12; 17

4.3 12; 16

4.6 12

4.7 12

4.9 12; 17

4.10 17

4.13 12

4.16 6; 11; 16; 26; 4-90-1; 4-96-5

4.17 Ext 5; Ext 9; 6; 11; 16; 19; 4-91-2

4.18 6; 11

4.19 7; 19

4.21 17

4.23 17

4.25 Ext 4; 7; 17; 27

4.26 Ext 4; 7

4.27 Ext 4; 7; 12; 16

4.28 Ext 7; Ext 9; 6; 7; 15

4.29 Ext 2; Ext 2-A; Ext 2-B; Ext 7; 2; 3; 6; 11; 17; 18; 26

4.30 Ext 7; 3; 11; 17; 18; 26

4.31 6; 4-93-1

4.40 11

4.41 11

4.42 11

4.43 11

4.44 10

4.45 10

4.46 10; 17

4.47 10; 4-97-1

4.48 10; 4-97-1

4.49 10; 4-97-1

4.50 10; 4-97-1

4.51 10; 4-97-1

4.52 10; 4-97-1

4.53 10; 19; 4-97-1

4.54 10; 19; 4-97-1

4.55 10; 19; 4-97-1

4.56 10; 19; 4-97-1

4.57 10

4.58 10

4.59 10

4.60 \[Reserved\]

4.61 10

4.62 10

4.63 Ext 3; 10; 19

4.64 Ext 10; 10

4.66 10

4.67 10

4.68 7; 10

4.69 10; 4-97-1

4.70 10

4.71 4; 10; 17; 19

4.71a 17; 4-99-2

5000 Ext 4; Ext 7; 7

5001 Ext 6-A; 4; 7; 14; 17

5002 10; 17

5003 Ext 7; 7; 10; 17

5004 \[No Revision since 1945 Schedule\]

5005 \[No Revision since 1945 Schedule\]

5006 \[No Revision since 1945 Schedule\]

5007 \[No Revision since 1945 Schedule\]

5008 \[No Revision since 1945 Schedule\]

5009 10

5010 10

5011 \[No Revision since 1945 Schedule\]

5012 17

5013 10

5014 10

5015 \[No Revision since 1945 Schedule\]

5016 \[No Revision since 1945 Schedule\]

5017 10

5018 \[No Revision since 1945 Schedule\]

5019 \[No Revision since 1945 Schedule\]

5020 \[No Revision since 1945 Schedule\]

5021 \[No Revision since 1945 Schedule\]

5022 \[No Revision since 1945 Schedule\]

5023 \[No Revision since 1945 Schedule

5024 10

5025 4-96-1; 4-99-2

5051 19

5052 19

5053 19

5054 19

5055 19

5056 19

5104 17

5105 17

5106 \[No Revision since 1945 Schedule\]

5107 \[No Revision since 1945 Schedule\]

5108 \[No Revision since 1945 Schedule\]

5109 \[No Revision since 1945 Schedule\]

5110 \[No Revision since 1945 Schedule\]

5111 \[No Revision since 1945 Schedule\]

5120 \[No Revision since 1945 Schedule\]

5121 \[No Revision since 1945 Schedule\]

5122 \[No Revision since 1945 Schedule\]

5123 \[No Revision since 1945 Schedule\]

5124 \[No Revision since 1945 Schedule\]

5125 \[No Revision since 1945 Schedule\]

5126 \[No Revision since 1945 Schedule\]

5127 \[No Revision since 1945 Schedule\]

5128 \[No Revision since 1945 Schedule\]

5129 \[No Revision since 1945 Schedule\]

5130 \[No Revision since 1945 Schedule\]

5131 \[No Revision since 1945 Schedule\]

5132 \[No Revision since 1945 Schedule\]

5133 \[No Revision since 1945 Schedule\]

5134 \[No Revision since 1945 Schedule\]

5135 \[No Revision since 1945 Schedule\]

5136 \[No Revision since 1945 Schedule\]

5137 \[No Revision since 1945 Schedule\]

5138 \[No Revision since 1945 Schedule\]

5139 \[No Revision since 1945 Schedule\]

5140 \[No Revision since 1945 Schedule\]

5141 \[No Revision since 1945 Schedule\]

5142 \[No Revision since 1945 Schedule\]

5143 \[No Revision since 1945 Schedule\]

5144 \[No Revision since 1945 Schedule\]

5145 \[No Revision since 1945 Schedule\]

5146 \[No Revision since 1945 Schedule\]

5147 \[No Revision since 1945 Schedule\]

5148 \[No Revision since 1945 Schedule\]

5149 \[No Revision since 1945 Schedule\]

5150 \[No Revision since 1945 Schedule\]

5151 17

5152 \[No Revision since 1945 Schedule\]

5153 \[No Revision since 1945 Schedule\]

5154 \[No Revision since 1945 Schedule\]

5155 \[No Revision since 1945 Schedule\]

5156 Ext 7; 7; 17

5160 \[No Revision since 1945 Schedule\]

5161 \[No Revision since 1945 Schedule\]

5162 \[No Revision since 1945 Schedule\]

5163 \[No Revision since 1945 Schedule\]

5164 Ext 9; 1

5165 \[No Revision since 1945 Schedule\]

5166 19

5167 \[No Revision since 1945 Schedule\]

5170 \[No Revision since 1945 Schedule\]

5171 \[No Revision since 1945 Schedule\]

5172 Ext 7

5173 Ext 7; Ext 9

5200 \[No Revision since 1945 Schedule\]

5201 \[No Revision since 1945 Schedule\]

5202 \[No Revision since 1945 Schedule\]

5203 \[No Revision since 1945 Schedule\]

5205 4

5206 4

5207 4

5208 4

5209 \[No Revision since 1945 Schedule\]

5210 \[No Revision since 1945 Schedule\]

5211 19

5212 19

5213 4

5214 19

5215 \[No Revision since 1945 Schedule\]

5216 4-02-2

5217 4-02-2

5218 4-02-2

5219 19; 4-02-2

5220 \[No Revision since 1945 Schedule\]

5221 4-02-2

5222 4-02-2

5223 1; 17; 19; 4-02-2

5224 4-02-2

5225 4-02-2

5226 4-02-2

5227 19; 4-02-2

5228 4-02-2

5229 4-02-2

5230 4-02-2

5235 4-03-2 (added)

5236 4-03-2 (added)

5237 4-03-2 (added)

5238 4-03-2 (added)

5239 4-03-2 (added)

5240 4-03-2 (added)

5241 4-03-2 (added)

5242 4-03-2 (added)

5243 4-03-2 (added)

5250 4; 10

5251 4

5252 4

5253 4

5254 \[No Revision since 1945 Schedule\]

5255 Ext 7

5256 4

5257 Ext 7

5258 \[No Revision since 1945 Schedule\]

5259 \[No Revision since 1945 Schedule\]

5260 4

5261 4

5262 \[No Revision since 1945 Schedule\]

5263 \[No Revision since 1945 Schedule\]

5270 4

5271 \[No Revision since 1945 Schedule\]

5272 \[No Revision since 1945 Schedule\]

5273 \[No Revision since 1945 Schedule\]

5274 \[No Revision since 1945 Schedule\]

5275 17; 19

5276 5

5277 \[No Revision since 1945 Schedule\]

5278 \[No Revision since 1945 Schedule\]

5279 \[No Revision since 1945 Schedule\]

5280 \[No Revision since 1945 Schedule\]

5281 \[No Revision since 1945 Schedule\]

5282 \[No Revision since 1945 Schedule\]

5283 \[No Revision since 1945 Schedule\]

5284 \[No Revision since 1945 Schedule\]

5285 1; 4-03-2 (removed)

5286 4-03-2 (removed)

5287 4-03-2 (removed)

5288 4-03-2 (removed)

5289 4-03-2 (removed)

5290 4-03-2 (removed)

5291 4-03-2 (removed)

5292 1; 4-03-2 (removed)

5293 17; 4-02-4; 4-03-2 (removed)

5294 17

5295 17

5296 17

5297 Ext 4; 7

5298 Ext 4

4.72 Ext 4; 12; 4-97-1

4.73 17; 4-97-1

5301 \[No Revision since 1945 Schedule\]

5302 \[No Revision since 1945 Schedule\]

5303 \[No Revision since 1945 Schedule\]

5304 8

5305 \[No Revision since 1945 Schedule\]

5306 \[No Revision since 1945 Schedule\]

5307 \[No Revision since 1945 Schedule\]

5308 \[No Revision since 1945 Schedule\]

5309 \[No Revision since 1945 Schedule\]

5310 4-97-1

5311 4-97-1

5312 4-97-1

5313 \[No Revision since 1945 Schedule\]

5314 19

5315 \[No Revision since 1945 Schedule\]

5316 19

5317 Ext 10; 12; 19; 4-97-1(note)

5318 \[No Revision since 1945 Schedule\]

5319 \[No Revision since 1945 Schedule\]

5320 \[No Revision since 1945 Schedule\]

5321 \[No Revision since 1945 Schedule\]

5322 \[No Revision since 1945 Schedule\]

5323 \[No Revision since 1945 Schedule\]

5324 7

5325 4-97-1

5326 \[No Revision since 1945 Schedule\]

5327 17; 4-91-1; 4-97-1

5328 17; 4-97-1

5329 4-91-1; 4-97-1

4.75 12; 16

4.76 12; 19

4.76a 19

4.77 12; 19

4.78 12; 19

4.79 Ext 4; 12; 19

4.80 12

4.81-2 \[Reserved\]

4.83 12; 18; 19

4.83a 17; 19

4.84 12; 14

4.84a 16; 17; 25

6000 \[No Revision since 1945 Schedule\]

6001 \[No Revision since 1945 Schedule\]

6002 \[No Revision since 1945 Schedule\]

6003 \[No Revision since 1945 Schedule\]

6004 \[No Revision since 1945 Schedule\]

6005 \[No Revision since 1945 Schedule\]

6006 \[No Revision since 1945 Schedule\]

6007 6

6008 \[No Revision since 1945 Schedule\]

6009 \[No Revision since 1945 Schedule\]

6010 Ext 6-A; 7; 14

6011 \[No Revision since 1945 Schedule\]

6012 \[No Revision since 1945 Schedule\]

6013 \[No Revision since 1945 Schedule\]

6014 \[No Revision since 1945 Schedule\]

6015 \[No Revision since 1945 Schedule\]

6016 \[No Revision since 1945 Schedule\]

6017 \[No Revision since 1945 Schedule\]

6018 \[No Revision since 1945 Schedule\]

6019 19

6020 \[No Revision since 1945 Schedule\]

6021 \[No Revision since 1945 Schedule\]

6022 \[No Revision since 1945 Schedule\]

6023 \[No Revision since 1945 Schedule\]

6024 \[No Revision since 1945 Schedule\]

6025 \[No Revision since 1945 Schedule\]

6026 \[No Revision since 1945 Schedule\]

6027 \[No Revision since 1945 Schedule\]

6028 \[No Revision since 1945 Schedule\]

6029 Ext 4; 16; 19

6030 \[No Revision since 1945 Schedule\]

6031 \[No Revision since 1945 Schedule\]

6032 12

6033 12

6034 12

6035 16

6061 17

6062 \[No Revision since 1945 Schedule\]

6063 19

6064 17; 19

6065 19

6066 19

6067 19

6068 19

6069 19

6070 19

6071 17, 19

6072 19

6073 19

6074 19

6075 19

6076 Ext 4; 19

6077 19

6078 16; 19

6079 16; 19

6080 Ext 7; 12; 16; 19

6081 17

6090 19; 25

6091 12

6092 12

4.85 Ext 8; Ext 8-A; Ext 8-B; Ext 8-C; 12; 19; 23; 4-99-1

4.86 Ext 4; Ext 8; Ext 8-B; Ext 8-C; 12; 19; 20; 4-99-1

4.86a Ext 8; Ext 8-B; 12; 17; 19; 23

4.87 17; 4-99-1

6100 23

6101 23; 4-99-1

6102 23; 4-99-1

6103 23; 4-99-1

6104 23; 4-99-1

6105 23; 4-99-1

6106 23; 4-99-1

6107 23; 4-99-1

6108 23; 4-99-1

6109 23; 4-99-1

6110 23; 4-99-1

4.87a 16; 23; 4-99-1

6200 4-99-1

6201 4-99-1

6202 \[No Revision since 1945 Schedule\]

6203 12; 4-99-1

6204 4-99-1

6205 1; 12; 4-99-1

6206 4-99-1

6207 4-99-1

6208 4-99-1

6209 4-99-1

6210 4-99-1

6211 12

6260 1; 6; 17; 4-99-1; 4-03-1

4.87b 16; 4-99-1

6275 4-99-1

6276 4-99-1

4.88 12; 19; 4-96-3

4.88a 16; 4-94-4

6300 4-96-3

6301 4-96-3

6302 Ext 4; 19; 4-96-3

6304 Ext 4; Ext 7; 4-96-3

6305 26; 4-96-3

6306 4-96-3

6307 4-96-3

6308 4-96-3

6309 10; 26; 4-96-3

6310 4-96-3

6311 4-96-3

6313 4-96-3

6314 26; 4-96-3

6315 4-96-3

6316 26; 4-96-3

6317 4-96-3

6318 26; 4-96-3

6319 4-96-3

6320 4-96-3

6350 10; 17; 4-96-3

6351 26; 4-92-1

6354 4-94-4

4.88b 14; 17; 4-94-4; 4-96-3

4.88c 4-94-4

4.89 Ext 6-A; Ext 9; 7; 11; 14; 17; 19

4.90-5 \[Reserved\]

4.96 11; 14; 4-96-4

4.97 17; 4-96-4

6501 4-96-4

6502 4-96-4

6504 4-96-4

6510 4-96-4

6511 4-96-4

6512 4-96-4

6513 4-96-4

6514 4-96-4

6515 7; 4-96-4

6516 4-96-4

6517 4-96-4

6518 4-96-4

6519 4-96-4

6520 4-96-4

6521 4-96-4

6522 4-96-4

6523 4-96-4

6524 4-96-4

6600 16; 4-96-4

6601 4-96-4

6602 16; 4-96-4

6603 16; 4-96-4

6604 4-96-4

6701 Ext 4; Ext 6

6702 Ext 4; Ext 6

6703 Ext 4; Ext 6

6704 Ext 1; Ext 4; Ext 6; Ext 7; Ext 9; 14

6721 Ext 6

6722 Ext 6

6723 Ext 6

6724 Ext 1 (Instr 4); Ext 1 (Instr 4-A); Ext 6; 7; 11

6730 19; 4-96-4

6731 14; 19; 4-96-4

6732 7; 19; 4-96-4

6800 4-96-4

6801 4-96-4

6802 16; 4-96-4

6803 4-96-4

6804 4-96-4

6805 4-96-4

6806 4-96-4

6807 4-96-4

6808 4-96-4

6809 4-96-4

6810 4-96-4

6811 11; 4-96-4

6812 4-96-4

6813 11; 4-96-4

6814 17; 4-96-4

6815 4-96-4

6816 11; 4-96-4

6817 4-96-4

6818 4-96-4

6819 17; 4-96-4

6820 4-96-4

6821 Ext 4

6822 4-96-4

6823 4-96-4

6824 4-96-4

6825 4-96-4

6826 4-96-4

6827 4-96-4

6828 4-96-4

6829 4-96-4

6830 4-96-4

6831 4-96-4

6832 4-96-4

6833 4-96-4

6834 4-96-4

6835 4-96-4

6836 4-96-4

6837 4-96-4

6838 4-96-4

6839 4-96-4

6840 4-96-4

6841 4-96-4

6842 4-96-4

6843 4-96-4

6844 4-96-4

6845 4-96-4

6846 4-96-4

6847 4-96-4

4.98-9 \[Reserved\]

4.100 12; 4-97-2

4.101 12; 4-97-2

4.102 12; 4-97-2

4.103 \[Reserved\]

4.104 19; 4-97-2; 4-98-1

7000 Ext 7; 19; 4-97-2

7001 4-97-2

7002 4-97-2

7003 4-97-2

7004 19; 4-97-2

7005 16; 19; 4-97-2

7006 4-97-2

7007 19; 4-97-2

7008 4-97-2

7010 4-97-2

7011 4-97-2

7012 4-97-2

7013 4-97-2

7014 4-97-2

7015 16; 4-97-2

7016 16; 4-97-2

7017 19; 4-97-2

7018 4-97-2

7019 4-97-2

7020 4-97-2

7100 Ext 7; 4-97-2

7101 5; 16; 4-97-2

7110 16; 17; 4-97-2

7111 16; 4-97-2

7112 4-97-2

7113 4-97-2

7114 Ext 9; 4-97-2

7115 Ext 7; Ext 9; 4-97-2

7116 Ext 7; Ext 9; 17; 4-97-2

7117 Ext 9; 4-97-2

7118 4-97-2

7119 4-97-2

7120 Ext 7; 4-97-2

7121 Ext 7; 17; 4-97-2

7122 Ext 7; 4-97-2; 4-98-1

7123 4-91-1; 4-97-2

4.105-9 \[Reserved\]

4.110 2; 9; 12

4.111 2; 9; 12

4.112 2; 9; 12; 4-01-1

4.113 2; 9; 12

4.114 9; 17; 4-01-1

7200 \[No Revision since 1945 Schedule\]

7201 \[No Revision since 1945 Schedule\]

7202 \[No Revision since 1945 Schedule\]

7203 \[No Revision since 1945 Schedule\]

7204 \[No Revision since 1945 Schedule\]

7205 \[No Revision since 1945 Schedule\]

7301 \[No Revision since 1945 Schedule\]

7304 \[No Revision since 1945 Schedule\]

7305 9

7306 2; 9; 12

7307 12

7308 2

7309 9

7310 \[No Revision since 1945 Schedule\]

7311 4-01-1

7312 17; 4-01-1

7313 17; 4-01-1

7314 \[No Revision since 1945 Schedule\]

7315 \[No Revision since 1945 Schedule\]

7316 \[No Revision since 1945 Schedule\]

7317 \[No Revision since 1945 Schedule\]

7318 Ext 4

7319 9

7321 Ext 7

7322 \[No Revision since 1945 Schedule\]

7323 \[No Revision since 1945 Schedule\]

7324 \[No Revision since 1945 Schedule\]

7325 9

7326 9

7327 9

7328 9; 10

7329 9; 10

7330 9; 10

7331 7; 14

7332 9

7333 \[No Revision since 1945 Schedule\]

7334 Ext 7; 9

7335 7

7336 Ext 4; 7; 9

7337 \[No Revision since 1945 Schedule\]

7338 Ext 9

7339 17

7340 \[No Revision since 1945 Schedule\]

7342 \[No Revision since 1945 Schedule\]

7343 17; 4-01-1

7344 4-01-1

7345 Ext 4; Ext 4-B; 7; 12; 4-01-1

7346 7

7347 16; 17

7348 17

7351 4-01-1

7354 4-01-1

4.115 12; 18; 4-94-1

4.115a 4-94-1

4.115b 17; 4-94-1; 4-94-3(NOTE)

7500 Ext 7; 7; 4-94-1

7501 \[No Revision since 1945 Schedule\]

7502 4-94-1

7503 4-94-1

7504 \[No Revision since 1945 Schedule\]

7505 Ext 7; Ext 6-A; Ext 9; 7; 14; 17

7507 \[No Revision since 1945 Schedule\]

7508 4-94-1

7509 4-94-1

7510 4-94-1

7511 4-94-1

7512 \[No Revision since 1945 Schedule\]

7513 4-94-1

7514 Ext 6-A; 7; 14; 17; 4-94-1

7515 \[No Revision since 1945 Schedule\]

7516 \[No Revision since 1945 Schedule\]

7517 \[No Revision since 1945 Schedule\]

7518 \[No Revision since 1945 Schedule\]

7519 12; 17

7520 \[No Revision since 1945 Schedule\]

7521 \[No Revision since 1945 Schedule\]

7522 \[No Revision since 1945 Schedule\]

7523 12

7524 Ext 7; 12; 4-94-1

7525 Ext 7; Ext 6-A; 7; 14; 17; 4-94-1

7526 4-94-1

7527 4-94-1

7528 17; 4-94-1

7529 \[No Revision since 1945 Schedule\]

7530 16; 4-94-1

7531 16; 4-94-1

7532 4-94-1

7533 4-94-1

7534 4-94-1

7535 4-94-1

7536 4-94-1

7537 4-94-1

7538 4-94-1

7539 4-94-1

7540 4-94-1

7541 4-94-1

7542 4-94-1

4.116 12; 18; 4-95-1

7610 4-95-1

7611 4-95-1

7612 4-95-1

7613 4-95-1

7614 4-95-1

7615 4-95-1

7617 4-95-1

7618 4-95-1

7619 4-95-1

7620 4-95-1

7621 4-95-1

7622 4-95-1

7623 4-95-1

7624 4-95-1

7625 4-95-1

7626 4-95-1; 4-02-1

7627 17; 4-95-1

7628 4-95-1

7629 4-95-1

4.116a 17; 4-95-1

4.117 16; 4-95-2

7700 4-95-2

7701 4-95-2

7702 4-95-2

7703 Ext 4; 4-95-2

7704 4-95-2

7705 4-95-2

7706 4-95-2

7707 4-95-2

7709 Ext 4; Ext 9; 17; 4-95-2

7710 Ext 4; Ext 6-A; 7; 14; 17; 4-95-2

7711 Ext 6-A; 7; 14; 17; 4-95-2

7712 Ext 6-A; 7; 14; 17; 4-95-2

7713 4-95-2

7714 16; 4-95-2

7715 4-90-2; 4-95-2

7716 4-95-2

4.118 16

7800 4-02-3

7801 Ext 7; 19; 4-02-3

7802 Ext 7; 19; 4-02-3

7803 4-02-3

7804 Ext 7; 7; 4-02-3

7805 \[No Revision since 1945 Schedule\]

7806 16; 4-02-3

7807 4-02-3

7808 4-02-3

7809 10; 4-02-3

7810 4-02-3(removed)

7811 Ext 6-A; 7; 14; 17; 19; 4-02-3

7812 4-02-3(removed)

7813 4-02-3

7814 4-02-3(removed)

7815 4-02-3

7816 4-02-3

7817 4-02-3

7818 4-02-3

7819 4-02-3

7820 4-02-3

7821 4-02-3

7822 4-02-3

7823 4-02-3

7824 4-02-3

7825. 4-02-3

7826 4-02-3

7827 4-02-3

7828 4-02-3

7829 4-02-3

7830 4-02-3

7831 4-02-3

7832 4-02-3

7833 4-02-3

4.119 12; 21

7900 21; 4-96-2

7901 21; 4-96-2

7902 21; 4-96-2

7903 21; 4-96-2

7904 21; 4-96-2

7905 21; 4-96-2

7907 21; 4-96-2

7908 21; 4-96-2

7909 21; 4-96-2

7910 4-96-2

7911 7; 10; 14; 17; 21; 4-96-2

7912 4-96-2

7913 16; 17; 21; 4-96-2

7914 17; 4-96-2

7915 4-96-2

7916 4-96-2

7917 4-96-2

7918 4-96-2

7919 4-96-2

4.120 12

4.121 6; 12

4.122 6; 12

4.123 12

4.124 12

4.124a 26

8000 \[No Revision since 1945 Schedule\]

8002 19

8003 \[No Revision since 1945 Schedule\]

8004 \[No Revision since 1945 Schedule\]

8005 \[No Revision since 1945 Schedule\]

8007 \[No Revision since 1945 Schedule\]

8008 \[No Revision since 1945 Schedule\]

8009 \[No Revision since 1945 Schedule\]

8010 \[No Revision since 1945 Schedule\]

8011 \[No Revision since 1945 Schedule\]

8012 \[No Revision since 1945 Schedule\]

8013 \[No Revision since 1945 Schedule\]

8014 \[No Revision since 1945 Schedule\]

8015 \[No Revision since 1945 Schedule\]

8017 \[No Revision since 1945 Schedule\]

8018 \[No Revision since 1945 Schedule\]

8019 \[No Revision since 1945 Schedule\]

8020 \[No Revision since 1945 Schedule\]

8021 19

8022 \[No Revision since 1945 Schedule\]

8023 \[No Revision since 1945 Schedule\]

8024 \[No Revision since 1945 Schedule\]

8025 Ext 7; 6

8045 6; 17; 26

8046 6; 26

8100 Ext 9

8103 6; 7

8104 \[No Revision since 1945 Schedule\]

8105 \[No Revision since 1945 Schedule\]

8106 \[No Revision since 1945 Schedule\]

8107 \[No Revision since 1945 Schedule\]

8108 6

8205 \[No Revision since 1945 Schedule\]

8305 \[No Revision since 1945 Schedule\]

8405 \[No Revision since 1945 Schedule\]

8207 \[No Revision since 1945 Schedule\]

8307 \[No Revision since 1945 Schedule\]

8407 \[No Revision since 1945 Schedule\]

8209 \[No Revision since 1945 Schedule\]

8309 \[No Revision since 1945 Schedule\]

8409 \[No Revision since 1945 Schedule\]

8210 \[No Revision since 1945 Schedule\]

8310 \[No Revision since 1945 Schedule\]

8410 \[No Revision since 1945 Schedule\]

8211 \[No Revision since 1945 Schedule\]

8311 \[No Revision since 1945 Schedule\]

8411 \[No Revision since 1945 Schedule\]

8212 \[No Revision since 1945 Schedule\]

8312 \[No Revision since 1945 Schedule\]

8412 \[No Revision since 1945 Schedule\]

8510 \[No Revision since 1945 Schedule\]

8610 \[No Revision since 1945 Schedule\]

8710 \[No Revision since 1945 Schedule\]

8511 \[No Revision since 1945 Schedule\]

8611 \[No Revision since 1945 Schedule\]

8711 \[No Revision since 1945 Schedule\]

8512 \[No Revision since 1945 Schedule\]

8612 \[No Revision since 1945 Schedule\]

8712 \[No Revision since 1945 Schedule\]

8513 \[No Revision since 1945 Schedule\]

8613 \[No Revision since 1945 Schedule\]

8713 \[No Revision since 1945 Schedule\]

8514 \[No Revision since 1945 Schedule\]

8614 \[No Revision since 1945 Schedule\]

8714 \[No Revision since 1945 Schedule\]

8515 \[No Revision since 1945 Schedule\]

8615 \[No Revision since 1945 Schedule\]

8715 \[No Revision since 1945 Schedule\]

8516 \[No Revision since 1945 Schedule\]

8616 \[No Revision since 1945 Schedule\]

8716 \[No Revision since 1945 Schedule\]

8517 \[No Revision since 1945 Schedule\]

8617 \[No Revision since 1945 Schedule\]

8717 \[No Revision since 1945 Schedule\]

8518 \[No Revision since 1945 Schedule\]

8618 \[No Revision since 1945 Schedule\]

8718 \[No Revision since 1945 Schedule\]

8519 \[No Revision since 1945 Schedule\]

8619 \[No Revision since 1945 Schedule\]

8719 \[No Revision since 1945 Schedule\]

8520 \[No Revision since 1945 Schedule\]

8620 \[No Revision since 1945 Schedule\]

8720 \[No Revision since 1945 Schedule\]

8521 \[No Revision since 1945 Schedule\]

8621 \[No Revision since 1945 Schedule\]

8721 \[No Revision since 1945 Schedule\]

8522 \[No Revision since 1945 Schedule\]

8622 \[No Revision since 1945 Schedule\]

8722 \[No Revision since 1945 Schedule\]

8523 \[No Revision since 1945 Schedule\]

8623 \[No Revision since 1945 Schedule\]

8723 \[No Revision since 1945 Schedule\]

8524 \[No Revision since 1945 Schedule\]

8624 \[No Revision since 1945 Schedule\]

8724 \[No Revision since 1945 Schedule\]

8525 \[No Revision since 1945 Schedule\]

8625 \[No Revision since 1945 Schedule\]

8725 \[No Revision since 1945 Schedule\]

8526 \[No Revision since 1945 Schedule\]

8626 \[No Revision since 1945 Schedule\]

8726 \[No Revision since 1945 Schedule\]

8527 \[No Revision since 1945 Schedule\]

8627 \[No Revision since 1945 Schedule\]

8727 \[No Revision since 1945 Schedule\]

8528 \[No Revision since 1945 Schedule\]

8628 \[No Revision since 1945 Schedule\]

8728 \[No Revision since 1945 Schedule\]

8529 \[No Revision since 1945 Schedule\]

8629 \[No Revision since 1945 Schedule\]

8729 \[No Revision since 1945 Schedule\]

8530 \[No Revision since 1945 Schedule\]

8630 \[No Revision since 1945 Schedule\]

8730 \[No Revision since 1945 Schedule\]

8540 4-91-1

8910 Ext 7; 6

8911 6; 16

8912 6

8913 6

8914 6; 7; 17; 26

4.125 6; 12; 18; 24; 4-96-5

4.126 6; 12; 24; 4-96-5

4.127 6; 12; 18; 24; 4-96-5

4.128 6; 12; 4-96-5

4.129 6; 12; 4-96-5

4.130 6; 12; 18; 24; 4-96-5

4.131 6; 12; 24; 4-96-5

4.132 Ext 4; Ext 7; 6; 17; 24; 4-96-5

9201 6; 17; 24

9202 6; 17

9203 6; 17

9204 6; 17; 24

9205 6; 17; 24; 4-96-5

9206 6; 17; 24; 4-96-5

9207 6; 24; 4-96-5

9208 6; 17; 24; 4-96-5

9209 6; 17; 24; 4-96-5

9210 6; 12, 17; 24; 4-96-5

9211 4-96-5

9300 6; 17; 24; 4-96-5

9301 6; 17; 24; 4-96-5

9302 6; 17; 24; 4-96-5

9303 6; 17; 24; 4-96-5

9304 6; 17; 24; 4-96-5

9305 6; 17; 24; 4-96-5

9306 6; 17; 24; 4-96-5

9307 6; 17; 24; 4-96-5

9308 6; 17; 24; 4-96-5

9309 6; 17; 24; 4-96-5

9310 6; 17; 24; 4-96-5

9311 6; 17; 24; 4-96-5

9312 17; 24; 4-96-5

9315 17; 24; 4-96-5

9322 17; 24; 4-96-5

9324 17; 24; 4-96-5

9325 17; 24; 4-96-5

9326 4-96-5

9327 4-96-5

9400 6; 17; 24

9401 6; 17; 24; 4-96-5

9402 6; 17; 24; 4-96-5

9403 6; 17; 24; 4-96-5

9404 6; 17; 24

9405 6; 17; 24; 4-96-5

9408 17; 24; 4-96-5

9409 17; 24; 4-96-5

9410 17

9411 20; 24

9412 4-96-5

9413 4-96-5

9416 4-96-5

9417 4-96-5

9421 4-96-5

9422 4-96-5

9423 4-96-5

9424 4-96-5

9425 4-96-5

9431 4-96-5

9432 4-96-5

9433 4-96-5

9434 4-96-5

9435 4-96-5

9440 4-96-5

9500 6; 17; 24; 4-96-5

9501 6; 17; 24; 4-96-5

9502 6; 17; 24; 4-96-5

9505 17; 24; 4-96-5

9506 17; 24; 4-96-5

9507 17; 24; 4-96-5

9508 17; 24; 4-96-5

9509 17; 24; 4-96-5

9510 17; 24; 4-96-5

9511 17; 24; 4-96-5

9520 4-96-5

9521 4-96-5

4.133-48 \[Reserved\]

4.149 4-94-2; 3-99-2

4.150 16; 4-94-2

9900 Ext 7; 19; 4-94-2

9901 \[No Revision since 1945 Schedule\]

9903 \[No Revision since 1945 Schedule\]

9904 \[No Revision since 1945 Schedule\]

9905 19; 4-94-2

9906 \[No Revision since 1945 Schedule\]

9907 \[No Revision since 1945 Schedule\]

9908 \[No Revision since 1945 Schedule\]

9909 19; 21

9910 \[No Revision since 1945 Schedule\]

9911 \[No Revision since 1945 Schedule\]

9912 4-94-2

9913 4-94-2

9914 4-94-2

9915 4-94-2

9916 4-94-2

**Program Guide 21-2**

APPENDIX B

38 CFR Part 4 \-- Rating Schedule

Regulatory Amendment Explanations

4-90-1 Through 4-03-2

REGULATORY AMENDMENT

4-90-1

Regulation Affected: 38 CFR 4.16(a)

EFFECTIVE DATE OF REGULATION: September 4, 1990.

Date Secretary Approved Regulation: July 10, 1990

Federal Register Citation: 55 FR 31579-80

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

[Section 4.16]{.underline}. In a report entitled \"Veterans Benefits:
Improving the Integrity of VA\'s Unemployability Compensation Program\",
the GAO recommended that VA define marginal employment so that the
criteria used in making determinations of marginal employment in claims
for unemployability are consistent between rating boards. 38 CFR 4.16(a)
has been amended to provide that marginal employment is not considered
substantially gainful employment. Generally, marginal employment is
deemed to exist when a veteran\'s earned annual income does not exceed
the amount established by the Bureau of the Census as the poverty
threshold for one person. This should not preclude a finding of marginal
employment in some cases when earned annual income exceeds the poverty
threshold. Consideration will be given in all claims to the nature of
the employment and the reasons for termination.

REGULATORY AMENDMENT

4-90-2

Regulation Affected: 38 CFR 4.117

EFFECTIVE DATE OF REGULATION: October 26, 1990

Date Secretary Approved Regulation: October 2, 1990

Federal Register Citation: 55 FR 43123-5 (October 26, 1990)

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

[Section 4.117]{.underline}. On March 29, 1990, the Centers for Disease
Control released a study entitled \"The Association of Selected Cancers
with Service in the U.S. Military in Vietnam\". That study found that
Vietnam veterans have a roughly 50 percent increased risk of developing
non-Hodgkin\'s lymphoma (NHL) after service in Vietnam. The Secretary
has determined that there is a relationship between Vietnam service and
the subsequent development of NHL. 38 CFR Part 3 has been amended to add
section 3.313 to provide the criteria to be used in considering claims
for service connection for NHL by Vietnam veterans.

38 CFR 4.117 has been amended to add a diagnostic code and evaluation
criteria for NHL.

REGULATORY AMENDMENT

4-91-1

Regulation Affected: 38 CFR 4.73, 4.104 and 4.124a

EFFECTIVE DATE OF REGULATION: October 15, 1991

Date Secretary Approved Regulation: September 16, 1991

Federal Register Citation: 56 FR 51651-3 (October 15, 1991)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why these changes
are being made. This comment is not regulatory.

Under 38 CFR 1.17(c), when VA determines that a significant statistical
association exists between exposure to a herbicide containing dioxin and
any disease, 38 CFR 3.311a shall be amended to provide guidelines for
the establishment of service connection for the disease. These
determinations are to be made after receiving the advice of the Veterans
Advisory Committee on Environmental Hazards (VACEH) based on its
evaluation of scientific or medical studies.

In a public meeting on May 16-17, 1990, the VACEH met in Washington, DC.
At that meeting, the VACEH considered more than 80 scientific and
medical documents relating to the connection, if any, between exposure
to a herbicide containing dioxin and the subsequent development of
soft-tissue sarcoma (STS). The VACEH found that the relative weights of
valid positive and valid negative studies permitted the conclusion that
it is at least as likely as not that there is a significant statistical
association between exposure to a herbicide containing dioxin and STS.
The Secretary has accepted that recommendation.

There is disagreement even among pathologists as to what tumors the term
\"soft-tissue sarcoma\" encompasses. With the assistance of VHA and the
VACEH, we compiled a list of those tumors which we consider to be
soft-tissue sarcomas and included it in the regulation. For compensation
purposes, such tumors must be malignant and arise from tissue of
mesenchymal origin, including muscle, fat, blood or lymph vessels, or
connective tissue (but not cartilage or bone). Tumors of infancy or
childhood, and those having a strong, known causal association with a
specific etiology have been excluded because it is unlikely that there
is a reasonable probability of a significant statistical association
between such tumors and exposure to a herbicide containing dioxin.

STS is currently rated by analogy because there are no specific
diagnostic codes in the rating schedule. 38 CFR Part 4 has been amended
to add specific diagnostic codes for STS as well as evaluation criteria.
In addition, diagnostic code 5327 has been amended to exclude STS and to
revise the point at which evaluations are based on residual disability
from 1 year to 6 months following cessation of treatment. The revision
has been made because medical advances have reduced the recovery time
needed following surgery, chemotherapy, etc.

[Section 4.73]{.underline}. Diagnostic code 5327 has been revised to
exclude STS, and new diagnostic code 5329 has been added.

[Section 4.104]{.underline}. New diagnostic code 7123 has been added.

[Section 4.124a]{.underline}. New diagnostic code 8540 has been added.

REGULATORY AMENDMENT

4-91-2

Regulation Affected: 38 CFR 4.17

EFFECTIVE DATE OF REGULATION: December 16, 1991

Date Secretary Approved Regulation: October 10, 1991

Federal Register Citation: 56 FR 57985 (November 15, 1991)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why these changes
are being made. This comment is not regulatory.

Section 8002 of the Omnibus Budget Reconciliation Act of 1990, Pub. L.
101-508, amended 38 U.S.C. 1502(a) to eliminate the presumption of total
disability at age 65 for pension purposes.

[Section 4.17]{.underline}. 38 CFR 4.17 has been amended to delete the
presumption of permanent and total disability at age 65. 38 CFR 4.17 has
also been amended to require for all veterans, regardless of age, a
single disability rated as 60 percent or a combined evaluation of 70
percent, with one disability ratable at 40 percent or higher (see §
4.16(a)). Claims of any veterans who fail to meet the required
percentages but are otherwise entitled and unemployable will continue to
be referred to the Adjudication Officer under § 3.321(b)(2).

REGULATORY AMENDMENT

4-92-1

Regulations Affected: 38 CFR 4.88a, diagnostic codes 6351, 6352, and
6353

EFFECTIVE DATE OF REGULATION: March 24, 1992

Date Secretary Approved Regulation: February 7, 1992

Federal Register Citation: 57 FR 10134-6 (March 24, 1992)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why these changes
are being made. This comment is not regulatory.

Three diagnostic codes were previously used for rating HIV-related
illnesses: diagnostic code 6351, Acquired immunodeficiency syndrome
(AIDS); diagnostic code 6352, AIDS related complex (ARC); and diagnostic
code 6353, HIV antibody positive. Diagnostic codes 6351 and 6352 were
rated by reference to the underlying disease, and diagnostic code 6353
was assigned a 0 percent evaluation. The need for more specific rating
criteria became clear when the multitude and complexity of symptoms
associated with HIV infection were considered. Constitutional and
neurological diseases can be rated under a variety of diagnostic codes,
and since many analogies are possible, inconsistent evaluations often
resulted. Opportunistic infections may resolve with minimal chronic
impairment of the affected body system, but the average person\'s
employment potential is markedly compromised. Although the HIV infection
may not have progressed to the stage of AIDS or ARC, an individual may
nevertheless be symptomatic and partially disabled.

Diagnostic codes 6352 and 6353 have been removed, and HIV-related
illnesses are now rated under a single diagnostic code, 6351. This code
contains evaluation criteria at the levels of 0, 10, 30, 60, and 100
percent which allow for rating by staging or symptomatology, whichever
permits a higher evaluation. Separate evaluations under other diagnostic
codes for manifestations of the disease are also permitted if a higher
overall evaluation would thereby result.

[Section 4.88a]{.underline}. Diagnostic codes 6351 (Acquired
Immunodeficiency Syndrome), 6352 (Aids Related Complex), and 6353 (HIV
Antibody positive) have been replaced by a single diagnostic code 6351
for HIV-related illnesses with evaluation criteria at the 0, 10, 30, 60,
and 100 percentage levels.

REGULATORY AMENDMENT

4-93-1

Regulation affected: 38 CFR 4.31

EFFECTIVE DATE OF REGULATION: October 6, 1993

Date Secretary Approved Regulation: August 26, 1993

Federal Register Citation: 58 FR 52017-18 (October 6, 1993)

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

A majority of the disabilities addressed in the VA\'s Schedule for
Rating Disabilities (38 CFR part 4) do not specify criteria for a zero
percent level. Once it has been determined that a disability is
service-connected, it has been VA\'s consistent practice to assign a
zero percent evaluation whenever the condition does not meet the stated
minimum requirements for compensable evaluation. In recent decisions,
however, the U.S. Court of Veterans Appeals (COVA) pointed out that
unless an individual diagnostic code requires residual disability for a
compensable evaluation, a zero percent evaluation is not authorized
under §§ 3.357(a) and 4.31. See [Rabideu]{.underline} [v.]{.underline}
[Derwinski]{.underline}, U.S. Vet. App. No. 90-1296 and
[Conley]{.underline} [v]{.underline}. [Derwinski]{.underline}, U.S. Vet.
App. No. 91-527. From the Court\'s analysis it is apparent that VA
regulations are seen as being inconsistent with VA\'s longstanding
practice of assigning a zero percent evaluation for any disability which
does not meet the minimum requirements for a compensable evaluation.

We have amended § 4.31 to eliminate this perceived discrepancy between
VA practice and regulations. We have changed the heading of § 4.31 from
\"A no-percent rating\" to \"Zero percent evaluations\" to more
accurately represent the issue addressed in the regulation.

We have deleted § 3.357(a) because it is a duplicate of § 4.31 and
because the issue is more appropriately addressed in the rating
schedule.

[Section 4.31]{.underline}: Section 4.31 has been revised to provide
that, in every instance where the schedule does not provide a zero
percent evaluation for a diagnostic code, a zero percent evaluation
shall be assigned when the requirements for a compensable evaluation are
not met.

REGULATORY AMENDMENT

4-94-1

Regulation affected: 38 CFR 4.115, 4.115a.

EFFECTIVE DATE OF REGULATION: February 17, 1994

Date Secretary Approved Regulation: March 5, 1993

Federal Register Citation: 59 FR 2523-2529, January 19, 1994

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

In December 1988, the General Accounting Office (GAO) recommended that
VA prepare a plan for a comprehensive review of the rating schedule and,
based on the results, revise the medical criteria accordingly. Based in
part on this recommendation, the Compensation and Pension Service
initiated a systematic review of the Schedule for Rating Disabilities
(38 CFR Part 4) in order to remove outdated medical terminology and
ambiguous rating criteria and to introduce recent medical advances.

We have made a number of editorial changes, primarily of syntax and
punctuation, throughout these section, intended to clarify the rating
criteria and represent no substantive amendment. We have deleted generic
terms such as \"severe\", \"moderate\", and \"mild\" from various
evaluation criteria and replaced them, whereever possible, with more
objective, unambiguous descriptions of the levels of disability. We have
also changed a number of terms to reflect current medical terminology
and to clarify various anatomical aspects or treatment procedures.

We added two sentences to § 4.115 to clarify that hypertension or heart
disease will be separately rated if absence of a kidney is the sole
renal disability and that hypertension or heart disease will be
separately rated if renal disease has progressed to the point where
regular dialysis is required. This makes regulatory the long-established
policy which is included in the [Department of Veterans Benefits
Manual]{.underline} [of Adjudication Procedures]{.underline}, M21-1.

We have redesignated § 4.115a as § 4.115b and replaced the existing §
4.115a with an explanation of the three new dysfuntion formulas which
follow.

In order to allow a broader range of possible evaluations for many
disabilities and a more accurate level of compensation for each, we have
provided three general dysfunction formulas for disabilities of the
genitourinary system. Diagnostic codes throughout the section refer to
these criteria for evaluation of the predominant dysfunction. The
evaluations prescribed for each catagory of dysfunction are generally
consistent with percentages and criteria currently specified under the
following diagnostic codes: 7502, nephritis, corresponding to renal
dysfunction; 7512, cystitis with criteria relating to frequency of
urination, corresponding to voiding dysfunction; 7518, stricture of
urethra with criteria relating to dialtion treatments, corresponding to
urinary tract infection, and also relating to obstructed voiding as a
catagory of voiding dysfunction; and, 7519, fistula of urethra with
criteria relating to frequency of drainage, corresponding to continual
urinary leakage as a catagory of voiding dysfunction.

Under renal dysfunction and diagnostic code 7530, chronic renal disease
requiring regular hemodialysis, the word dialysis has been used instead
of hemodialysis in order to include consideration of continuous
ambulatory peritoneal dialysis, as well as hemodialysis, in the
assignment of a total evaluation. Specific measurements of creatinine
and blood urea nitrogen (BUN) are provided for the 100 and 80 percent
evaluations under renal dysfunction. The term \"nonprotein nitrogen\"
shown under diagnostic code 7502, chronic nephritis, is obsolete and has
been removed as a measure of kidney dysfunction. We have described
hypertension requirements in terms of diagnostic code 7101, essential
hypertension, under the 60, 30 and 0 percent levels of evaluation for
renal dysfunction in order to promote a clear understanding of the rule
and for internal consistency within the rating schedule.

We have deleted the one year period of convalescence under diagnostic
code 7528, malignancies of the genitourinary system in favor of an
indefinite period of convalescence with mandatory examination at the end
of six months; any reduction in evaluation based on the findings of the
examination will be implimented in accordance with § 3.105(e). This will
provide the claimant contemporaneous notification and base any reduction
on current medical findings rather than a regulatory assumption that
there has been an improvement.

Similarly, we have deleted the two year convalescence period under
diagnostic code 7531, kidney transplant. Kidney transplants have become
far more common since 1975, when a total evaluation for two years was
first specified in the rating schedule, and improved surgical techniques
and experience with immuno-suppressive management make it possible to
assess residual impairment one year after surgery instead of two. As
with malignancies, there will be an indefinite period of convalescence
with a mandatory VA examination, in this case one year after hospital
discharge following surgery, and any reduction will be based on the
findings of this examination, subject to the provisions of 38 CFR
3.105(e). We have retained the 30 percent minimum evaluation. Subsequent
to convalescence, the residuals are to be evaluated as renal
dysfunction, in order to provide consistent evaluations and objective
criteria.

We have eliminated four of the diagnostic categories. Pyelitis,
diagnostic code 7503, is not currently used in medical practice and is
generally understood to be included under pyelonephritis, which remains
as diagnostic code 7504. Intersitial cystitis, diagnostic code 7513 is
included under chronic cystitis, diagnostic code 7512, since these are
essentially the same disability. Chronic cystitis is amended to include
cystitis of all etiologies, infectious and non-infectious. Tuberculosis
of the bladder, diagnostic code 7514, is a very uncommon disease and it
does not warrant a separate code in this section of the schedule.
Ratings for nonpulmonary tuberculosis are prescribed by §§ 4.88b and
4.89. Resection or removal of the prostate gland is included under
diagnostic code 7527, prostate gland injuries. Residuals of total
prostatectomy are to be evaluated according to the severity of the
individual disability instead of assigning a minimum evaluation of 20
percent. A separate diagnostic code is therefore redundant.

Eleven new codes have been added to this section of the rating schedule.
Renal tubular dysfunctions, diagnostic code 7532, is given a minimum 20
percent evaluation if symptomatic, with instructions to otherwise rate
as renal dysfunction. The following nine conditions are to be rated as
renal dysfunction: Cystic disease of the kidneys, code 7533;
atherosclerotic renal disease, 7534; toxic neuropathy, 7535;
glomerulonephritis, 7536; interstitial nephritis, 7537; papillary
necrosis, 7538; renal amyloid disease, 7539; disseminated intravascular
coagulation with renal cortical necrosis, 7540; and renal involvement in
diabetes mellitus, sickle cell anemia, systemic lupus erythematosus,
vasculitis, or other systemic disease processes, 7541. These additional
codes have been added in order to reduce reliance on the uncertain
practice of rating many kidney disorders by analogy. We have added
diagnostic code 7542, neurogenic bladder, with instructions to rate the
condition under the criteria for voiding dysfunction. This is a common
condition in cases of severe spinal cord injury.

Diagnostic code 7500, removal of one kidney, is changed to instruct the
rater to evaluate the condition as renal dysfunction if there is
nephritis, infection or pathology of the other kidney. This represents
consideration of entire renal dysfunction and is the most consistent
means of rating kidney disorders.

Diagnostic code 7508, nephrolithiasis, has been changed to provide a 30
percent evaluation for recurrent stone formation if drug or diet therapy
or invasive or non-invasive procedures, more than two times per year are
required. If stone formation is not recurrent to this extent, the
condition will be evaluated according to the criteria for
hydronephrosis, diagnostic code 7509. Ureterolithiasis, code 7510, and
stricture of the ureter, code 7511, have been given the same criteria
for evaluation. This provides objective criteria and consistency within
this section of the schedule.

We have changed the criteria for the \"severe\" level of hydronephrosis,
diagnostic code 7509, to to instruct the rater to use objective
evaluation criteria under the general formula for renal dysfunction.

The percentage evaluation for loss of one testicle under diagnostic code
7524 has been reduced from 10 percent to zero percent and the term
\"other than undecended or congenitally undeveloped\" has been deleted
from the new zero percent level. No significant employment handicap is
anticipated from loss of a single testical, any retrogressive changes in
secondary sex characteristics even following removal of both testes
after sexual maturity would occur slowly, if at all, and a solitary
testis is adequate to sustain normal endocrine function without hormone
replacement.

The title of epididymo-orchitis, tuberculous, active or inactive,
diagnostic code 7525, has been changed to epididymo-orchitis, chronic
only, with instructions to rate as urinary tract infection. The
instructions to rate tubercular infections under §§ 4.88b or 4.89 has
been retained. These new instructions allow for evaluation of any type
of epididymal infection under this code.

The instructions for evaluation of prostate gland injuries, infections,
hypertrophy, or postoperative residuals, diagnostic code 7527, have been
changed to evaluate the conditions as voiding dysfunction or urinary
tract infection, consistent with other codes in this section and to
provide the widest, most objective range of criteria.

The title of diagnostic code 7528, new growths, malignant, any specified
part of genitourinary system, has been changed to malignant neoplasms of
the genitourinary system because the term neoplasm better connotes the
pathological abnormality. Following convalescence, as explained above,
the condition will be evaluated as voiding dysfunction or renal
dysfunction, whichever is predominant, in order to provide consistent
evaluations and objective criteria.

[Section 4.115:]{.underline} Revised to clarify that hypertension or
heart disease will be separately rated if absence of a kidney is the
sole renal disability, if it has progressed to the point where regular
dialysis is required.

[Section 4.115a:]{.underline} Redesignated as section 4.115b, and
replaced with the explanation of the three new dysfunction formulas for
evaluating a number of genitourinary disabilities.

[Section 4.115b:]{.underline} Added as the heading for the section
containing the rating codes and diagnoses for genitourinary
disabilities.

Diagnostic codes Diagnostic codes Diagnostic codes

Revised Added Removed

7500 7532 7503

7502 7533 7513

7508 7534 7514

7509 7535 7526

7510 7536

7511 7537

7524 7538

7525 7539

7527 7540

7528 7541

7530 7542

7531

REGULATORY AMENDMENT

4-94-2

Regulation affected: 38 CFR 4.150.

EFFECTIVE DATE OF REGULATION: February 17, 1994

Date Secretary Approved Regulation: August 19, 1993

Federal Register Citation: 59 FR 2529-2530, January 18, 1994

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

In December 1988, the General Accounting Office (GAO) recommended that
VA prepare a plan for a comprehensive review of the rating schedule and,
based on the results, revise the medical criteria accordingly. Based in
part on this recommendation, the Compensation and Pension Service
initiated a systematic review of the Schedule for Rating Disabilities
(38 CFR Part 4) in order to remove outdated medical terminology and
ambiguous rating criteria and to introduce recent medical advances.

The schedule of ratings for Dental and Oral Conditions lists five
disabilities without diagnostic codes: Carious teeth, treatable; missing
teeth, replaceable; dento-alveolar abscess; pyorrhea alveolaris; and
Vincent\'s stomatitis. These conditions are not considered disabling and
the issue of service-connection is addressed by raters only for the
purpose of determining entitlement to out patient dental treatment under
the provisions of 38 CFR 3.382 and 17.123. We have deleted them from §
4.150 and added a new section designated as § 4.149 which states, in
more contemporary terms, that these conditions are not compensable
conditions, but that they may be considered service-connected solely for
the purpose of establishing entitlement to dental examination or
outpatient dental treatment.

We have included osteoradionecrosis under diagnostic code 9900,
osteomyelitis of the maxilla or mandible, because this condition occurs
often enough in the veteran population to warrant inclusion and because
its disabling effects are similar to osteomyelitis.

We have denoted categories of both inter-incisal and lateral excursion
of the temporomandibular joint, diagnostic code 9905 because this
diagnostic code does not specify this type of limitation. We have
provided evaluation levels of 10, 20, 30, and 40 percent for precise
ranges of inter-incisal motion limitation and a 10 percent evaluation
for limited lateral excursion from 0 to 4 millimeters. We have provided
a NOTE following the code specifying that ratings for limited
inter-incisal movement will not be combined with ratings for limited
lateral excursion under this code in accordance with the prohibition
against pyramiding (38 CFR 4.14).

We have deleted diagnostic code 9510, maxilla, loss of whole or part of
substance of, nonunion of , or malunion of because disabilities of the
maxilla are not comparable to those of the mandible, as the instructions
to rate the disability imply. We have added three new codes, 9914, 9915
and 9916, each with its own percentage ranges and evaluation criteria in
order to provide complete and equitable evaluations for these
disabilities.

We have revised the note following diagnostic code 9913, teeth, loss of,
due to loss of substance of maxilla or mandible to use the less
ambiguous term \"periodontal disease\" instead of \"natural resorption\"
and to explain why loss of the alveolar process without loss of bone is
not compensable.

We have revised the evaluation criteria of diagnostic code 9913 because
the current descriptions are confusing and unclear. No substantive
change is intended by this revision.

We have substituted the word \"prosthesis\" for the term \"prosthetic
appliance under codes 9911 and 9912 for the sake of consistency, since
\"prosthesis\" is used under code 9913 and other diagnostic codes
throughout the schedule.

[Section 4.149]{.underline}: This section is added to include the
non-disabling conditions which are listed for the purpose of determining
entitlement to dental examination and dental outpatient treatment and to
instruct the rater that these are not compensable conditions.

[Section 4.150:]{.underline} This section is amended to:

1\) Include osteoradionecrosis under diagnostic code 9900, osteomyelitis
of the maxilla or mandible,

2\) Provide specific criteria for limitations of ranges of motion of the
jaw, diagnostic code 9905, and to add a NOTE cautioning against
pyramiding,

3\) Add three diagnostic codes: 9914, maxilla, loss of more than half,
9915, maxilla, loss of half or less, and 9916, maxilla, malunion or
nonunion, with percentage evaluations for each at levels appropriate to
the levels of disability,

4\) Amend the note following diagnostic code 9913, tooth loss due to
damage of the mandible or maxilla, for clarity and to explain why loss
of the alveolar process without bone loss is not compensable,

5\) Clarify the descriptions of combinations of loss of teeth in
diagnostic code 9913,

6\) Substitute the word \"prosthesis\" for the term \"prosthetic
appliance\" under diagnostic code 9912.

Diagnostic codes Diagnostic codes Diagnostic codes

Revised Added Removed

9900 9914 NONE

9905 9915

9912 9916

9913

REGULATORY AMENDMENT

4-94-3

Regulation Affected: 38 CFR 4.115b

EFFECTIVE DATE OF REGULATION: September 8, 1994

Date Secretary Approved Regulation: July 28, 1994

Federal Register Citation: 59 FR 46338-9 (September 8, 1994)

The purpose of the following comments on the changes included in these
amendments of VA regulations is to inform all concerned why the changes
are being made. These comments are not regulatory.

The final revision of the section of the Schedule for Rating
Disabilities of the Genitourinary System was published in the Federal
Register on January 18, 1994. Taking into account a comment we received
after publication of the proposed revision of the genitourinary section
of the rating schedule that we should add a n note under DC 7522 (Penis
deformity, with loss of erectile power) indicating entitlement to SMC,
we have reconsidered the issue of providing guidance to rating
specialists in the rating schedule on the issue of special monthly
compensation (SMC). We concluded that the combination of the two
provisions added by this amendment is the best means of assuring that
potential entitlement to SMC is considered.

The amendment adds a note at the beginning of 38 CFR 4.115b requiring
rating specialists to refer to 38 CFR 3.350 any time they evaluate a
claim involving loss or loss of use of a creative organ, and also adds a
footnote at diagnostic codes 7522, 7523, and 7524 directing the rater to
review for entitlement to special monthly compensation under § 3.350.

REGULATORY AMENDMENT

4-94-4

Regulation affected: 38 CFR 4.88a and 4.88b.

EFFECTIVE DATE OF REGULATION: November 29, 1994

Date Secretary Approved Regulation: August 1, 1994

Federal Register Citation: 59 FR 60901-2, November 29, 1994

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

We have amended 38 CFR 4.88a and 4.88b and added 4.88c by means of an
interim rule with request for comments in order to add a diagnostic code
and evaluation criteria for chronic fatigue syndrome to the portion of
the rating schedule on systemic diseases. We have provided evaluation
levels of 10, 20, 40, 60, and 100 percent. Chronic fatigue syndrome is
of unknown etiology and is characterized by non-specific symptoms.
Because it has been ill-defined and sometimes confused with other
conditions, we have also added a section that provides diagnostic
criteria for the syndrome.

We have made this an interim rule with request for comments so that it
can be effective immediately, but comments will be received for 60 days,
and the rule may be amended based on the comments.

[Sections 4.88a and 4.88b]{.underline} are redesignated 4.88b and 4.88c
respectively.

[Section 4.88a]{.underline} is added to provide diagnostic criteria for
chronic fatigue syndrome.

[Section 4.88b]{.underline}. New diagnostic code 6354 has been added.

REGULATORY AMENDMENT

4-95-1

Regulation affected: 38 CFR 4.116 and 4.116a

EFFECTIVE DATE OF REGULATION: May 22, 1995.

Date Secretary approved regulation: December 22, 1994.

Federal Register Citation: 60 FR 19851-6, April 21, 1995

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.116 and
4.116a of 38 CFR, Part 4, the sections of the rating schedule that deal
with gynecological conditions and disorders of the breast. The intended
effect of this action is to update the gynecological and breast
disorders section of the rating schedule to ensure that it uses current
medical terminology, unambiguous criteria, and that it reflects medical
advances which have occurred since the last review.

We changed the title of this part of the rating schedule from
\"gynecological conditions\" to \"gynecological conditions and disorders
of the breast\" to reflect more accurately the content. We made language
changes consistent with current medical usage, such as changing
\"mammary glands\" to \"breasts,\" \"new growths\" to \"neoplasms,\" and
\"extirpation,\" \"resection,\" and \"excision\" to \"removal.\"

We deleted the introductory section, 4.116, removing some material and
putting the material that remained in the form of a note. We removed
from the material the statement that excision of uterus, ovaries, etc.,
prior to the natural menopause is considered disabling because the
implied distinction of the effects of the surgery itself before and
after the menopause is not warranted.

We also removed from the material in § 4.116 the statement that surgical
complications of pregnancy will not be held the result of service except
when additional disability resulted from treatment, or they are
otherwise attributable to unusual circumstances of service. These
remarks were unclear, seemingly restricting service connection in most
cases, and such chronic disabilities, if incurred during service, would
be subject to service connection, as with other chronic disabilities.
For further clarification, we added the statement that chronic residuals
of medical or surgical complications of pregnancy may be disabilities
for rating purposes.

We added footnotes at diagnostic codes (DC\'s) 7617 through 7620 and a
note at the beginning of § 4.116 to alert the rater to consider special
monthly compensation (SMC) because we believe that the combination of
the footnotes and note is the best method of assuring that potential
entitlement to SMC is considered.

We removed the criteria of \"mild,\" \"moderate,\" and \"severe\" that
had been used to evaluate disease or injury of vulva, vagina, or cervix,
and for disease, injury, or adhesions of uterus, Fallopian tube
(including PID), or ovary (DC\'s 7610 through 7615). In their place, we
provided a general rating formula using objective evaluation criteria
based on the need for continuous treatment and whether symptoms are
controlled by treatment. These changes will assure that comparable
medical conditions are assigned comparable evaluations. We also revised
the titles of DC\'s 7610 through 7615 to clarify the proper
classification of gynecological conditions.

We changed the convalescent period following the removal of uterus and
ovaries, or ovaries alone (DC\'s 7617 and 7619) from 6 months to 3
months, in accord with current medical practice, and taking into account
improved surgical techniques, postoperative care, and the practice of
early ambulation. We also changed the title of DC 7619 from \"ovaries,
removal of both\" to \"ovary, removal of\" so that a three-month period
of convalescence will apply to the removal of one or both ovaries. The
evaluation for removal of one ovary with or without partial removal of
the other (DC 7619) has been changed from 10 percent to 0 percent
because the loss of one ovary does not compromise endocrine or
reproductive function to such an extent that an impairment of earning
capacity ordinarily results.

We provided specific criteria for rectovaginal fistula and
urethrovaginal fistula (DC\'s 7624 and 7625, respectively) rather than
referring the rater to diagnostic codes in other systems for evaluation
criteria. We also removed subjective terminology such as \"extensive
leakage\" and \"fairly frequent\" from the criteria for rectovaginal
fistula (which we had proposed to be the same as the criteria for rectum
and anus, impairment of sphincter control, DC 7332), replacing that
language with more precise criteria, although with the same basis of
evaluation.

We added definitions of the various types of breast surgery for clarity
and also provided a compensable evaluation (30%) for less than a total
mastectomy when there is significant alteration of size or form (DC
7626). This is a type of breast surgery that may be done for neoplasms
and other conditions that is more conservative than a total mastectomy,
but which may still be disabling.

We added a new diagnostic code and evaluation criteria for two common
conditions that previously required rating by analogy: endometriosis (DC
7628) and benign neoplasms of the gynecological system or breast (DC
7629). In order to assure more consistent evaluations of endometriosis
than rating by analogy, we provided evaluation criteria based on the
presence of pelvic pain or heavy or irregular bleeding and whether they
are controlled by treatment, and on whether there is symptomatic
involvement of bladder or bowel. Benign neoplasms are to be evaluated on
the basis of impairment of function

We made a minor revision in the language of the evaluation criteria for
prolapse of uterus (DC 7621) to be more precise, changing \"complete,
through vulva\" to \"complete, through vagina and introitus.\"

We made changes in the convalescent period following treatment for
malignant neoplasm (DC 7627) similar to changes we have made in other
body systems, i.e., requiring a mandatory VA examination 6 months
following completion of treatment and implementation of § 3.105(e)
before any reduction can be made.

[Section 4.116]{.underline} is removed.

[Section 4.116a]{.underline} is redesignated as [§ 4.116]{.underline}.

Diagnostic codes Diagnostic codes Diagnostic codes

revised added removed

7610 7621 7628 NONE

7611 7622 7629

7612 7623

7613 7624

7614 7625

7615 7626

7617 7627

7618

7619

7620

> REGULATORY AMENDMENT

4-95-2

Regulation affected: 38 CFR 4.117

EFFECTIVE DATE OF REGULATION: October 23, 1995.

Date Secretary approved regulation: June 13, 1995.

Federal Register Citation: 60 FR 49225-28, September 22, 1995.

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended section 4.117 of 38
CFR, Part 4, the section of the rating schedule that deal with the hemic
and lymphatic systems. The intended effect of this action is to update
this section of the rating schedule to ensure that it uses current
medical terminology, unambiguous criteria, and that it reflects medical
advances which have occurred since the last review.

We changed the title of DC 7700 from \"pernicious anemia\" to
\"hypochromic-microcytic and megaloblastic anemia\" because we have
expanded this code to include additional anemias that will be evaluated
under the same criteria. The schedule formerly had evaluation levels for
30, 60, 70, and 100 percent. We changed the levels to 0, 10, 30, 70, and
100 percent since the difference between the 60 and 70 percent levels
would be so slight as to be meaningless for rating purposes. We added a
zero percent level to make it clear that those who are asymptomatic
despite a hemoglobin level of 10gm/100ml or less warrant only a zero
percent evaluation, and we added a ten percent level for those who are
anemic and have mild symptoms such as weakness, easy fatigability, or
headaches. We changed the criteria for these anemias to make them more
objective, basing them on a certain range of hemoglobin levels plus
specific signs and symptoms. Finally, we added a note directing that
complications of pernicious anemia be rated separately because such
complications occur often enough to warrant instructions in order to
ensure consistent ratings.

We deleted DC 7701, secondary anemia, because this represents a symptom
of another more specific disease and does not warrant its own diagnostic
code.

For acute agranulocytosis, DC 7702, we changed the evaluation levels
from 30, 60, 70, and 100 percent to 10, 30, 60, and 100 percent. We
removed the 70 percent level because, as stated under DC 7700, the
difference between the 60 and 70 percent levels would be so slight as to
be meaningless for rating purposes. We added a 10 percent level when the
condition requires continuous medication for control. Previously, acute
agranulocytosis was rated under the criteria for acute pernicious
anemia. However, the course and treatment of agranulocytosis are usually
substantially different from those of pernicious anemia, and we have
therefore provided new criteria based on the need for a bone marrow
transplant or transfusions, the presence of recurrent infections, or the
need for continuous medication for control, since these are more
appropriate means of evaluating this condition than the criteria we have
used for DC 7700. We added a note stating that a 100 percent evaluation
will be assigned from the date of hospital admission for a bone marrow
transplant, with a mandatory VA examination to be done six months later,
and any change in evaluation to be subject to the provisions of §
3.105(e). This will ensure that no evaluation after bone marrow
transplant is reduced without current medical evidence, offers veterans
prior notice of any proposed action, and provides an opportunity for the
veteran to present evidence showing that the action should not be taken.

Under DC 7703, leukemia, we edited the language regarding requirements
for a 100 percent evaluation and changed the direction for rating
otherwise, directing that it be under either DC 7700 or 7716 (a new code
for aplastic anemia), depending on which results in a higher evaluation.
This provides a broader range of evaluations, consistent with what may
be seen in this condition. For consistency with the method of evaluating
malignancies of other body systems, we added a note directing that the
total evaluation be continued, with a mandatory VA examination six
months following completion of therapy, and any change in evaluation be
subject to the provisions of § 3.105(e).

We changed the title of DC 7704, primary polycythemia, to the more
current name for this condition, polycythemia vera. This condition was
formerly rated as pernicious anemia, but we have provided criteria more
specific to this condition, with evaluation levels of 10, 40, and 100
percent, based on the need for phlebotomy or myelosuppressant therapy,
and on whether it is stable. We added a note directing that
complications be rated separately because they occur often enough that
this instruction is needed to assure that veterans are rated
consistently.

We changed the title of DC 7705 from purpura hemorrhagica to the more
modern term, thrombocytopenia, primary, idiopathic or immune. We made
the criteria more objective, basing them primarily on the blood platelet
count, requirement for treatment, and whether there is bleeding. As with
several other conditions in this section, we changed the evaluation
levels from 30, 60, 70, and 100 percent to 0, 30, 70, and 100 percent
because the 60 percent level is clinically indistinguishable from the 70
percent level for rating purposes, and we added a zero percent level to
indicate that when the platelet count is stable and above 100,000, and
there is no bleeding, the condition does not warrant more than a zero
percent evaluation.

We changed the evaluation level for splenectomy, DC 7706, from 30
percent to 20 percent because, although antibiotics now available can
diminish the consequences of splenectomy (such as increased
susceptibility to infection), the spleen also has other functions, and
splenectomy is therefore still considered moderately disabling. We added
a note under DC 7706 to clarify that complications of splenectomy are to
be separately evaluated.

Under DC 7707, spleen, injury of, healed, we changed the direction from
\"rate as peritoneal adhesions\" to \"rate for any residuals\" to take
into account the fact that residuals other than peritoneal adhesions may
occur.

We changed the title of DC 7709 from lymphogranulomatosis (Hodgkin\'s
disease) to Hodgkin\'s disease because this is the modern name for the
condition. Rather than continuing evaluation levels of 30, 60, and 100
percent based on specific signs and symptoms, we based the 100 percent
evaluation level on the presence of active disease or during a treatment
phase and added a note directing the same procedure as for leukemia and
other malignancies \-- a mandatory VA examination six months following
the cessation of treatment, and any change in evaluation to be subject
to the provisions of § 3.105(e). In addition to the benefits mentioned
above (under the discussion of DC 7702) regarding the use of § 3.105(e),
this change will allow the assignment of any level of evaluation based
on the findings at examination.

We changed the title of DC 7710 from adenitis, cervical, tuberculous,
active or inactive, to adenitis, tuberculous, active or inactive. This
consolidates three types of tuberculous adenitis that are now relatively
uncommon: cervical, axillary (formerly DC 7711), and inguinal (formerly
DC 7712), into a single code. We have deleted DC\'s 7711 and 7712. We
also removed the direction to rate active disease at 100 percent and
inactive as §§ 4.88b and 4.89 in favor of a direction to rate as §§
4.88c or 4.89, which are the sections that direct how to evaluate
nonpulmonary tuberculosis.

We have deleted DC 7713, adenitis, secondary, because it is commonly
accepted as a symptom of a specific disease and would be included in the
evaluation for that disease.

Under DC 7714, sickle cell anemia, we revised the language of the
criteria for the sake of more objectivity by removing the subjective
terms \"mild,\" \"moderately severe,\" \"severe,\" and \"pronounced\";
and we made other editorial, non-substantive changes in the criteria and
the note under the code.

There was an instruction under non-Hodgkin\'s lymphoma, DC 7715, to rate
as Hodgkin\'s disease (DC 7709). For the sake of convenience of those
using the schedule, we repeated the criteria used to evaluate Hodgkin\'s
disease under DC 7715.

We added a new condition, aplastic anemia, DC 7716, with the same
criteria and evaluation levels we have provided for acute
agranulocytosis, DC 7702, because the treatment of these conditions is
similar.

Diagnostic codes Diagnostic codes Diagnostic codes

revised added removed

7700 7716 7701

7702 7711

7703 7712

7704 7713

7705

7706

7707

7709

7710

7714

7715

REGULATORY AMENDMENT

4-96-1

Regulation affected: 38 CFR 4.71a.

EFFECTIVE DATE OF REGULATION: May 7, 1996

Date Secretary Approved Regulation: December 7, 1995

Federal Register Citation: 61FR 20438-9

The purpose of the following comment on the change included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

We have amended 38 CFR 4.71a by means of an interim rule with request
for comments in order to add a diagnostic code and evaluation criteria
for fibromyalgia to the portion of the rating schedule on
musculoskeletal diseases. We have provided evaluation levels of 10, 20,
and 40 percent. Fibromyalgia is a syndrome of unknown etiology that is
characterized by chronic, widespread musculoskeletal pain associated
with multiple tender or \"trigger\" points, and often with multiple
somatic complaints, such as sleep disorders, anxiety, fatigue, headache,
and irritable bowel symptoms. Other possible associated complaints
include neurologic symptoms such as numbness and weakness without
objective neurologic findings, depression, Raynaud\'s-like syndrome, and
weakness.

Classification criteria for fibromyalgia for research and
epidemiological purposes were established by the American College of
Rheumatology in 1990. The first requirement is a history of widespread
pain, which means pain in both the left and right sides of the body,
pain both above and below the waist, and pain in both the axial
(cervical spine, anterior chest, thoracic spine, or low back) and
peripheral (extremity) skeleton. The second requirement is the presence
of pain on digital palpation at a minimum of 11 of the following 18
tender point sites: occiput, low cervical, trapezius, supraspinatus,
second rib, lateral epicondyle, gluteal, greater trochanter, knee (there
is a left site and a right site at each location). In clinical practice,
the diagnosis is often made on less stringent criteria, with fewer
tender points required.

We are providing three levels of evaluation: 10, 20, and 40 percent,
consistent, in our judgment, with the clinical range of impairment of
this condition. While patients may have numerous symptoms that may be
chronic, it is a benign disease that does not result in loss of
musculoskeletal function. For the 40 percent level, the requirements are
that the widespread pain and multiple tender points, with or without
certain associated complaints, be constant, or nearly so, and refractory
to therapy. For the 20 percent level, the requirements are that the pain
and tender points, etc., be episodic, with exacerbations often
precipitated by environmental or emotional stress or by overexertion,
but present more than one-third of the time. For the 10 percent level,
the requirement is that the pain and tender points, etc., require
continuous medication for control.

We have made this an interim rule with request for comments so that it
can be effective immediately, but comments will be received for 60 days,
and the rule may be amended based on the comments.

[Section 4.71a]{.underline}. New diagnostic code 5025 has been added.

REGULATORY AMENDMENT

4-96-2

Regulation affected: 38 CFR 4.119.

EFFECTIVE DATE OF REGULATION: June 6, 1996.

Date Secretary approved regulation: December 5, 1995.

Federal Register Citation: 61 FR 20440-47

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended section 4.119 of 38
CFR, Part 4, the section of the rating schedule that deals with
endocrine system disabilities.

We changed the evaluation criteria for hyperthyroidism (DC 7900) to make
them more objective, for example, by removing subjective terms such as
\"pronounced,\" \"severe,\" \"moderately severe,\" \"marked,\" and
\"moderate,\" because they serve no objective function, and by defining
tachycardia as more than 100 beats per minute. The former schedule
required \"severe\" tachycardia at the 100-percent level, but since the
medical literature does not define severe tachycardia, we have removed
\"severe.\" We added eye involvement to the criteria for a 100-percent
evaluation because long-standing hyperthyroidism can lead to significant
impairment affecting the eyes. We deleted references to surgery because
they are of no value in explaining the qualifying symptoms. We specified
that the \"nervous symptoms\" formerly included in the 100-percent
criteria are \"sympathetic nervous system\" symptoms since this is the
part of the nervous system affected. We edited the notes under DC7900
for clarity.

We removed the zero-percent levels for DC\'s 7900 and 7903, which
required that the condition be \"in remission\" because they merely
restate the general rule found in §4.32. We deleted the criteria that
referred to hormone levels for DC\'s 7900, 7903, and 7904 because
although many endocrine conditions require laboratory confirmation of
hormone levels for diagnosis, the hormone levels may not correlate with
the severity of the clinical findings, and laboratory findings are
therefore more useful for diagnosis than for evaluation.

Rather than directing in a note the assignment of a 10-percent
evaluation for hyperthyroidism, hypothyroidism (DC 7903), and
hypoparathyroidism (DC 7905) when continuous medication is required for
control, we have added \"continuous medication required for control\" to
the evaluation criteria themselves at the 10-percent level. For the sake
of consistency, we have made \"continuous medication required for
control\" a criterion for a 10-percent evaluation for
hyperparathyroidism (DC 7904) as well.

For the convenience of rating specialists, we repeated the criteria for
DC 7900 (hyperthyroidism) under DC 7901 (thyroid gland, toxic adenoma
of) rather than directing to rate as DC 7900.

We removed \"with pressure symptoms\" from the criteria (because they
are rarely encountered) in favor of a note directing that if there are
symptoms due to pressure on adjacent organs, evaluation is to be made
under the diagnostic code for disability of the affected organ, if doing
so would result in a higher evaluation. We also removed \"marked\" as a
modifier of disfigurement for a 20-percent evaluation because it is our
judgment that any adenoma substantial enough to be disfiguring warrants
a 20-percent evaluation.

As under DC 7900, we removed the subjective terms \"pronounced,\"
\"severe,\" \"moderately severe,\" and \"moderate\" from the criteria
for DC 7903 (hypothyroidism). We also removed the requirement for slow
return of reflexes for a 100-percent evaluation and added criteria of
cold intolerance, muscular weakness, and cardiovascular involvement
because these symptoms are typical of the disease when it is totally
disabling. Also at the 100-percent level, we changed \"slow pulse\" to
the more objective \"bradycardia (less than 60 beats per minute)\" and
removed \"sluggish mentality\" in favor of \"mental disturbance
(dementia, slowing of thought, depression)\" because these are the
common mental disturbances that may be seen in advanced hypothyroidism.
We revised the former criteria for the 60-percent level in favor of the
more objective criteria: \"muscular weakness, mental disturbance, and
weight gain\". We made \"fatigability, constipation, and mental
sluggishness,\" instead of \"sluggish mentality and other indications of
myxedema,\" the criteria for the 30-percent level because they are
commonly encountered symptoms and are more specific than the former
criteria.

We removed \"osteitis fibrosa cystica\" from the title of DC 7904
(hyperparathyroidism) because that term represents certain bony findings
that may be seen in hyperparathyroidism rather than being another term
for hyperparathyroidism itself. As under other endocrine criteria, we
removed subjective terms such as \"pronounced,\" \"severe,\" and
\"marked.\" We removed \"high blood and urinary calcium\" from the
criteria for a 100-percent evaluation and \"manifestations of
hypercalcemia and urinary calcium\" from the 60-percent level for the
same reason we deleted criteria related to hormone levels under other
endocrine conditions\--these laboratory findings are more pertinent to
diagnosis than to evaluation of functional impairment. We removed
\"marked weight loss\" in favor of \"gastrointestinal symptoms (nausea,
vomiting, anorexia, constipation, weight loss, or peptic ulcer) because
this is more representative of the variety of gastrointestinal symptoms
that may be seen in hyperparathyroidism. We added \"kidney stones\" as
an additional criterion at the 100-percent level because they are
indicative of a totally disabling level. For consistency with the
100-percent level criteria, we changed \"muscular weakness,\" one of the
former criteria for the 60-percent level, to \"weakness.\" We deleted
the indefinite \"with symptom combinations less than under
\'pronounced\' \" from the 60-percent level criteria and, as at the
100-percent level, changed \"marked weight loss\" to \"gastrointestinal
symptoms. We revised the instructions under DC 7904 regarding
post-operative or post-treatment evaluation, deleting the reference to
\"residual of benign tumor, considering especially bones and kidneys\"
to a more general direction to evaluate, following surgery or treatment
as \"digestive, skeletal, renal, or cardiovascular residuals.\"

We removed the reference to thyroidectomy in the criteria for a
100-percent level of hypoparathyroidism (DC 7905) because, although
hypoparathyroidism may follow thyroidectomy if the parathyroid glands
are also removed, there are other causes as well. There was a single
100-percent evaluation level based on painful muscular spasms or marked
neuromuscular excitability. We revised the 100-percent criteria to
\"marked neuromuscular excitability,\" with examples, \"plus either
cataract or evidence of increased intracranial pressure,\" with
examples. We added the alternative criteria because they are additional
objective findings that may be seen at this level of disability. We
clarified \"marked neuromuscular excitability\" by adding in parentheses
\"convulsions, muscular spasms (tetany), and laryngeal stridor\" and
eliminated the redundancy of including both \"tetany\" and \"marked
neuromuscular excitability\" as separate symptoms. We added a 60-percent
level based on either marked neuromuscular excitability or a combination
of paresthesias (of arms, legs, or circumoral area) plus cataract or
evidence of increased intracranial pressure, and a 10-percent level
based on the need for continuous medication.

We changed the title of DC 7907 from \"hyperpituitarism (pituitary
basophilism, Cushing\'s syndrome)\" to \"Cushing\'s syndrome\" since
this is the medically accepted term for the condition. We removed the
requirements at the 100-percent level for pathological fractures and
enlargement of the sella turcica, which are rarely encountered, in favor
of the more frequently seen findings of hypertension and weakness, and
removed the subjective term \"marked\" modifying loss of muscle
strength. We replaced the indefinite criteria of \"severe; with symptom
combination less than for the 100-percent rating with only partial
control by treatment\" at the 60-percent level with the more specific
requirements of loss of muscle strength and enlargement of pituitary or
adrenal gland. We added a 30-percent level for milder cases, especially
those that are secondary to steroid treatment, with criteria of striae,
obesity, moon face, glucose intolerance, and vascular fragility, which
are indicators of milder disease than those criteria named at the 60-
and 100-percent levels. We edited the note directing evaluation after
recovery or control by expanding the list of possible residuals.

We changed the title of DC 7908 from \"hyperpituitarism (acromegaly or
gigantism)\" to \"acromegaly,\" since this is the most commonly used
term for this disability. We removed the phrase \"hypofunctional stage
of hyperfunction\" from the criteria for the 100-percent level because
this description does not assist in the evaluation of the condition. We
edited and partially revised the list of symptoms for a 100-percent
evaluation to \"evidence of increased intra-cranial pressure (such as
visual field defect), arthropathy, glucose intolerance, and either
hypertension or cardiomegaly because these findings more accurately
represent the 100-percent level of severity. We also replaced the former
criteria for the 60-percent level with \"arthropathy, glucose
intolerance, and hypertension\" because these are more frequently
encountered symptoms. We removed the phrase \"X-ray evidence of\"
modifying enlarged sella turcica at the 30-percent level as unnecessary.

We changed the title of DC 7909 from \"hypopituitarism (diabetes
insipidus)\" to \"diabetes insipidus\" since this name alone is
sufficient to identify this category of disease. We removed the
subjective modifiers \"pronounced,\" \"severe,\" \"moderately severe,\"
and \"moderate\" because they did not aid in the evaluation of the
condition. As elsewhere in the endocrine system, we removed the
laboratory findings, in this case related to serum and urine osmolality
from the criteria because they are not necessarily consistent with
particular levels of functional impairment. In place of \"excessive
thirst,\" \"polyuria,\" and :polydipsia,\" we added \"polyuria with
near-continuous thirst\" as criteria for all levels. For clarity, we
replaced \"parenteral replacement therapy\" with \"episodes of
dehydration requiring parenteral hydration\" and specified a number of
episodes of dehydration per year for the 40-, 60-, and 100-percent level
for more objectivity.

Under Addison\'s disease, DC 7911, the former criteria included
references to \"episodes\" and \"crises,\" but they were not defined. We
have added notes under DC 7911 defining them, and specified in the
criteria the number of each that warrant each percentage evaluation. We
removed the references to laboratory findings of hyponatremia,
hyperpotassemia, azotemia, hypoglycemia, and cortisol deficiency for the
same reasons as discussed under other endocrine conditions.

We revised the evaluation criteria for diabetes mellitus (DC 7913) to
make them more objective and base them on how well the diabetes is
controlled. The frequency of insulin injection and medical treatment are
valid measures of the severity of diabetes, and we have stipulated a
requirement for more than one daily injection of insulin for the
100-percent evaluation level. We also specified the number of
hospitalizations per year required because of episodes of ketoacidosis
or hypoglycemic reactions and the frequency of visits to a diabetic care
provider that warrant a 60- or 100-percent evaluation. We eliminated the
requirement for a \"large\" or \"moderate\" insulin dosage at the 40-
and 20-percent levels respectively because the severity of diabetes is
better determined by the degree of control in response to treatment than
by the amount of medication required for control.

We deleted from the criteria for the 10- and 20-percent evaluation
levels under DC 7913 the requirement \"without impairment of health or
vigor or limitation of activity\" because they do not affirmatively
denote required criteria for those evaluation levels. A requirement for
regulation of activities was formerly one of the criteria for the 40-
and 100-percent levels but not for the 60-percent level. For the sake of
consistency, we have made \"regulation of activities\" one of the
required criteria for the 40-. 60-, and 100-percent levels. We clarified
the meaning of \"severe\" complications of diabetes and how to evaluate
complications by means of a note and by including a reference to
complications that would and would not be separately compensable under
the 100- and 60-percent criteria respectively.

Under DC 7914, malignant neoplasms of the endocrine system, we made
changes in the convalescent period following treatment that are similar
to changes we have made in other body systems, i.e., requiring a
mandatory VA examination 6 months following completion of treatment and
implementation of § 3.105(e) before any reduction can be made.

We added four commonly occurring endocrine disorders: hyperpituitarism
(prolactin secreting pituitary dysfunction) as DC 7916,
hyperaldosteronism (benign or malignant) as DC 7917, and
pheochromocytoma (benign or malignant) as DC 7918), all to be evaluated
as malignant or benign neoplasm as appropriate, and C-cell hyperplasia
of the thyroid as DC 7919, to be evaluated as malignant neoplasm.

We removed one condition from this section, hyperadrenia (adrenal
genital syndrome), DC 7910, because it is a condition that occurs during
infancy and childhood and is rarely encountered in individuals in
service.

Diagnostic codes Diagnostic codes Diagnostic codes

revised added removed

7900 7916 7910

7901 7917

7902 7918

7903 7919

7904

7905

7907

7908

7909

7911

7912

7913

7914

7915

REGULATORY AMENDMENT

4-96-3

Regulation affected: 38 CFR 4.88 and 4.88b

EFFECTIVE DATE OF REGULATION: August 30, 1996

Date Secretary approved regulation: March 7, 1996

Federal Register Citation: 61 FR 39873 (July 31, 1996)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.88 and
4.88b of 38 CFR, Part 4, the sections of the rating schedule that deal
with infectious diseases, immune disorders, and nutritional
deficiencies. The intended effect of this action is to update these
sections to ensure that they use current medical terminology and
unambiguous criteria, and that they reflect medical advances which have
occurred since the last review.

We changed the title of this portion of the rating schedule from
\"Systemic diseases\" to \"Infectious diseases, immune disorders, and
nutritional deficiencies\" because the former title did not adequately
depict the range of conditions that this section addresses.

We changed the convalescent period for Asiatic cholera (DC 6300) from
six months to three months because treatment of this condition is now
simple, and the condition is ordinarily self-limited to a few days
duration. We also added a note under DC 6300 regarding the rating of
residuals to assure that they will be evaluated.

We changed the title of DC 6301 from \"kala-azar\" to the more modern
term for this condition, \"visceral leishmaniasis.\" We also changed the
convalescent period for this condition from one year to a requirement
for a VA examination six months after the date of inactivity and any
reduction in the total evaluation to be made under the provisions of §
3.105(e). This convalescence will allow a period for recuperation and
also assure that the extent of residual impairment is documented by
examination before any change in evaluation is considered. We added a
note under DC 6301 regarding the rating of residuals such as liver
damage or lymphadenopathy to assure that they will be evaluated.

Similarly, we changed the period of convalescence for leprosy (DC 6302)
from one year to a requirement for a VA examination six months after the
date of inactivity and any reduction in the total evaluation to be made
under the provisions of § 3.105(e). This change was made for the same
reason as for leishmaniasis. We edited the note regarding residuals,
removing the instructions regarding contagious and noncontagious cases,
because all active disease is regarded as 100 percent disabling; and,
following the period of convalescence, the condition is to be evaluated
on the basis of residuals such as skin lesions or peripheral neuropathy.

We changed the criteria for the evaluation of malaria (DC 6304) from
those based on number of relapses and presence of symptoms such as
anemia to a direction to rate active disease at 100 percent, since
active infection is normally totally disabling, and there is no need to
specify the signs and symptoms. We also provided a note explaining the
diagnostic requirements for malaria in current medical practice and
directing that residuals be rated under the appropriate system. This
information replaces the two former notes that discussed diagnosis and
evaluation.

We changed the title of DC 6305 from \"filariasis\" to \"lymphatic
filariasis\" because the criteria formerly used for the evaluation of
filariasis applied only to the lymphatic type. Other types of filariasis
are included in DC 6320, Parasitic diseases otherwise not specified. We
simplified the evaluation by changing the criteria from those based on
recurrences and involvement of extremities and genitalia to a direction
to rate active disease at 100 percent and to rate residuals under the
appropriate system, as we have done for a number of infectious diseases,
and for the same reasons as discussed under malaria.

We modernized the title of DC 6306 by changing it from Oroya fever to
Bartonellosis. We changed the period of convalescence from six months to
three months, which is an adequate period of time for recuperation and
stabilization of red blood cells in the average individual, according to
our consultants. We also added a note regarding evaluation of residuals.

The only change we made under DC 6307, plague, is the addition of a note
regarding residuals, and under DC 6308, relapsing fever, we added
specific examples of residuals that might occur---liver or spleen damage
or central nervous system involvement. We made only minor editorial
changes in DC 6309, rheumatic fever. We also made editorial changes
under DC 6310, syphilis, expanded the title to \"syphilis, and other
treponemal infections\" to accommodate additional treponemal conditions
that can be rated similarly, and listed specific diagnostic codes where
complications might be rated. Under DC 6311, miliary tuberculosis, we
referred the rater to §§ 4.88c or 4.89, the specific sections that apply
to the evaluation of inactive nonpulmonary disease.

For the convenience of the rater, we repeated the criteria for the
evaluation of pellagra, DC 6315, under DC 6313, avitaminosis, rather
than referring the rater to DC 6315. We provided more objective criteria
for beriberi, DC 6314, providing evaluation levels of 30- 60- and
100-percent. We removed the 10-percent level because it was to be
assigned for \"moderate residuals.\" By removing this level and adding a
note regarding residuals, we provide more latitude in evaluating
residuals at any level of disability and also indicate that active
beriberi warrants at least a 30 percent evaluation.

We revised the criteria for the evaluation of pellagra, DC 6315, by
removing subjective language and otherwise made only minor changes. We
removed \"Malta or undulant fever,\" alternative names that are no
longer used, from the title of DC 6316, Brucellosis. We revised the
criteria by establishing a 100-percent evaluation for active disease. We
removed all other criteria and instead stated that residuals such as
liver or spleen damage or meningitis are to be rated under the
appropriate system.

We changed the period of convalescence for scrub typhus, DC 6317, from
six months to three months because with modern therapy, recovery is
prompt and uneventful, and convalescence is short. We also updated the
note regarding the evaluation of residuals.

For melioidosis, DC 6318, we changed the requirement for 100 percent to
active disease, as we have done for several other infectious diseases,
rather than requiring specific signs or symptoms, and we modified the
note regarding residuals.

We added two new diagnostic codes: 6319 for Lyme disease, which has been
identified as a distinct disease and occurs often enough in the veteran
population to warrant a separate code, and 6320, parasitic diseases
otherwise not specified, to accommodate all parasitic diseases not
otherwise listed without the need to rate by analogy. Active disease
under both new codes warrants 100 percent, and residuals are to be rated
under the appropriate system.

We changed the evaluation percentage levels and the criteria for lupus
erythematosus, DC 6350, because the former three highest levels were
indistinguishable clinically, and they are now included in the
100-percent evaluation level. Furthermore, two or three exacerbations
per year of a week or more were felt to be more consistent with a
60-percent level of evaluation rather than the current 30 percent. We
also added two additional potential residuals, adverse effects of
medication, and neurological complications, to the note regarding
residuals and also revised the note for clarity.

[Section 4.88]{.underline} is removed and reserved.

Diagnostic codes Diagnostic codes Diagnostic codes

revised added removed

6300 6319 NONE

6301 6320

6302

6304

6305

6306

6307

6308

6309

6310

6311

6313

6314

6315

6316

6317

6318

6350

REGULATORY AMENDMENT

4-96-4

Regulation affected: 38 CFR 4.96 and 4.97

EFFECTIVE DATE OF REGULATION: October 7, 1996

Date Secretary approved regulation: May 13, 1996

Federal Register Citation: 61FR 46720-31

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.96 and
4.97 of 38 CFR, Part 4, the sections of the rating schedule that deal
with the respiratory system. The intended effect of this action is to
update this portion of the rating schedule to ensure that it uses
current medical terminology and unambiguous criteria, and that it
reflects medical advances which have occurred since the last review.

We revised § 4.96 (a) only to reflect changed diagnostic codes in §
4.97. We added paragraph (c), concerning special monthly compensation
(SMC), to § 4.96 as an additional reminder to the rating agency to refer
to § 3.350 of this chapter to determine whether the veteran may be
entitled to SMC. We also retitled § 4.96 to better reflect its content.

We have made one other change to remind the rating agency to consider
SMC when there is organic aphonia. We placed footnotes at DC\'s 6518
(total laryngectomy) and 6519 (complete organic aphonia), conditions
that may be associated with complete organic aphonia, directing to
review for entitlement to SMC.

We removed chronic atrophic rhinitis (DC 6501) and in its place added
three new diagnostic codes for specific types of rhinitis that may
result in atrophic rhinitis: DC\'s 6522, allergic or vasomotor rhinitis,
with evaluation levels of 10 and 30 percent; 6523, bacterial rhinitis,
with evaluation levels of 10 and 50 percent; and 6524, granulomatous
rhinitis, with evaluation levels of 20 and 100 percent. The percentage
levels are highest for granulomatous diseases because they are most
seriously disabling.

We modernized the title of DC 6502 by changing it from \"septum, nasal,
deflection of\" to \"septum, nasal, deviation of\" and made the criteria
more objective by requiring 50-percent obstruction of the nasal passage
on both sides or complete obstruction on one side for a 10-percent
evaluation rather than using the indefinite term \"marked\" for the
required degree of interference with the breathing space.

We changed \"exposing both nares\" to \"exposing both nasal passages\"
under DC 6504 (nose, loss of part of, or scars) for clarity, and added a
note regarding alternative evaluation under DC 7800, scars, disfiguring,
head, face, or neck.

We provided a general rating formula for sinusitis (DC\'s 6510 through
6514) based on more objective criteria, including signs, symptoms, and
frequency of nonincapacitating episodes, and frequency and duration of
antibiotic treatment of incapacitating episodes (defined in a note) that
warrant a 10- or 30-percent evaluation, and specific findings following
surgery that warrant a 50-percent evaluation.

In order to clarify and distinguish the criteria for the given
percentages of DC 6516, chronic laryngitis, we have removed the
indefinite terms \"severe,\" \"marked,\" and \"moderate\" and revised
the requirements for a ten-percent evaluation to \"hoarseness with
inflammation of cords or mucous membrane\" and for a thirty-percent
evaluation to \"hoarseness with thickening or nodules of cords, polyps,
submucous infiltration, or pre-malignant changes on biopsy.\" We removed
DC 6517, healed injuries of larynx, and combined residuals of laryngeal
trauma and stenosis of the larynx under DC 6520, larynx, stenosis of,
including residuals of laryngeal trauma, with evaluation based on
results of pulmonary function testing or on aphonia (under DC 6519).
This provides more flexibility by providing alternative methods of
evaluation. Under laryngectomy, DC 6518, in addition to adding a
footnote regarding SMC, we added a direction on the evaluation of
partial laryngectomy under DC\'s 6516, 6519, or 6520. We added more
objective criteria for the evaluation of larynx, stenosis of, including
residuals of laryngeal trauma (DC 6520) by basing them on pulmonary
function tests (FEV-1) and the pattern of the Flow-Volume Loop instead
of on subjective indicators such as whether there is dyspnea on
\"slight,\" \"moderate,\" or \"heavy\" exertion.

We added a new diagnostic code, DC 6521, for injuries to the pharynx,
with a single evaluation level of 50-percent based on the presence of
stricture or obstruction of the pharynx or nasopharynx or on paralysis
or absence of the soft palate.

We made the evaluation criteria for chronic bronchitis (DC 6600) more
objective by basing them on the results of pulmonary function tests or,
for the 100-percent level, the alternative criteria of cor pulmonale,
right ventricular hypertrophy, pulmonary hypertension, episode(s) of
acute respiratory failure, or a need for outpatient oxygen therapy. We
established the similar criteria for conditions with similar functional
impairments: pulmonary emphysema (DC 6603), chronic obstructive
pulmonary disease (DC 6604), and the restrictive lung
diseases\--diaphragm paralysis or paresis (DC 6840), spinal cord injury
with respiratory insufficiency (DC 6841), kyphoscoliosis, pectus
excavatum, pectus carinatum (DC 6842), traumatic chest wall defect (DC
6843), post-surgical residual (DC 6844), and chronic pleural effusion or
fibrosis (DC 6845).

We removed indefinite terms such as \"pronounced,\" \"severe,\"
\"considerable,\" \"occasional,\" \"moderate,\" etc., from the criteria
under DC 6601, bronchiectasis and instead provided more objective, but
flexible, criteria based either on the total duration per year of
incapacitating episodes of infection, or on symptoms requiring a certain
frequency and duration of antibiotic treatment. Using pulmonary
impairment as for chronic bronchitis as an alternative was also added.
We removed indefinite terms such as \"pronounced,\" \"severe,\"
\"frequent,\" and \"several\" from the criteria for bronchial asthma (DC
6602) and provided objective evaluation criteria based either on the
results of selected pulmonary function tests (FEV-1 or FEV-1/FVC) or on
treatment requirements.

We made a technical change in Note (1) under the general rating formula
for inactive pulmonary tuberculosis by referring to a footnote under 38
U.S.C. 1156 rather than to 38 U.S.C. 356, as in the former schedule,
because 38 U.S.C. has been repealed by Public Law 90-493. Because of
modern treatment methods of tuberculosis, we have revised the provision
under DC 6731 (tuberculosis, pulmonary, chronic, inactive) for a total
evaluation for one year after date of attainment of inactivity of
tuberculosis to the requirement for a mandatory examination to be
requested immediately following notification that active tuberculosis
under DC 6730 has become inactive, and with any change in evaluation to
be carried out under the provisions of § 3.105(e). We also removed
subjective terms such as \"pronounced,\" \"severe,\" \"extensive,\" and
\"slight\" from the former criteria and replaced them with more
objective, but flexible, criteria by directing to rate residuals as
interstitial lung disease, restrictive lung disease, or, when
obstructive lung disease is the major residual, as chronic bronchitis
and to rate thoracoplasty as removal of ribs under DC 5297.

We reorganized the nontuberculous diseases that formerly included DC\'s
6800 through 6821 by grouping most of them into several
categories\--bacterial infections of the lung, interstitial lung
disease, mycotic lung disease, and restrictive lung disease\--and by
providing a general rating formula for each of these categories of
disease. Many conditions were given new diagnostic codes in order to
group conditions in the same category together. Bacterial infections of
the lung include actinomycosis, DC 6822 (formerly 6803); nocardiosis, DC
6823 (a new condition added because it is one of the common conditions
in this category), and chronic lung abscess, DC 6824 (formerly DC 6809).
This group is evaluated under a general rating formula with a total
evaluation when there is active infection with systemic symptoms, and
residuals are evaluated as interstitial or restrictive lung disease, or
as chronic bronchitis when obstructive lung disease is the major
residual. We deleted streptotrichosis of lung (DC 6804), because this is
a term no longer in use.

We deleted DC\'s 6800 (anthracosis), 6801 (silicosis), and 6802
(pneumoconiosis, unspecified) and included all of these in the newly
added DC 6832, titled \"pneumoconiosis (silicosis, anthracosis, etc.)\"
in the category of interstitial lung disease. We also added under this
category: diffuse interstitial fibrosis (DC 6825), desquamative
interstitial pneumonitis (DC 6826), pulmonary alveolar proteinosis (DC
6827), eosinophilic granuloma of lung (DC 6828), drug-induced pulmonary
pneumonitis and fibrosis (DC 6829), radiation-induced pulmonary
pneumonitis and fibrosis (DC 6830), hypersensitivity pneumonitis (DC
6831), and asbestosis (DC 6832). All of these are evaluated under a
general rating formula for interstitial lung disease that has 10-, 30-,
60-, and 100-percent evaluation levels based on FVC, DLCO, maximum
exercise capacity measured in oxygen consumption, or, at the 100-percent
level, alternative criteria of cor pulmonale, pulmonary hypertension, or
a requirement for outpatient oxygen therapy.

For mycotic diseases, we removed sporotrichosis (DC 6806) because it
usually affects only skin and lymph nodes rather than lung, and mycosis
of lung, unspecified (DC 6808), and assigned new diagnostic codes for
blastomycosis (changed from DC 6805 to 6836), aspergillosis (changed
from DC 6807 to 6838), and coccidioidomycosis (changed from DC 6821 to
6835). We added histoplasmosis of lung (DC 6833), cryptococcosis (DC
6837), and mucormycosis (DC 6838). All of the mycotic diseases are
evaluated under a general rating formula with percentage evaluation
levels of zero-, 30- 50-, and 100-percent based on symptoms and
treatment requirements. We placed the note (edited) about the incubation
period of coccidioidomycosis that had been under DC 6821 under the
general rating formula.

For restrictive lung diseases, we removed serofibrinous pleurisy (DC
6810), purulent pleurisy (DC 6811), bronchocutaneous or bronchopleural
fistula (DC 6812), permanent collapse of the lung (DC 6813), spontaneous
pneumothorax (DC 6814), pneumonectomy (DC 6815), lobectomy (DC 6816),
and residuals of pleural cavity injuries (DC 6818). We added diaphragm
paralysis or paresis (DC 6839); spinal cord injury with respiratory
insufficiency (DC 6840); kyphoscoliosis, pectus excavatum, pectus
carinatum (DC 6841); traumatic chest wall defect, pneumothorax, hernia,
etc. (DC 6842); post-surgical residuals (lobectomy, pneumonectomy, etc.)
(DC 6843); and chronic pleural effusion or fibrosis (DC 6844). DC 6813
was removed because collapse therapy for tuberculosis is no longer
common. The conditions currently rated as pleurisy will be rated as
chronic pleural effusion or fibrosis; fistula, pneumonectomy, and
lobectomy will be rated under post-surgical residuals; pleural cavity
injuries and pneumothorax will be rated as traumatic chest wall defect.
The restrictive lung diseases will be evaluated under a general rating
formula with 10-, 30-, 60-, and 100-percent levels based on the same
criteria used to evaluate chronic bronchitis, emphysema, etc.
Alternatively, the primary disorder may be rated.

We added three notes following the rating formula for restrictive lung
diseases. One note stipulates a three-month period of convalescent
evaluation from the date of hospital admission for a total spontaneous
pneumothorax, a change from the assignment of a 100-percent evaluation
for six months for spontaneous pneumothorax under DC 6814. A second note
states that pleurisy with empyema will be evaluated at 100 percent until
resolved. There was a range of evaluation levels from 10 to 100 percent
in the former schedule. The third note discusses the evaluation of
gunshot wounds of the pleural cavity, and this represents no substantive
change from directions in the former schedule except for an added
statement that muscle group XXI (the respiratory muscles) will not be
combined with these injuries, a statement added to prevent pyramiding in
evaluating these disabilities.

We retitled DC 6817 (lung, chronic passive congestion of) to \"pulmonary
vascular disease,\" a more inclusive title to accommodate all types of
pulmonary vascular disease. Evaluation under this diagnostic code was
formerly done by rating the underlying disease. However, we have
provided objective criteria specific to pulmonary vascular disease with
evaluation percentage levels of 100-, 60-, 30, and zero-percent.

We changed the method of evaluating respiratory system malignancies in
favor of the same system we have used in other revised sections of the
rating schedule, namely, a mandatory examination six following cessation
of therapy, and implementation of any change in the total evaluation
under the provisions of § 3.105(e).

We added a new diagnostic code, 6846, for sarcoidosis, with evaluation
levels of zero, 30, 60, and 100 percent based on symptoms, cardiac
involvement, treatment requirements, and X-ray findings. Alternatively,
sarcoidosis can be evaluated as chronic bronchitis or, with
extra-pulmonary involvement, under the specific body system involved. We
also added a new diagnostic code, 6847, for sleep apnea, with evaluation
levels of zero, 30, 50, and 100 percent based on symptoms, treatment
requirements, and the presence of cor pulmonale or respiratory failure.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

6502 6501 6521

6504 6517 6522

6510 6800 6523

6511 6801 6524

6512 6802 6604

6513 6803 6822

6514 6804 6823

6515 6805 6824

6516 6806 6825

6518 6807 6826

6519 6808 6827

6520 6809 6828

6600 6810 6829

6601 6811 6830

6602 6812 6831

6603 6813 6832

6730 6814 6833

6731 6815 6834

6732 6816 6835

6817 6818 6836

6819 6837

6820 6838

6839

6840

6841

6842

6843

6844

6845

6846

6847

REGULATORY AMENDMENT

4-96-5

Regulation affected: 38 CFR 4.16 and 4.125 through 4.132

EFFECTIVE DATE OF REGULATION: November 7, 1996.

Date Secretary approved regulation: September 9, 1996.

Federal Register Citation: 61FR 52695-702.

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.16 and
4.125 through 4.132 of 38 CFR, Part 4, the sections of the rating
schedule that deal with mental disorders. The intended effect of this
action is to update the mental disorders section of the rating schedule
to ensure that it uses current medical terminology, such as mental
retardation instead of mental deficiency, unambiguous criteria, and that
it reflects medical advances which have occurred since the last review.

Since DSM-IV is the common language of both VA and non-VA health care
providers and researchers, we changed the basis of diagnosis and
terminology of mental disorders in the rating schedule from DSM-III to
DSM-IV in order to provide rating specialists with a standard by which
examinations from all sources can be compared and assessed. This
required some reorganization and renaming of the categories of mental
disorders as well as changes in the terminology and organization of some
of the mental disorders themselves.

In order to conform more closely to the categories in DSM-IV, we have
provided eight, instead of four, categories of mental disorders:
Schizophrenia and other psychotic disorders; Delirium, dementia, and
amnestic and other cognitive disorders; Anxiety disorders; Dissociative
disorders; Somatoform disorders; Mood disorders; Chronic adjustment
disorder; and Eating disorders. We provided a general rating formula for
all categories of mental disorders except eating disorders. The latter
are manifested primarily by physical findings and therefore required a
separate set of criteria.

We removed 29 diagnostic codes, added 20, revised 10, and did not change
8 codes. The added codes represent conditions not included in the former
schedule that are encountered frequently enough in VA claims to warrant
their inclusion.

We added a new category of \"Schizophrenia and other psychotic
disorders.\" Except for schizoaffective disorder, we did not change the
diagnostic codes pertaining to schizophrenia (DC\'s 9201 through 9205).
We deleted DC\'s 9206, bipolar disorder, manic, depressed, or mixed, and
9207, major depression with psychotic features, since we have provided a
category for mood disorders that includes conditions such as these.

We updated the title of DC 9208 from \"paranoid disorders (specify
type)\" to \"delusional disorder\" and placed it in the category of
schizophrenia and other psychotic disorders, in accord with DSM-IV. We
deleted DC 9209, major depression with melancholia, another condition
that we moved to the category of mood disorders.

We revised the title of DC 9210 from \"atypical psychosis\" to
\"psychotic disorder, not otherwise specified (atypical psychosis),\"
and included it in the psychotic disorders category, in accord with
DSM-IV. We also put schizoaffective disorder, formerly part of DC 9205,
in this category as DC 9211. Although schizoaffective disorder was
linked to schizophrenia in the former schedule, DSM-IV named it as a
separate psychotic disorder rather than as a type of schizophrenia.

We changed the name of the category of \"Organic mental disorders\" to
\"Delirium, dementia, and amnestic and other cognitive disorders,\" in
accordance with the more current terminology in DSM-IV. The conditions
in this category demonstrate a psychological or behavioral abnormality
associated with transient or permanent dysfunction of the brain. We
consolidated the 16 types of dementia in the former schedule into fewer
categories because several of them, e.g., dementia associated with
endocrine disorder (DC 9322) and dementia associated with systemic
infection (DC 9324), are quite uncommon (only about one-tenth of one
percent of VA beneficiaries being compensated for dementia have one of
these types of dementia); and a number of others, such as dementia
associated with central nervous system syphilis (DC 9301), dementia
associated with intracranial infections other than syphilis (DC 9302),
and dementia associated with epidemic encephalitis (DC 9315), lend
themselves to logical groupings based on etiology (in this case,
infection).

DSM-IV uses a more complex classification of dementias than is needed or
useful for VA purposes. For example, it has separate categories for
dementia due to Huntington\'s disease, Pick\'s disease, and
Creutzfeldt-Jacob disease, each of which is uncommonly seen for VA
rating purposes. We reorganized the dementias into six diagnostic codes,
retaining some types because of their frequent occurrence and relevance
to veterans, for example, dementia due to head trauma, (DC 9304,
dementia associated with brain trauma in the current schedule) and some
because they represent clusters of a particular etiology. We propose to
retain diagnostic codes for the types of dementia most commonly seen in
the general population, vascular dementia (which encompasses the former
DC\'s 9305 and 9306, multi-infarct dementia with cerebral
arteriosclerosis and multi-infarct dementia due to causes other than
cerebral arteriosclerosis, respectively), and dementia of the
Alzheimer\'s type (formerly DC 9312, primary degenerative dementia).
This reorganization will not affect how dementias are evaluated, since
all types will be evaluated under the same criteria, but will allow
separation of the most common types by etiology.

We deleted DC\'s 9303 (dementia associated with alcoholism) and 9325
(dementia associated with drug or poison intoxication (other than
alcohol)), in favor of including them under DC 9326, as discussed below.
We revised DC 9304 (dementia associated with brain trauma) to dementia
due to head trauma, because this is more modern terminology, and DC 9301
(dementia associated with central nervous system syphilis) to dementia
associated with infection. We included in DC 9301 the conditions
formerly under DC\'s 9301, 9302 (dementia associated with intracranial
infections other than syphilis), 9315 (dementia associated with epidemic
encephalitis), and 9324 (dementia associated with systemic infection),
since the number of cases of dementia due to infection is small, and the
specific type of infection has no bearing on the evaluation.

We deleted DC\'s 9307 (dementia associated with convulsive disorder),
9308 (dementia associated with disturbances of metabolism), 9309
(dementia associated with brain tumor), and 9322 (dementia associated
with endocrine disorder), and included these conditions in DC 9326,
Dementia due to other neurologic or general medical conditions
(endocrine disorders, metabolic disorders, Pick\'s disease, brain
tumors, etc.) or which are substance-induced (drugs, alcohol, poisons).
This category encompasses in a single miscellaneous category a number of
uncommon conditions that DSM-IV names separately.

We retitled \"multi-infarct dementia with cerebral arteriosclerosis\"
(DC 9305) as \"vascular dementia\" and included in it the former DC 9306
(multi-infarct dementia due to causes other than cerebral
arteriosclerosis) because both types are due to vascular disease, may be
difficult to distinguish, and are addressed as a single entity in
DSM-IV.

We revised the title of DC 9310 (formerly dementia due to unknown cause)
to dementia of unknown etiology and included in it the former DC 9311
(dementia due to undiagnosed cause), now deleted, because, in practice,
it may be impossible to differentiate these types. We retitled DC 9312
(formerly dementia, primary, degenerative) to dementia of the
Alzheimer\'s type, in accord with DSM-IV.

We added DC 9327, organic mental disorder, other, to provide a code for
conditions such as amnestic disorder, organic personality disorder, and
other cognitive disorders that are not dementias.

We established a category for anxiety disorders, in accord with DSM-IV,
that includes several conditions formerly in the category of
psychoneurotic disorders: \"generalized anxiety disorder\" (DC 9400),
\"obsessive compulsive disorder\" (DC 9404), \"other and unspecified
neurosis\" (DC 9410), \"post-traumatic stress disorder\" (DC 9411), and
\"specific (simple) phobia; social phobia\" (DC 9403) (modified from the
former \"phobic disorder,\" in accord with terminology in DSM-IV).

We moved some conditions formerly in the category of psychoneurotic
disorders to new categories: DC 9401, dissociative amnesia; dissociative
fugue; dissociative identity disorder (currently psychogenic amnesia;
psychogenic fugue; multiple personality) and DC 9408, depersonalization
disorder, to the category of dissociative disorders, as discussed below;
DC 9402, conversion disorder; psychogenic pain disorder, and DC 9409,
hypochondriasis, to somatoform disorders, as discussed below; and
deleted DC 9405, dysthymic disorder; adjustment disorder with depressed
mood; major depression without melancholia, also as discussed below. We
added to anxiety disorders two conditions that occur frequently enough
that diagnostic codes are needed and which are not now included in the
rating schedule: \"panic disorder and/or agoraphobia\" (DC 9412) and
\"anxiety disorder, not otherwise specified\" (DC 9413). While \"other
and unspecified neurosis\" (DC 9410 in the current schedule) is not
limited to anxiety disorders, we placed it in this category as a matter
of convenience, rather than giving it a separate category.

We added a category for dissociative disorders, conditions, according to
DSM-IV, where there is a disturbance in the usually integrated functions
of identity, memory, consciousness, or perception of the environment.
Included in this category are: \"dissociative amnesia; dissociative
fugue; dissociative identity disorder (multiple personality disorder)\"
(DC 9416, which we changed from DC 9401 to keep conditions in this
category together) and \"depersonalization disorder\" (DC 9417, changed
from DC 9408 for the same reason).

In accord with DSM-IV, we added a category for somatoform disorders,
conditions characterized by the presence of physical symptoms that
suggest a general medical condition and are not explained by a general
medical condition, by the direct effects of a substance, or by another
mental disorder. We moved \"conversion disorder; psychogenic pain
disorder\" (DC 9402) and \"hypochondriasis\" (DC 9409), formerly under
the category of psychoneuroses, to this category and assigned them new
diagnostic codes so that the somatoform disorders are grouped together.
We split \"conversion disorder; psychogenic pain disorder\" into
\"conversion disorder\" (DC 9424), and \"pain disorder (DC 9422), since
the two conditions are distinct, and changed the code for
\"hypochondriasis\" from DC 9409 to DC 9425. (Pain disorder is the
current term for \"psychogenic pain disorder.\") We added two other
conditions: \"somatization disorder\" (DC 9421), a commonly seen
somatoform disorder not in the former schedule, and \"undifferentiated
somatoform disorder\" (DC 9423), for somatoform disorders that do not
fit elsewhere and for which there was no suitable code in the former
schedule.

We established a category for mood disorders and placed in this
category: bipolar disorder (DC 9432), dysthymic disorder (DC 9433), and
major depressive disorder (DC 9434). Major depressive disorder was
formerly under three diagnostic codes: 9207 (major depression with
psychotic features), 9209 (major depression with melancholia), and 9405
(dysthymic disorder; adjustment disorder with depressed mood; major
depression without melancholia). Since DSM-IV does not recognize three
varieties of major depressive disorder, we have used a single diagnostic
code, 9434, for major depressive disorder. We changed the diagnostic
codes for dysthymic disorder (formerly dysthymia, DC 9405) and bipolar
disorder (formerly DC 9206) to DC 9433 and DC 9432, respectively, in
order to group the mood disorders together.

For the sake of completeness, we provided diagnostic codes for two
additional mood disorders: cyclothymic disorder (DC 9431), which,
although related to bipolar disorder, is classified as a separate entity
by DSM-IV, and mood disorder, not otherwise specified (DC 9435), which
allows the evaluation of conditions with mood symptoms that do not meet
the criteria for any specific mood disorder. As part of this
reorganization, we removed DC 9405 (\"dysthymic disorder; adjustment
disorder with depressed mood; major depression without melancholia\")
since we have provided separate diagnostic codes for both \"dysthymic
disorder\" (DC 9433) and \"major depressive disorder\" (DC 9434) under
the category of mood disorders.

We added a new category and diagnostic code (9440) for chronic
adjustment disorder, a condition seen fairly often in the veteran
population.

We added a category for eating disorders, a group of mental disorders
characterized by gross disturbances in eating behavior. This includes
anorexia nervosa (DC 9520) and bulimia nervosa (DC 9521), and we have
based their evaluation criteria partly on the extent of weight loss (per
DSM-IV) and partly on the extent of incapacitating episodes and needed
periods of hospitalization.

We deleted § 4.16 (c), because, in our judgment, it is possible that a
veteran may be properly evaluated at a level less than 100 percent based
on average impairment, but because of unique aspects of his or her
individual situation, might still be unable to secure or follow a
substantially gainful occupation. In order to allow rating specialists
the flexibility to fairly evaluate such situations, we deleted § 4.16
(c) to allow § 4.16 (a) to apply to mental disorders in the same manner
that it does to other disabilities.

We removed DC\'s 9500 through 9511, the codes for psychological factors
affecting physical conditions, for the following reasons. DSM-IV renamed
this group of disorders as \"psychological factors affecting medical
condition\" (PFAMC) and placed them in a new category: \"Other
conditions that may be a focus of clinical attention.\" It said that
PFAMC has two components: a medical condition and psychological factors.
If the psychological factors do not constitute a recognized mental
disorder, they would not be service-connectable in their own right. If
one of the components is a service-connected medical condition or mental
disorder, it would be evaluated under the appropriate code. If both
components are service-connected, each would be separately evaluated. In
either case, an additional separate evaluation for PFAMC would not then
be warranted, and in fact would represent pyramiding (see 38 CFR 4.14).

The former mental disorders section provided separate rating formulas
for psychotic disorders, organic mental disorders, and psychoneurotic
disorders. There were some specific evaluation criteria at each level
for psychoneurotic disorders, but the other formulas used only \"mild,\"
\"definite,\" \"considerable,\" or \"severe\" social and industrial
adaptability as criteria for most levels. Because those are non-specific
terms, and the formulas offered no objective guidance for the rater,
they were subject to interpretation by individual raters and made
comparison of one exam with another difficult.

We have therefore provided a general rating formula for mental disorders
that contains more objective criteria based on signs and symptoms which
characteristically produce a particular level of disability. These
criteria are meant to assure more consistent evaluations and offer
greater ease in comparing examinations. The symptoms indicated at each
level are not intended to be comprehensive (and could not be, because of
the multitude of symptoms in mental disorders), but to provide an
objective framework for raters to use. The criteria focus on the level
of impairment of occupational and social functioning as related to the
specific symptoms which are present, whether the symptoms are persistent
or transient, their frequency, and their severity. With these more
specific and objective criteria, raters can make a determination of the
level of severity based on all the evidence of record, including the
detailed report of all signs and symptoms, relevant information
regarding employment, report of daily activities, etc., rather than
attempting an assessment based on whether the evidence corresponds to
the non-specific language in the former schedule.

We reorganized and edited the material in §§ 4.125 through 4.131 and the
notes in § 4.132 for clarity, less ambiguity, and to be more current,
but the changes are not meant to be substantive. We also removed
material which is not regulatory, i.e., which neither prescribes VA
policy nor limits the action a rating board may take.

We changed the title of § 4.125 from \"General considerations\" to
\"Diagnosis of mental disorders\" and divided it into one paragraph
requiring that the rating board return an examination report to the
examiner if the diagnosis does not conform to DSM-IV or is not supported
by the findings in the report, and a second paragraph directing the
rating board to determine whether a change in diagnosis of a mental
disorder represents progression of a prior diagnosis, correction of an
error in a prior diagnosis, or development of a new and separate
condition. This material is taken from §§ 4.126 (Substantiation of
diagnosis) and 4.128 (Change of diagnosis).

We placed material on the evaluation of mental disorders from §§ 4.129
and 4.130, a statement and notes under DC 9511, notes (1) and (4) under
DC 9325, and notes under the general rating formula for psychoneurotic
disorders about evaluation of mental disorders in § 4.126 and changed
its title from \"Substantiation of diagnosis\" to \"Evaluation of
disability from mental disorders.\" We divided it into four paragraphs,
with paragraph (a) establishing the general basis for evaluating mental
disorders as the frequency, severity, and duration of psychiatric
symptoms, the length of remissions, and the veteran\'s capacity for
adjustment during remissions, with the requirement that evaluation be
based on all evidence of record bearing on occupational and social
impairment. This is derived from material currently found at § 4.130. We
removed from § 4.130 the statement that the examiner\'s analysis of the
symptomatology is an \"essential\" because it is the signs and symptoms
that the examiner documents rather than his or her assessment of their
level of severity that will determine the evaluation. We also deleted
the statement that describes time lost from gainful work and decrease in
work efficiency as \"two of the most important determinants of
disability.\" Since the proposed evaluation criteria are structured
around the nature and extent of occupational and social impairment,
including decreased reliability, productivity, and work efficiency, that
statement is no longer necessary.

Paragraph (b), which is based on § 4.129 and note (1) following the
general rating formula for psychoneurotic disorders, directs the rating
board to consider the extent of social impairment, but not to assign an
evaluation solely on the basis of social impairment. This does not
represent a substantive change.

Paragraph (c) discusses the evaluation of delirium, dementia, and
amnestic and other cognitive mental disorders and represents no
substantive change from material currently contained in notes (1) and
(2) under DC 9325.

Paragraph (d), which represents no substantive change from information
in notes (4) and (2) at the end of the rating schedules for
psychoneurotic disorders and psychological factors affecting physical
condition, respectively, directs the rating board to evaluate a single
disability that has been diagnosed both as a physical condition and as a
mental disorder under the diagnostic code which represents the dominant
(more disabling) aspect of the condition. We substituted \"dominant
(more disabling) aspect of the condition\" for \"major degree of
disability\" for clarity.

Section 4.127 represents a revision of the former § 4.127 and states
that mental retardation and personality disorders will not be considered
as diseases or injuries for compensation purposes, but a mental disorder
that is superimposed upon the mental retardation or personality disorder
may be a disability for VA compensation purposes.

We retitled § 4.128 \"Convalescence ratings following extended
hospitalization,\" and included material from a note under DC 9210
regarding a total evaluation following a period of hospitalization
lasting six months or more and a mandatory examination six months after
the veteran is discharged or released to nonbed care. We added a
requirement that a change in evaluation based on that or any subsequent
examination shall be subject to the provisions of 38 CFR 3.105(e)
because stabilization and return to usual activities in the face of a
severe mental disorder is often difficult to achieve. This change will
help to prevent a cycle of changes in evaluations followed by further
examinations, further changes in evaluations, etc.

We modernized the title of § 4.129 to \"Mental disorders due to
traumatic stress,\" and it includes the requirement from the former §
4.131 to assign an evaluation of not less than 50 percent when a mental
disorder that develops in service as a result of a highly stressful
event is severe enough to cause the veteran\'s release from active
service.

We retained the substance of the former § 4.131, \"Mental disorders due
to psychic trauma,\" in § 4 129 and deleted § 4.131.

There were four notes in § 4.132 following the rating formula for
psychoneuroses. We deleted note (2) as redundant, since §§ 4.125 and
4.126 and the general rating formula set forth clear diagnostic and
evaluation requirements. We incorporated the regulatory content of note
(3) (regarding the return of an inadequate examination report to the
examiner), and note (1) under DC 9511 (concerning the diagnosis of
psychological disorders) into § 4.125 and deleted the part of note (3)
that discussed the diagnosis of conversion disorder as unnecessary,
since this is discussed in detail in DSM-IV.

We incorporated the regulatory content of note (2) under DC 9511,
regarding a single condition diagnosed both as a mental and a physical
disorder, into § 4.126 in order to keep in one place all of the
regulatory material on evaluation of mental disorders.

We retitled § 4.130 \"Schedule of ratings\--mental disorders.\"

Section 4.16(c), § 4.131, and § 4.132 are removed.

Diagnostic codes Diagnostic codes Diagnostic codes

revised added removed

9205 9211 9206 9507

9208 9326 9207 9508

9210 9327 9209 9509

9300 9412 9302 9510

9301 9413 9303 9511

9304 9416 9306

9305 9417 9307

9310 9421 9308

9312 9422 9309

9403 9423 9311

9424 9315

9425 9322

9431 9324

9432 9325

9433 9401

9434 9402

9435 9405

9520 9408

9521 9409

9440 9500

9501

9502

9505

9506

REGULATORY AMENDMENT

4-97-1

Regulation affected: 38 CFR 4.47 through 4.56, 4.69, 4.72, and 4.73.

EFFECTIVE DATE OF REGULATION: July 3, 1997.

Date Secretary approved regulation: March 5, 1997.

Federal Register Citation: 62 FR 30235-30240 (June 3, 1997).

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended §§ 4.47 through
4.56, 4.69, 4.72, and 4.73 of 38 CFR, Part 4, the sections of the rating
schedule that address muscle injuries.

Section 4.47 was, in effect, a discussion of the results of missile
wounds on muscles, pointing out that residual muscle fusion and scarring
interfere with coordination and strength, and that fatigue and pain
result from prolonged exertion of the injured muscles. Since this is
common medical fact readily available in more complete form elsewhere,
we deleted § 4.47 from the schedule. Similarly, § 4.48 was a discussion
of scars resulting from wounds, emphasizing the importance of a complete
examination to assess any disability arising from the scars. It was
redundant because there was a regulatory requirement elsewhere that
evaluations be based on a complete examination, and we deleted it.

Section 4.49 discussed residuals of wounds in deeper structures and the
importance of reviewing the complete history of injury, which is also
required by 38 CFR 4.1. Residuals of wounds and evaluation of evidence
are discussed in Part VI of the VBA Manual and Chapter 2 of the
Physician\'s Guide, and we deleted § 4.49 as unnecessary.

Section 4.50 recited the symptoms of missile wounds, emphasizing that it
is the deeper scarring of muscles that is disabling. This information is
not regulatory in nature, and we deleted it. The final three sentences
of § 4.50, however, were regulatory; they specifically prohibited the
evaluation of injured muscle groups which act upon ankylosed joints,
with the two exceptions of the shoulder or knee joints. We incorporated
all of the instructions concerning ankylosed joints into § 4.55 and
deleted § 4.50 altogether.

Section 4.51 discussed muscle weakness due to injury, and the testing of
muscles to evaluate occupational efficiency. Since symptoms of muscle
injury are detailed in the section concerning factors for evaluating
muscle disabilities (§ 4.56), we deleted § 4.51.

The section titled Muscle damage, § 4.52, discussed the anatomical
structure of muscles and the effects of missile wounds, also discussing
the symptoms of muscle injury. Since this subject is addressed in §
4.56, we deleted § 4.52.

Muscle patterns and the interaction of individual muscles in producing
movement were discussed in § 4.53, with a list of the cardinal symptoms
of muscle disability. These cardinal symptoms are an important factor in
the evaluation of muscle injuries, and we moved them to § 4.56, the
section dealing with evaluation of muscle injuries. Since the remaining
material dealing with muscle patterns and the mechanics of movement in §
4.53 was medical in nature and not regulatory, we deleted it.

Section 4.54 listed the muscle groups and anatomical regions, repeated
the cardinal symptoms of muscle disability, and listed the cardinal
signs of muscle injuries. For the sake of clarity, we deleted § 4.54 and
incorporated the portion dealing with muscle groups and anatomical
regions into § 4.55, and the portion addressing cardinal signs and
symptoms of muscle injury into § 4.56.

The scheme for rating muscle injuries placed individual muscles into 23
muscle groups, each with its own diagnostic code. Each muscle group was
assigned to one of five anatomical regions: (1) the shoulder girdle and
arm, (2) the forearm and hand, (3) the foot and leg, (4) the pelvic
girdle and thigh, or (5) the torso and neck. The former schedule had
interchangeable references to anatomical \"regions\" and \"segments.\"
For the sake of consistency, we used only anatomical regions.

In § 4.55, in addition to the revisions of paragraphs (a) through (f)
described above, we removed paragraph (g), which stated that muscle
injury ratings will not be combined with peripheral nerve paralysis for
the same part, unless affecting entirely different functions because we
have made § 4.55 deal exclusively with the principles of rating muscle
injuries. We revised paragraph (d) to require that the combined
evaluation of muscle groups acting upon a single unankylosed joint must
be lower than the evaluation for unfavorable ankylosis of that joint.

Section 4.56 defined the four levels of muscle disability and the type
of injury, history and complaint of the injury, and objective findings
for each. We revised the descriptions of the various levels of muscle
injury for clarity. The descriptions of objective findings within the
categories of moderate and moderately severe injuries used the
subjective adjectives \"moderate\" and \"moderately severe.\" We deleted
these words since they caused confusion within the categories by using
the same words to describe the terms they were defining, and we deleted
the word \"marked\" as ambiguous.

In part, § 4.72 described the significance of fractures and wounds.
Since fractures are now classified in medical practice as either open or
closed, we changed the term \"compound\" comminuted fracture, which is
currently used in this section, to \"open\" comminuted fracture. Two
regulatory instructions were stated in § 4.72, the first concerning
evaluation of open comminuted fractures and the second concerning
evaluation of through and through missile wounds. For ease of reference,
we put these instructions under § 4.56 with the other factors relating
to evaluation of muscle disabilities. We deleted the phrase \"from the
missile,\" since muscle wounds may also be due to other causes. With the
rearranging of these regulatory instructions into § 4.56, we deleted §
4.72.

We listed the functions of the muscle group under each diagnostic code
ahead of the specific muscles which comprise the group and perform those
movements to simplify the rating process by identifying the muscle group
by functional disability rather than by the names of the individual
muscles involved.

The preferred medical terms describing handedness are \"dominant\" and
\"nondominant,\" and we substituted these designations for \"major\" and
\"minor,\" and changed the heading of § 4.69 to avoid confusion. We also
amended § 4.69 to indicate that in an ambidextrous individual, the
injured hand, or the most severely injured, will be considered the
dominant hand for rating purposes.

The 50 percent level under diagnostic code 5317 (gluteus muscles)
included a footnote directing that entitlement to special monthly
compensation be considered when bilateral function of the buttocks is
severely impaired. We retained the footnote and also added a note under
§ 4.73, preceding the coded evaluations of disabilities, instructing
raters to refer to § 3.350 whenever they rate a muscle injury which has
resulted in loss of use of any extremity or loss of use of both
buttocks. We believe that this combination of note and footnote will be
the most effective way to ensure complete review for special monthly
compensation.

Since the word \"neoplasm\" connotes a pathological abnormality better
than the term \"new growth,\" we substituted that word under diagnostic
codes 5327 and 5328, which pertain to malignant and benign muscle
conditions, respectively.

Diagnostic codes 5327 (malignancies of muscles) and 5329 (soft tissue
sarcomas) provided a 100 percent evaluation for six months following
surgery or the cessation of antineoplastic therapy. We revised these
codes to continue the total evaluation indefinitely after treatment is
discontinued, and to examine the veteran six months thereafter. If the
results of this or any subsequent examination warrant a reduction in
evaluation, the reduction will be implemented under the provisions of 38
CFR 3.105(e). This method is the same as that used in other revised body
systems.

We changed the heading of § 4.56 to \"Evaluation of muscle
disabilities\" and of § 4.69 to \"Dominant hand.\"

In DC 5325, \"Muscle injury, facial muscles,\" we revised the evaluation
instructions by directing that functional impairment due to injury to
facial muscles be evaluated as seventh (facial) cranial nerve neuropathy
(DC 8207), disfiguring scar (DC 7800), etc.

We added a the note at the beginning of § 4.73, referring to § 3.350, to
clearly remind rating specialists that there is potential entitlement to
special monthly compensation when evaluating any muscle injuries
resulting in loss of use of any extremity or of both buttocks.

We also corrected the list of the plantar group of intrinsic muscles of
the foot under Group X (DC 5310) by removing \"opponens digiti V\" (a
hand muscle), moving \"dorsal interossei\" from the dorsal group (the
plantar and dorsal interossei are both considered plantar muscles in
standard anatomy textbooks), changing \"flexor hallucis\" to \"flexor
hallucis brevis,\" its more complete name, in order to distinguish it
from \"flexor hallucis longus,\" a muscle in another group, and changing
\"abductor hallucis\" to \"adductor hallucis.\" We changed \"V\" to the
current designation \"minimi\" wherever \"V\" was used to indicate the
fifth digit. We added \"peroneus brevis\" and \"plantaris\" to the list
of posterior and lateral crural muscles and muscles of the calf in Group
XI (DC 5311) because standard anatomy textbooks place them in this
group. We changed \"long extensors of toes\" in Group XII (DC 5312) to
\"extensor digitorum longus\" and \"extensor hallucis longus,\" the
specific names of these muscles.

We made several other nonsubstantive, editorial changes to the proposed
rule based on our own review of the proposed regulation.

REGULATORY AMENDMENT

4-97-2

Regulation affected: 38 CFR 4.100, 4.101, 4.102, and 4.104.

EFFECTIVE DATE OF REGULATION: January 12, 1998

Date Secretary approved regulation: August 7, 1997

Federal Register Citation: 62 FR 65207-65224 (December 11, 1997)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.100,
4.101, 4.102, and 4.104 of CFR, Part 4, the sections of the rating
schedule that address the cardiovascular system. The intended effect of
this action is to update this portion of the rating schedule to ensure
that it uses current medical terminology and unambiguous criteria, and
that it reflects medical advances which have occurred since the last
review.

We removed introductory sections 4.100, 4.101, and 4.102 for several
reasons. Some of the material in them pertained to issues of service
connection, which belong in the regulations beginning at 38 CFR 3.303,
rather than in the rating schedule, which is intended as a guide to
evaluation. Some material in the removed sections was general medical
information about the types and course of heart disease, some of it now
obsolete, and it did not bear on evaluation. Some material discussed
issues related to the diagnosis of heart disease, but diagnosis is the
responsibility of the examiner. The information about varicose veins in
former § 4.102 became unnecessary in view of the revised evaluation
criteria for varicose veins. The material about determining the separate
effects of coexisting heart diseases was moved to a note in § 4.104.

We changed the title of DC 7000 from \"rheumatic heart disease\" to
\"valvular heart disease (including rheumatic heart disease)\" to
include all types of valvular heart disease, including traumatic. We
changed the period of convalescence evaluation following active
infection with valvular heart damage from six months to three months, in
view of current medical information about the course of the condition.
We provided a new set of more objective evaluation criteria for valvular
heart disease and most other types of heart disease, based on such
clinical or laboratory findings as the level of METs (metabolic
equivalents) at which cardiac symptoms develop; the presence of chronic
or recurrent congestive heart failure, the extent of ventricular
dysfunction, as assessed by the ventricular ejection fraction; objective
evidence of cardiac hypertrophy or dilatation; and whetheror a
requirement for continuous medication. These remove the necessity of
interpreting the meaning of \"moderate exertion\" or whether \"more than
light manual labor is not feasible.\"

One MET is the energy cost of standing quietly at rest and represents an
oxygen uptake of 3.5 milliliters per kilogram of body weight per minute.
The calculation of work activities in multiples of METs is a useful
measurement for assessing disability. METs are measured by means of a
treadmill exercise test, which is the most widely used test for
diagnosing coronary artery disease and for assessing the ability of the
coronary circulation to deliver oxygen according to the metabolic needs
of the myocardium. Because administering a treadmill exercise test may
not be feasible in some instances, we indicated in a note at the
beginning of § 4.104 that when a treadmill test cannot be done for
medical reasons, the examiner\'s estimation of the level of activity,
expressed in METs and supported by examples of specific activities, such
as slow stair climbing, or shoveling snow, that results in dyspnea,
fatigue, angina, dizziness, or syncope, is acceptable as an alternative.
The alternative objective evaluation criteria, such as cardiac
hypertrophy or dilatation, decreased left ventricular ejection fraction,
and congestive heart failure, may also be used in those cases.

A 100-percent evaluation is warranted if a workload of three METs or
less produces dyspnea, fatigue, angina, dizziness, or syncope. A
workload of three METs represents such activities as level walking,
driving, and very light calisthenics. A 60-percent evaluation is
warranted if a workload of greater than three METs but not greater than
five METs results in cardiac symptoms. Activities that fall into this
range include walking two and a half miles per hour, social dancing,
light carpentry, etc. A 30-percent evaluation is warranted if a workload
of greater than five METs but not greater than seven METs produces
symptoms. Activities that fall into this range include slow stair
climbing, gardening, shoveling light earth, skating, bicycling at a
speed of nine to ten miles per hour, carpentry, and swimming. Some
conditions also include a 10-percent evaluation, that is warranted if
symptoms develop at a workload of greater than 7 METs but not greater
than 10 METs. Activities that fall into this range include jogging,
playing basketball, digging ditches, and sawing hardwood. When symptoms
develop only during such activities, there may be some impairment of
earning capacity, but it is likely to be slight. The alternative of the
need for continuous medication warrants a 10-percent evaluation for some
conditions.

We provided the same METs-based and other objective criteria for the
evaluation of endocarditis (DC 7001), pericarditis (DC 7002),
pericardial adhesions (DC 7003), syphilitic heart disease (DC 7004),
arteriosclerotic heart disease (DC 7005), myocardial infarction (DC
7006), hypertensive heart disease (DC 7007), ventricular arrhythmias (DC
7011), atrioventricular block (DC 7015), heart valve replacement (DC
7016), coronary bypass surgery (DC 7017), and two newly added
conditions---cardiac transplantation (DC 7019), and cardiomyopathy (DC
7020). They are also provided as alternative criteria for implantable
cardiac pacemakers (DC 7018), another newly added condition. DC 7018
will otherwise be evaluated the same as supraventricular arrhythmias (DC
7010). We provided more objective criteria for the evaluation of
supraventricular arrhythmias, based on the number of episodes per year
of supraventricular arrhythmias or whether there is permanent atrial
fibrillation. We removed the former evaluation criteria for hyperthyroid
heart disease (DC 7008) and instead directed several possible ways of
evaluation, depending on the specific findings, including under
hyperthyroidism (DC 7900) or under supraventricular arrhythmias (DC
7010).

We removed permanent auricular fibrillation (DC 7012), paroxysmal
tachycardia (DC 7013), and sinus tachycardia (DC 7014) in favor of using
two codes for all arrhythmias---DC 7010 for supraventricular arrhythmias
and DC 7011 for ventricular arrhythmias. These two codes distinguish
between the ordinarily milder supraventricular arrhythmias, with
evaluations of ten or 30 percent, and the more potentially disabling
ventricular arrhythmias, with a range of evaluation from ten to 100
percent. We eliminated the need for a distinction between complete and
incomplete heart block in the assessment of atrioventricular block (DC
7015) because the symptoms and severity of heart block of each type vary
from individual to individual, and an assessment on the actual disabling
symptoms that are present is more equitable than an evaluation based
solely on the type of heart block. An evaluation of 100 percent under DC
7011 is also warranted if an Automatic Implantable
Cardioverter-Defibrillator (AICD), a device used to treat
supraventricular arrhythmias that has the potential for serious
complications, is present.

We added several new conditions, based on the fact that they occur
commonly enough in veterans to warrant inclusion in the schedule:
implantable cardiac pacemakers (DC 7018), cardiac transplantation (DC
7019), and cardiomyopathy (DC 7020). Pacemakers were formerly included
under auriculoventricular block (DC 7015), but we provided a separate
code because pacemakers are used for conditions other than heart blocks.
Cardiac transplantation was formerly rated analogous to renal
transplantation, but was not listed in the schedule. We provided
evaluation criteria for cardiac transplantation identical to those for
most other heart diseases, based on a METs assessment or other objective
findings, except that we stipulated a minimum evaluation of 30 percent,
because of the ongoing need for immunosuppressive therapy in this
condition. Cardiomyopathy has similar criteria but no minimum
evaluation.

We removed \"general arteriosclerosis\" (DC 7100) because it was too
broad a category for appropriate evaluation, and the effects of
widespread arteriosclerosis can be better evaluated under the specific
disabilities in various body systems as cerebrovascular disease, renal
disease, etc.

We revised the convalescence evaluations for several conditions. The
previous schedule provided convalescence evaluations for six months for
the following conditions: rheumatic heart disease (DC 7000);
arteriosclerotic heart disease, following coronary occlusion (DC 7005);
myocardial infarction (DC 7006); and soft tissue sarcoma (of vascular
origin) (DC 7123). It provided convalescence evaluations for one year
for the following conditions: auriculoventricular block, with
implantation of a pacemaker (DC 7015); heart valve replacement (DC
7016); coronary artery bypass (DC 7017); and aortic aneurysm, following
surgical correction (DC 7110). We changed the duration of convalescence
evaluations for DC's 7000, 7005, and 7006 to three months; for DC 7018
(pacemaker implantation, formerly DC 7015) to two months; and for DC
7017 to three months. We proposed an indefinite period of convalescence
evaluation with an examination at six months for DC's 7016, 7110, 7011
(now ventricular arrhythmias), 7111 (aneurysm of any large artery), and
7123 (soft-tissue sarcoma). We also provided an indefinite period of
convalescence evaluation, but with an examination at one year, for
cardiac transplantation (DC 7019). The new periods of convalescence
evaluation reflect, according to medical sources we consulted, the
average periods of recovery needed by the average person following
certain procedures and illnesses. They can, of course, be extended, when
medically warranted, under the authority of 38 CFR 4.29 and 4.30. The
indefinite periods of convalescence require application of the notice
and effective date provisions of 38 CFR 3.105(e) before a change in
evaluation can be made.

In response to comments that it was needed to assure consistency, we
added a note under hypertensive vascular disease (DC 7101) stating what
the term hypertension means, and also added what the term \"isolated
systolic hypertension\" means, for purposes of evaluation under § 4.104.
We also specified the number of readings required (two or more times on
at least three different days) to confirm the diagnosis of hypertension,
because the former schedule gave an indefinite recommendation. We moved
the provision for a ten-percent evaluation when hypertension is
controlled by continuous medication and there is a history of diastolic
blood pressure predominantly 100 or more from a note to the criteria for
a ten-percent evaluation. We also added \"systolic blood pressure
predominantly 160 or more\" to the criteria for a ten-percent evaluation
to indicate the appropriate evaluation for isolated systolic
hypertension of this extent.

We edited and made more objective the criteria for evaluating aortic
aneurysm (DC 7110) by providing a 100-percent evaluation if the aneurysm
is 5 cm. or greater in diameter or if it is symptomatic. Under DC 7111,
aneurysm of any large artery is evaluated at 100 percent if it is
symptomatic. Since the aorta is the largest artery in the body, it would
be inconsistent and inequitable not to allow the same evaluation that
the schedule provides for symptomatic aneurysms of other large arteries.

The previous schedule established a minimum evaluation of 20 percent
following surgical correction of an aortic aneurysm (DC 7110). Because
there is a wide range of possible complications and residual disability
following surgical correction of an aortic aneurysm, depending on such
factors as the location of the aneurysm, its type (dissecting or not),
etc., with some warranting a higher, and some a lower, evaluation than
20 percent, we removed the minimum evaluation in favor of a direction to
evaluate the actual residuals.

For the sake of consistency, we also provided objective criteria for
aneurysm of any large artery (DC 7111), in place of the former
subjective requirement that the lower extremities be \"symptomatic\"
(for 60 percent) or the upper extremities be \"symptomatic\" (for 40
percent). As with aortic aneurysm, a 100-percent evaluation is required
if symptomatic, or for an indefinite period from the date of hospital
admission for correction. There is a range of evaluation levels for the
postoperative state based on the objective criteria of severity of
claudication, the ankle/brachial index, and the presence of trophic
changes, ulcers, rest pain, and whether the extremity is cold. The same
criteria apply to arteriosclerosis obliterans (DC 7114) and
thrombo-angiitis obliterans (DC 7115). Those two conditions, plus
intermittent claudication (DC 7166), which we removed because it is a
symptom and not a disease, were all formerly evaluated under the same
set of criteria, which were based on findings similar to, but more
subjective than, the new criteria. We added three notes under DC 7111,
the first explaining the ankle/brachial index, the second explaining the
method of evaluation when more than one extremity is affected, and the
third describing the method of postoperative convalescence evaluation.

The previous schedule provided a 10-percent evaluation for aneurysm of
any small artery (DC 7112). We changed the evaluation for asymptomatic
aneurysm of a small artery to zero percent, since asymptomatic small
artery aneurysms are found in about five percent of the population and
are not considered disabling. Symptomatic aneurysms can be evaluated
under the appropriate body system, depending on the actual findings, and
we added a note directing how to evaluate them.

We changed the title of DC 7113 from \"arteriovenous aneurysm,
traumatic,\" to the currently accepted term for the condition,
\"arteriovenous fistula, traumatic,\" because the condition represents a
direct communication between an artery and a vein rather than an
aneurysm of a blood vessel. For the sake of more objectivity, we revised
the criteria under DC 7113 to include such findings as enlarged heart,
wide pulse pressure, tachycardia, edema, stasis dermatitis, ulceration,
and cellulitis, in place of the former indefinite criteria, such as
\"with marked vascular symptoms.\" In addition, because the most serious
cardiac consequence of arteriovenous aneurysm is high output congestive
heart failure, we added a 100-percent evaluation level for that
condition.

As described above, we provided evaluation criteria for arteriosclerosis
obliterans (DC 7114) and thrombo-angiitis obliterans (DC 7115) that are
identical to those of the postoperative criteria for aneurysm of any
large artery (DC 7111). The notes regarding the ankle/brachial index and
explaining the method of evaluation when more than one extremity is
affected are the same as those following DC 7111. However, we also
provided another note directing that the residuals of aortic and large
arterial bypass surgery or arterial graft be evaluated as
arteriosclerosis obliterans, since there had been no direction on how to
rate those conditions. Under DC 7115, we provided only the notes about
the ankle/brachial index and the evaluation when more than one extremity
is affected.

The new method of evaluation when more than one extremity is affected by
peripheral arterial disease requires a separate evaluation of each
affected extremity, with use of the bilateral factor when applicable.
These evaluations are to be combined, as other multiple disabilities of
the extremities are. These instructions replace the former notes
following DC 7117, which were complex, open to misinterpretation, and
could result in an evaluation for involvement of multiple extremities no
higher than that for involvement of a single extremity.

The former criteria for Raynaud's syndrome (DC 7117) required subjective
assessments of the meaning of \"severe form,\" \"multiple areas,\"
\"frequent vasomotor attacks,\" and \"occasional attacks.\" In addition
to adding a note defining \"characteristic attacks\" of Raynaud\'s
disease, for VA purposes, we provided more objective criteria for
evaluation using the specific frequency of characteristic attacks, the
number of digital ulcers, and whether there is autoamputation of one or
more digits, in order to ensure more consistent evaluations.

The former criteria for angioneurotic edema (DC 7118) were also
subjective, e.g., \"severe, frequent attacks with severe
manifestations.\" We established more objective criteria based on the
typical duration of attacks, their frequency, and on whether there is
laryngeal involvement. In our judgment, angioneurotic edema affecting
the larynx warrants separate consideration because laryngeal edema
commonly causes respiratory distress due to airway obstruction and
requires emergency treatment. Laryngeal edema is serious enough that if
it occurs once or twice a year, it warrants a 20-percent evaluation; if
it occurs more than twice a year, it warrants a 40-percent evaluation.
We also added a 10-percent evaluation level for attacks without
laryngeal involvement that occur two to four times a year. These
criteria will foster more consistent evaluations.

The former criteria for erythromelalgia (DC 7119) were
subjective---\"severe,\" \"moderate,\" or \"mild.\" We provided a note
that defines \"characteristic attacks\" of erythromelalgia, for purposes
of § 4.104, and provided evaluation criteria based on the frequency and
duration of attacks and their response to treatment.

As with the peripheral arterial diseases, we revised the method of
evaluating multiple extremity involvement by venous diseases. Under the
previous schedule, a variety of methods were used to evaluate vascular
diseases affecting the extremities, particularly when more than one
extremity was affected. For example, the criteria for thrombophlebitis
(DC 7121) applied to a single extremity, and if other extremities were
affected, they were separately evaluated. For varicose veins (DC 7120),
the criteria for a 10-percent evaluation applied to either unilateral or
bilateral involvement, but at other evaluation levels, different
percentages were assigned for unilateral and bilateral involvement.
There was no direction for evaluation if one extremity was more severely
affected than the other. We therefore revised the method of evaluating
varicose veins (DC 71720) to have the criteria apply to a single
extremity, as for DC 7121, as well as arteriosclerosis obliterans (DC
7114), thrombo-angiitis obliterans (DC 7115), and postoperative aneurysm
of any large artery (DC 7111).

We revised the evaluation criteria for varicose veins (DC 7120) and
post-phlebitic syndrome of any etiology (DC 7121) in order to adopt the
more consistent method of separately evaluating each extremity and to
assure that venous conditions with similar findings receive consistent
evaluations,. Varicose veins are ordinarily asymptomatic or mildly
symptomatic, but may produce prolonged venous insufficiency and progress
to thrombophlebitis and postphlebitic syndrome. Signs of venous
insufficiency, such as edema, stasis pigmentation, ulceration, eczema,
and induration, and symptoms such as aching and fatigue, are the major
disabling effects of varicose veins. The size, location, extent, etc.,
of varicose veins, do not correlate with symptoms, and we removed those
criteria as factors in evaluation. The presence or absence of impairment
of the deep circulation is more an indicator of the feasibility of
surgical repair than of functional impairment, and we therefore also
removed references to the deep circulation and replaced them with
criteria based on symptoms (such as aching and fatigue after prolonged
standing or walking) or objective physical findings (such as edema,
stasis pigmentation, eczema, or ulceration). These changes will allow
accurate and consistent evaluations when more than one extremity is
affected by varicose veins, but to different degrees.

The effects of chronic venous insufficiency are the same, whether from
varicosities, thrombophlebitis, or some other cause. The postphlebitic
syndrome may itself lead to the development of varicosities because of
chronic venous insufficiency, and the possible manifestations and
disabling effects of varicose veins and postphlebitic syndrome are very
similar. We therefore used the same criteria to evaluate both
conditions, with evaluation levels of 0, 10, 20, 40, 60, and 100 percent
for involvement of a single extremity. We added under DC 7120: \"With
the following findings attributed to the effects of varicose veins,\"
and under DC 7121: \"With the following findings attributed to venous
disease\" in order to assure that the examiner has determined that the
abnormal findings are attributed to venous disease. We changed the title
of DC 7121 from \"phlebitis or thrombophlebitis\" to \"post-phlebitic
syndrome of any etiology\" because both superficial and deep acute
thrombophlebitis are transient conditions, but it is the chronic form of
thrombophlebitis with venous insufficiency, known as \"postphlebitic
leg,\" \"postphlebitic sequelae of chronic venous insufficiency,\"
\"postphlebitic syndrome,\" or \"stasis syndrome,\" that is the
disabling residual of thrombophlebitis.

We revised the title of DC 7122 from \"frozen feet, residuals of\" to
\"cold injury residuals\" to indicate that this code may be used to
evaluate any cold injury. Because cold injury produces similar tissue
changes wherever it occurs, a single diagnostic code and set of
evaluation criteria are adequate. However, we revised the criteria to
more accurately reflect the range of effects that cold injury may
produce, such as arthralgia, tissue loss, nail abnormalities, and color
changes. We also deleted the bilateral evaluations in favor of
evaluating each affected part separately and combining them for the
overall evaluation for cold injury, similar to changes we made in the
method of evaluating peripheral arterial and venous diseases of the
extremities, and for the same reasons. In the case of paired
extremities, the evaluations will be combined, if appropriate, in
accordance with §§ 4.25 and 4.26 (as described in Note (2), following DC
7122). Note (1) has been amended to include more information about the
evaluation of complications that may occur following cold injury, such
as peripheral neuropathy, or squamous cell carcinoma of the skin at the
site of a scar.

The former schedule provided six-months of convalescence evaluation for
soft tissue sarcoma of vascular origin (DC 7123). The change to an
indefinite period of a 100-percent evaluation is described earlier.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

7000 7012 7018

7001 7013 7019

7002 7014 7020

7003 7100

7004 7116

7005

7006

7007

7008

7010

7011

7015

7016

7017

7101

7110

7111

7112

7113

7114

7115

7117

7118

7119

7120

7121

7122

7123

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

1\. The authority citation for part 4 continues to read as follows:

AUTHORITY: 38 U.S.C. 1155, unless otherwise noted.

Subpart B\--Disability Ratings

[§§ 4.100 through 4.102 \[Removed and Reserved\]]{.underline}

2\. Sections 4.100, 4.101, 4.102 are removed and reserved.

3\. Section 4.104 is revised to read as follows:

[§ 4.104 Schedule of ratings---cardiovascular system]{.underline}.

[DISEASES OF THE HEART]{.underline}

NOTE (1): Evaluate cor pulmonale, which is a form of secondary heart
disease, as part of the pulmonary condition that causes it.

NOTE (2): One MET (metabolic equivalent) is the energy cost of standing
quietly at

rest and represents an oxygen uptake of 3.5 milliliters per kilogram of
body weight per minute. When the level of METs at which dyspnea,
fatigue, angina, dizziness, or syncope develops is required for
evaluation, and a laboratory determination of METs by exercise testing
cannot be done for medical reasons, an estimation by a medical examiner
of the level of activity (expressed in METs and supported by specific
examples, such as slow stair climbing or shoveling snow) that results in
dyspnea, fatigue, angina, dizziness, or syncope may be used.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7000 Valvular heart disease (including rheumatic heart disease):

During active infection with valvular heart damage and for

three months following cessation of therapy for the active

infection\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\................................100

Thereafter, with valvular heart disease (documented by findings

on physical examination and either echocardiogram, Doppler

echocardiogram, or cardiac catheterization) resulting in:

Chronic congestive heart failure, or; workload of 3 METs or less

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

left ventricular dysfunction with an ejection fraction of less

than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50 percent
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\....60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; evidence of cardiac hypertrophy or dilatation on electro-

cardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............................\....30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...10

7001 Endocarditis:

For three months following cessation of therapy for active

infection with cardiac
involvement\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\....100

Thereafter, with endocarditis (documented by findings on physical

examination and either echocardiogram, Doppler echocardiogram,

or cardiac catheterization) resulting in:

Chronic congestive heart failure, or; workload of 3 METs or less

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; left ventricular dysfunction with an ejection fraction of

less than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not

greater than 5 METs results in dyspnea, fatigue, angina,

dizziness, or syncope, or; left ventricular dysfunction with

an ejection fraction of 30 to 50
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; evidence of cardiac hypertrophy or dilatation on

electrocardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or

syncope, or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................10

7002 Pericarditis:

For three months following cessation of therapy for active

infection with cardiac
involvement\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................100

Thereafter, with documented pericarditis resulting in:

Chronic congestive heart failure, or; workload of 3 METs or

less results in dyspnea, fatigue, angina, dizziness, or syncope,

or; left ventricular dysfunction with an ejection fraction of less

than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness,

or syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50 percent
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

evidence of cardiac hypertrophy or dilatation on electro-

cardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................10

7003 Pericardial adhesions:

Chronic congestive heart failure, or; workload of 3 METs or less

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

left ventricular dysfunction with an ejection fraction of less

than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness, or

syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

evidence of cardiac hypertrophy or dilatation on electro-

cardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................10

7004 Syphilitic heart disease:

Chronic congestive heart failure, or; workload of 3 METs or less

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; left ventricular dysfunction with an ejection fraction of

than 30
percent\...\...\...\...\...\.................................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness, or

syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50
percent\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...\...\...\...\...\...\...\...\...\...\...\...\...\....60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

evidence of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\....30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...10

NOTE: Evaluate syphilitic aortic aneurysms under DC 7110 (aortic
aneurysm).

7005 Arteriosclerotic heart disease (Coronary artery disease):

With documented coronary artery disease resulting in:

Chronic congestive heart failure, or; workload of 3 METs or less

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

left ventricular dysfunction with an ejection fraction of less

than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness, or

syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

evidence of cardiac hypertrophy or dilatation on

electrocardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................10

NOTE: If nonservice-connected arteriosclerotic heart disease is
superimposed on service-connected valvular or other non-arteriosclerotic
heart disease, request a medical opinion as to which condition is
causing the current signs and symptoms.

7006 Myocardial infarction.

During and for three months following myocardial infarction,

documented by laboratory
tests\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...100

Thereafter:

With history of documented myocardial infarction, resulting in:

Chronic congestive heart failure, or; workload of 3 METs or

less results in dyspnea, fatigue, angina, dizziness, or syncope,

or; left ventricular dysfunction with an ejection fraction of

less than 30
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...\...\...\...\.....100

More than one episode of acute congestive heart failure in the

past year, or; workload of greater than 3 METs but not greater

than 5 METs results in dyspnea, fatigue, angina, dizziness, or

syncope, or; left ventricular dysfunction with an ejection

fraction of 30 to 50
percent\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...60

Workload of greater than 5 METs but not greater than 7 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or;

evidence of cardiac hypertrophy or dilatation on

electrocardiogram, echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...30

Workload of greater than 7 METs but not greater than 10 METs

results in dyspnea, fatigue, angina, dizziness, or syncope,

or; continuous medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...10

7007 Hypertensive heart disease:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30
percent\...\...\...\...\...\.................................\........100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50
percent\...\...\...\...\................................\...60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence

of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................10

7008 Hyperthyroid heart disease:

Include as part of the overall evaluation for hyperthyroidism under DC
7900. However, when atrial fibrillation is present, hyperthyroidism may
evaluated either under DC 7900 or under DC 7010 (supraventricular
arrhythmia), whichever results in a higher evaluation.

7010 Supraventricular arrhythmias:

Paroxysmal atrial fibrillation or other supraventricular tachycardia,

with more than four episodes per year documented by ECG

or Holter
monitor\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\.....30

Permanent atrial fibrillation (lone atrial fibrillation), or; one to
four episodes

per year of paroxysmal atrial fibrillation or other supraventricular

tachycardia documented by ECG or Holter
monitor\...\...\...\...\...\...\...\...\...\...\...\...\....................................10

7011 Ventricular arrhythmias (sustained):

For indefinite period from date of hospital admission for initial

evaluation and medical therapy for a sustained ventricular arrhythmia,

or; for indefinite period from date of hospital admission for

ventricular aneurysmectomy, or; with an automatic implantable

Cardioverter-Defibrillator (AICD) in
place\...\...\...\...\...\...\...\...\...\...\...\...\.....................................\...\...\...\...100

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent
\...\...\...\...\...\...\...\.............................\...\...100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50 percent
\...\...\...\...\..................... .........\....60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence

of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................10

NOTE: A rating of 100 percent shall be assigned from the date of
hospital admission for initial evaluation and medical therapy for a
sustained ventricular arrhythmia or for ventricular aneurysmectomy. Six
months following discharge, the appropriate disability rating shall be
determined by mandatory VA examination. Any change in evaluation based
upon that or any subsequent examination shall be subject to the
provisions of § 3.105(e) of this chapter.

7015 Atrioventricular block:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent
\...\...\...\...\...\...\...\..................................100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50
ercent\...\...\...\...\..................................\...60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence

of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication or a pacemaker
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................10

NOTE: Unusual cases of arrhythmia such as atrioventricular block
associated with a supraventricular arrhythmia or pathological
bradycardia should be submitted to the Director, Compensation and
Pension Service. Simple delayed P-R conduction time, in the absence of
other evidence of cardiac disease, is not a disability.

7016 Heart valve replacement (prosthesis):

For indefinite period following date of hospital admission for valve
replacement........................\...100

Thereafter:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent
\...\...\...\...\...\...\...\..............................\....100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50
percent\...\...\...\...\.........\........................\....60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence

of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...\...\...\....30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...\...\...\...\.....10

NOTE: A rating of 100 percent shall be assigned as of the date of
hospital admission for valve replacement. Six months following
discharge, the appropriate disability rating shall be determined by
mandatory VA examination. Any change in evaluation based upon that or
any subsequent examination shall be subject to the provisions of §
3.105(e) of this chapter.

7017 Coronary bypass surgery:

For three months following hospital admission for
surgery\...\...\...\...\...\...\...............................\...\...\...\.....100

Thereafter:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent
\...\...\...\...\...\...\...\....................................100

More than one episode of acute congestive heart failure in the past
year, or;

workload of greater than 3 METs but not greater than 5 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of 30 to 50 percent
\...\...\...\...\...\...\...\...\...\...\...................................60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence

of cardiac hypertrophy or dilatation on electrocardiogram,

echocardiogram, or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................30

Workload greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................10

7018 Implantable cardiac pacemakers.

For two months following hospital admission for implantation or

reimplantation\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................100

Thereafter:

Evaluate as supraventricular arrhythmias (DC 7010), ventricular

arrhythmias (DC 7011), or atrioventricular block (DC 7015).

Minimum\...\.................................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....10

NOTE: Evaluate implantable Cardioverter-Defibrillators (AICD\'s) under
DC 7011.

7019 Cardiac transplantation:

For an indefinite period from date of hospital admission for cardiac

transplantation\...\...\...\...\...\...\...\...\...\...\...................................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....100

Thereafter:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30
percent\..................................\...\...\...\...\...\...\.....100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50
percent\...\...\.........\............................\.....60

Minimum\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\....30

NOTE: A rating of 100 percent shall be assigned as of the date of
hospital admission for cardiac transplantation. One year following
discharge,the appropriate disability rating shall be determined by
mandatory VA examination. Any change in evaluation based upon that or
any subsequent examination shall be subject to the provisions of §
3.105(e) of this chapter.

7020 Cardiomyopathy:

Chronic congestive heart failure, or; workload of 3 METs or less results

in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular

dysfunction with an ejection fraction of less than 30 percent
\...\...\...\...\...\...\...\................................\....100

More than one episode of acute congestive heart failure in the past
year,

or; workload of greater than 3 METs but not greater than 5 METs

results in dyspnea, fatigue, angina, dizziness, or syncope, or; left

ventricular dysfunction with an ejection fraction of 30 to 50
percent\...\...\...\...\.................................\...60

Workload of greater than 5 METs but not greater than 7 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of

cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram,

or
X-ray\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................30

Workload of greater than 7 METs but not greater than 10 METs results

in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous

medication
required\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................10

[DISEASES OF THE ARTERIES AND VEINS]{.underline}

7101 Hypertensive vascular disease (hypertension and isolated systolic
hypertension).

Diastolic pressure predominantly 130 or
more\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............................\...60

Diastolic pressure predominantly 120 or
more\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............................\...40

Diastolic pressure predominantly 110 or more, or; systolic pressure

predominantly 200 or more\...
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......................
......\...20

Diastolic pressure predominantly 100 or more, or; systolic pressure

predominantly 160 or more, or; minimum evaluation for an

individual with a history of diastolic pressure predominantly 100

or more who requires continuous medication for
control...........................\..............................\...10

NOTE (1): Hypertension or isolated systolic hypertension must be
confirmed by readings taken two or more times on at least three
different days. For purposes of this section, the term hypertension
means that the diastolic blood pressure is predominantly 90mm. or
greater, and isolated systolic hypertension means that the systolic
blood pressure is predominantly 160mm. or greater with a diastolic blood
pressure of less than 90mm.

NOTE (2): Evaluate hypertension due to aortic insufficiency or
hyperthyroidism, which is usually the isolated systolic type, as part of
the condition causing it rather than by a separate evaluation.

7110 Aortic aneurysm:

If five centimeters or larger in diameter, or; if symptomatic, or; for
indefinite

period from date of hospital admission for surgical correction
(including

any type of graft
insertion)\...........................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........\...\...\...\...\...\...\...\...\...\...\...100

Precluding
exertion\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\................................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....60

Evaluate residuals of surgical correction according to organ systems
affected.

NOTE: A rating of 100 percent shall be assigned as of the date of
admission for surgical correction. Six months following discharge, the
appropriate disability rating shall be determined by mandatory VA
examination. Any change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of § 3.105(e) of this
chapter.

7111 Aneurysm, any large artery:

If symptomatic, or; for indefinite period from date of hospital
admission

for surgical
correction\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...\....100

Following surgery:

Ischemic limb pain at rest, and; either deep ischemic ulcers or
ankle/brachial

index of 0.4 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................100

Claudication on walking less than 25 yards on a level grade at 2 miles

per hour, and; persistent coldness of the extremity, one or more deep

ischemic ulcers, or ankle/brachial index of 0.5 or
less\...\...\...\...\...\...\...\...\...\...\...\...................................\...60

Claudication on walking between 25 and 100 yards on a level grade at

2 miles per hour, and; trophic changes (thin skin, absence of hair,

dystrophic nails) or ankle/brachial index of 0.7 or
less\...\...\...\...\...\...\...\...\...\...\...\.....................................40

Claudication on walking more than 100 yards, and; diminished peripheral

pulses or ankle/brachial index of 0.9 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................20

NOTE (1): The ankle/brachial index is the ratio of the systolic blood
pressure at the ankle (determined by Doppler study) divided by the
simultaneous brachial artery systolic blood pressure. The normal index
is 1.0 or greater.

NOTE (2): These evaluations are for involvement of a single extremity.
If more than one extremity is affected, evaluate each extremity
separately and combine (under § 4.25), using the bilateral factor, if
applicable.

NOTE (3): A rating of 100 percent shall be assigned as of the date
hospital admission for surgical correction. Six months following
discharge, the appropriate disability rating shall be determined by
mandatory VA examination. Any change in evaluation based upon that or
any subsequent examination shall be subject to the provisions of §
3.105(e) of this chapter.

7112 Aneurysm, any small artery:

Asymptomatic\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....................................0

NOTE: If symptomatic, evaluate according to body system affected.
Following surgery, evaluate residuals under the body system affected.

7113 Arteriovenous fistula, traumatic:

With high output heart
failure\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............................100

Without heart failure but with enlarged heart, wide pulse pressure, and

tachycardia\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\....60

Without cardiac involvement but with edema, stasis dermatitis, and
either

ulceration or cellulitis:

Lower
extremity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\......................................50

Upper
extremity\...\...\...\...\...\...\...................................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......\.....40

With edema or stasis dermatitis:

Lower
extremity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................\...\...\...\...\...\...\...\...\...\...\...\.....30

Upper
extremity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........................................20

7114 Arteriosclerosis obliterans:

Ischemic limb pain at rest, and; either deep ischemic ulcers or
ankle/brachial

index of 0.4 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...100

Claudication on walking less than 25 yards on a level grade at 2 miles
per

hour, and; either persistent coldness of the extremity or ankle/brachial

index of 0.5 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\................................\....60

Claudication on walking between 25 and 100 yards on a level grade at

2 miles per hour, and; trophic changes (thin skin, absence of hair,

dystrophic nails) or ankle/brachial index of 0.7 or
less\...\...\...\...\...\...\...\...\...\...\...\.................................\....40

Claudication on walking more than 100 yards, and; diminished

peripheral pulses or ankle/brachial index of 0.9 or
less\...\...\...\...\...\...\...\...\...\...\.......................................20

NOTE (1): The ankle/brachial index is the ratio of the systolic blood
pressure at the ankle (determined by Doppler study) divided by the
simultaneous brachial artery systolic blood pressure. The normal index
is 1.0 or greater.

NOTE (2): Evaluate residuals of aortic and large arterial bypass surgery
or arterial graft as arteriosclerosis obliterans.

NOTE (3): These evaluations are for involvement of a single extremity.
If more than one extremity is affected, evaluate each extremity
separately and combine (under § 4.25), using the bilateral factor (§
4.26), if applicable.

7115 Thrombo-angiitis obliterans (Buerger\'s Disease):

Ischemic limb pain at rest, and; either deep ischemic ulcers or

ankle/brachial index of 0.4 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\................................\...100

Claudication on walking less than 25 yards on a level grade at 2 miles

per hour, and; either persistent coldness of the extremity or

ankle/brachial index of 0.5 or
less\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...60

Claudication on walking between 25 and 100 yards on a level grade

at 2 miles per hour, and; trophic changes (thin skin, absence of

hair, dystrophic nails) or ankle/brachial index of 0.7 or
less\...\...\...\...\...\...\...\...\...................................\...40

Claudication on walking more than 100 yards, and; diminished

peripheral pulses or ankle/brachial index of 0.9 or
less\...\...\...\...\...\...\...\...\...\...\...\.................................\...20

NOTE (1): The ankle/brachial index is the ratio of the systolic blood
pressure at the ankle (determined by Doppler study) divided by the
simultaneous brachial artery systolic blood pressure. The normal index
is 1.0 or greater.

NOTE (2): These evaluations are for involvement of a single extremity.
If more than one extremity is affected, evaluate each extremity
separately and combine (under § 4.25), using the bilateral factor (§
4.26), if applicable.

7117 Raynaud\'s syndrome:

With two or more digital ulcers plus autoamputation of one or more
digits

and history of characteristic
attacks\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...\...100

With two or more digital ulcers and history of characteristic
attacks\...\...\...\...\...\...\.................................60

Characteristic attacks occurring at least
daily\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................40

Characteristic attacks occurring four to six times a
week\...\...\...\...\...\...\...\...\...\...\...\...............................\.....20

Characteristic attacks occurring one to three times a
week\...\...\...\...\...\...\...\...\...\...\...\.................................10

NOTE: For purposes of this section, characteristic attacks consist of
sequential color changes of the digits of one or more extremities
lasting minutes to hours, sometimes with pain and paresthesias, and
precipitated by exposure to cold or by emotional upsets. These
evaluations are for the disease as a whole, regardless of the number of
extremities involved or whether the nose and ears are involved.

7118 Angioneurotic edema:

Attacks without laryngeal involvement lasting one to seven days or
longer and

occurring more than eight times a year, or; attacks with laryngeal
involvement

of any duration occurring more than twice a
year\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................40

Attacks without laryngeal involvement lasting one to seven days and

occurring five to eight times a year, or; attacks with laryngeal

involvement of any duration occurring once or twice a
year\...\...\...\...\...\...\...\...\...\................................20

Attacks without laryngeal involvement lasting one to seven days and

occurring two to four times a
year\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................10

7119 Erythromelalgia:

Characteristic attacks that occur more than once a day, last an average

of more than two hours each, respond poorly to treatment, and that

restrict most routine daily
activities\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\.....100

Characteristic attacks that occur more than once a day, last an average

of more than two hours each, and respond poorly to treatment, but

that do not restrict most routine daily
activities\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....................................60

Characteristic attacks that occur daily or more often but that respond
to

treatment\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................30

Characteristic attacks that occur less than daily but at least three
times a

week and that respond to
treatment\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................10

NOTE: For purposes of this section, a characteristic attack of
erythromelalgia consists of burning pain in the hands, feet, or both,
usually bilateral and symmetrical, with increased skin temperature and
redness, occurring at warm ambient temperatures. These evaluations are
for the disease as a whole, regardless of the number of extremities
involved.

7120 Varicose veins:

With the following findings attributed to the effects of varicose veins:

Massive board-like edema with constant pain at
rest\...\...\...\...\...\...\...\...\...\...\...\...\................................\....100

Persistent edema or subcutaneous induration, stasis pigmentation or

eczema, and persistent ulceration
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..................................\...60

Persistent edema and stasis pigmentation or eczema, with or without

intermittent
ulceration\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\....40

Persistent edema, incompletely relieved by elevation of extremity, with

or without beginning stasis pigmentation or
eczema\...\...\...\...\...\...\...\...\...\...\...\...\...\................................\....20

Intermittent edema of extremity or aching and fatigue in leg after
prolonged

standing or walking, with symptoms relieved by elevation of extremity

or compression
hosiery\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\.....10

Asymptomatic palpable or visible varicose
veins\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..............................0

NOTE: These evaluations are for involvement of a single extremity. If
more than one extremity is involved, evaluate each extremity separately
and combine (under § 4.25), using the bilateral factor (§ 4.26), if
applicable.

7121 Post-phlebitic syndrome of any etiology:

With the following findings attributed to venous disease:

Massive board-like edema with constant pain at
rest\...\...\...\...\...\...\...\...\...\...\...\...\...\..............................\.....100

Persistent edema or subcutaneous induration, stasis pigmentation or

eczema, and persistent
ulceration\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\....60

Persistent edema and stasis pigmentation or eczema, with or without

intermittent
ulceration\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\....40

Persistent edema, incompletely relieved by elevation of extremity, with

or without beginning stasis pigmentation or
eczema\...\...\...\...\...\...\...\...\...\...\...\...\..................................\....20

Intermittent edema of extremity or aching and fatigue in leg after

prolonged standing or walking, with symptoms relieved by elevation

of extremity or compression
hosiery\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...................................\...10

Asymptomatic palpable or visible varicose
veins\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\................................0

NOTE: These evaluations are for involvement of a single extremity. If
more than one extremity is involved, evaluate each extremity separately
and combine (under § 4.25), using the bilateral factor (§ 4.26), if
applicable.

7122 Cold injury residuals:

With pain, numbness, cold sensitivity, or arthralgia plus two or more of

the following: tissue loss, nail abnormalities, color changes, locally

impaired sensation, hyperhidrosis, X-ray abnormalities (osteoporosis,

subarticular punched out lesions, or osteoarthritis) of affected
parts\...\...\......\..............................\...\....30

With pain, numbness, cold sensitivity, or arthralgia plus tissue loss,
nail

abnormalities, color changes, locally impaired sensation, hyperhidrosis,

or X-ray abnormalities (osteoporosis, subarticular punched out lesions,

or osteoarthritis) of affected
parts\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.................................\...20

With pain, numbness, cold sensitivity, or
arthralgia\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............................\....10

NOTE (1): Amputations of fingers or toes, and complications such as
squamous cell carcinoma at the site of a cold injury scar or peripheral
neuropathy should be separately evaluated under other diagnostic codes.

NOTE (2): Evaluate each affected part (hand, foot, ear, nose) separately
and combine the ratings, if appropriate, in accordance with §§ 4.25 and
4.26.

7123 Soft tissue sarcoma (of vascular
origin)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\........................\...\...100

NOTE: A rating of 100 percent shall continue beyond the cessation of any
surgical, X-ray, antineoplastic chemotherapy or other therapeutic
procedure. Six months after discontinuance of such treatment, the
appropriate disability rating shall be determined by mandatory VA
examination. Any change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of § 3.105(e) of this
chapter. If there has been no local recurrence or metastasis, rate on
residuals.

(Authority: 38 U.S.C. 1155)

REGULATORY AMENDMENT

4-98-1

Regulation affected: 38 CFR 4.104.

EFFECTIVE DATE OF REGULATION: August 13, 1998

Date Secretary approved regulation: June 30, 1998

Federal Register Citation: 63 FR 37778-79 (July 14, 1998)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

In the [Federal Register]{.underline} of March 28, 1997 (62 FR 14832) we
published a proposal to revise the provisions of VA's rating schedule
(38 CFR part 4) governing evaluations for frozen feet (38 CFR 4.104,
diagnostic code 7122). As part of a final rule published in the [Federal
Register]{.underline} on December 11, 1997, revising the cardiovascular
portion of the rating schedule, we adopted the revision proposed on
March 28, 1997, with only minor changes. This final rule responds to
comments received in response to the proposed rule and makes additional
nonsubstantive technical changes. It also expands the discussion of
possible residual effects in note (1).

In the evaluation criteria, we changed \"pain\" to \"arthralgia or other
pain\" to emphasize the relatively new concept that arthralgia may
result from cold injury, and we added a direction in note (1) to
separately evaluate other disabilities that are determined to be
residuals of cold injury, such as Raynaud's phenomenon and muscle
atrophy, unless they are used to support an evaluation under diagnostic
code 7122, in response to a comment.

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:

Part 4\--SCHEDULE FOR RATING DISABILITIES

Subpart B---Disability Ratings

1\. The authority citation for part 4 continues to read as follows:

AUTHORITY: 38 U.S.C. 1155 unless otherwise noted.

2\. Section 4.104 is amended by revising diagnostic code 7122 to read as
follows:

[§ 4.104 Schedule of ratings---cardiovascular system.]{.underline}

\* \* \* \* \*

7122 Cold injury residuals.

With the following in affected parts: Arthralgia or other pain,
numbness, or cold

sensitivity plus two or more of the following: tissue loss, nail
abnormalities,

color changes, locally impaired sensation, hyperhidrosis, X-ray
abnormalities

(osteoporosis, subarticular punched out lesions, or
osteoarthritis)................................................30

Arthralgia or other pain, numbness, or cold sensitivity plus tissue
loss,

nail abnormalities, color changes, locally impaired sensation,

hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular

punched out lesions, or
osteoarthritis)..............................................................................
20

Arthralgia or other pain, numbness, or cold sensitivity
.............................................................10

NOTE (1): Separately evaluate amputations of fingers or toes, and
complications such as squamous cell carcinoma at the site of a cold
injury scar or peripheral neuropathy, under other diagnostic codes.
Separately evaluate other disabilities that have been diagnosed as the
residual effects of cold injury, such as Raynaud's phenomenon, muscle
atrophy, etc., unless they are used to support an evaluation under
diagnostic code 7122.

NOTE (2): Evaluate each affected part (e.g., hand, foot, ear, nose)
separately and combine the ratings in accordance with §§ 4.25 and 4.26.

.

\* \* \* \* \*

(Authority: 38 U.S.C. 1155)

REGULATORY AMENDMENT

4-99-1

Regulation affected: 38 CFR 4.85, 4.86, 4.87, 4.87a, and 4.87b.

EFFECTIVE DATE OF REGULATION: June 10, 1999.

Date Secretary approved regulation: January 8, 1999.

Federal Register Citation: 64 FR 25202 (May 11, 1999).

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of its ongoing revision of the Schedule for Rating Disabilities,
the Department of Veterans Affairs (VA) has amended sections 4.85
through 4.87b of 38 CFR, Part 4, the sections of the rating schedule
that address the ear and other sense organs. The intended effect of this
action is to update this portion of the rating schedule to ensure that
it uses current medical terminology and unambiguous criteria, and that
it reflects medical advances which have occurred since the last review.

We revised introductory section 4.85 to indicate that an examination for
hearing impairment must be conducted by a state-licensed audiologist, to
state what puretone frequencies are averaged to obtain the puretone
threshold average and to state that it is the Maryland CNC speech
discrimination test that must be used, to direct that if only one ear is
service-connected, the NSC ear will be assigned a hearing impairment
level of I, and to refer the rater to 38 CFR 3.383 for consideration of
SMC in any claim for impaired hearing. Section 4.86 was revised to
provide directions on evaluating veterans with either of two exceptional
patterns of hearing impairment. This change is based on a VHA study
indicating that without these special provisions, these small groups of
veterans would be underrated. We removed § 4.86a and revised 4.87 by
providing more objective criteria for peripheral vestibular disorders,
DC 6204, (formerly chronic labyrinthitis) and Meniere\'s syndrome, DC
6205. We removed DC 6206, mastoiditis, and included mastoiditis with
chronic suppurative otitis media and cholesteatoma in DC 6200, since
these are closely related and often co-existent. We removed DC 6203,
otitis interna, as an obsolete term. The condition is included in DC
6204. More detailed explanations for some of these changes are included
in the \"Supplementary Information\" section of both the final revision,
which is enclosed, and the proposed revision, which was published in the
[Federal Register]{.underline} on April 12, 1994 (59 FR 17295).

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

6200 6203

6201 6206 None

6204 6101

6205 6102

6207 6103

6208 6104

6209 6105

6210 6106

6260 6107

6275 6108

6276 6109

6110

\[Federal Register: May 11, 1999 (Volume 64, Number 90)\]

\[Rules and Regulations\]

\[Page 25202-25210\]

From the Federal Register Online via GPO Access \[wais.access.gpo.gov\]

\[DOCID:fr11my99-7\]

=======================================================================

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AF22

Schedule for Rating Disabilities; Diseases of the Ear and Other Sense
Organs

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

SUMMARY: This document amends that portion of the Department of Veterans
Affairs (VA) Schedule for Rating Disabilities that addresses the ear and
other sense organs. The intended effect of this action is to update this
portion of the rating schedule to ensure that it uses current medical
terminology and unambiguous criteria, and that it reflects medical
advances that have occurred since the last review.

DATES: Effective Dates: This amendment is effective June 10, 1999.

FOR FURTHER INFORMATION CONTACT: Vickie Milton, M.D., Consultant,
Regulations Staff (211B), Compensation and Pension Service, Veterans
Benefits Administration, Department of Veterans Affairs, 810 Vermont
Ave., NW, Washington DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of its review of the Schedule for
Rating Disabilities, VA published a proposal to amend that portion of
the Schedule pertaining to the ear and other sense organs in the Federal
Register of April 12, 1994 (59 FR 17295-17301). Interested persons were
invited to submit written comments on or before June 13, 1994. We
received comments from the Veterans of Foreign Wars, Disabled American
Veterans, and three individuals.

The evaluation of hearing impairment in the previous rating schedule was
based on two criteria: the results of a puretone audiometry test and the
results of a controlled speech discrimination test. Based on the results
of these tests, one of two tables was used to determine a Roman numeral
designation for hearing impairment: Table VI, where the number is
determined by combining the percent of speech discrimination with the
average puretone decibel (dB) loss, and Table VIa, which is based solely
on average puretone dB loss, and was used only if language difficulties
or inconsistent speech audiometric scores made use of Table VI
inappropriate. The Roman numeral designations determined for each ear
using Table VI or VIa were then combined using Table VII, in order to
determine the percentage evaluation for hearing impairment. We proposed
no change in this method of evaluation and included information about it
in Sec. 4.85, \`\`Evaluation of hearing impairment\'\' and Sec. 4.86,
\`\`Auditory acuity, hearing aids, and evidence other than puretone
audiometry and controlled speech.\'\' In response to several comments we
received about the method of evaluation, and requesting more specific
details, we have reorganized Secs. 4.85 and 4.86 for the sake of
clarity, as explained in detail below.

One commenter stated that nowhere is VA\'s authority to use the specific
hearing tests it uses spelled out in the regulations. We agree that the
tests required were not specified in the rating schedule and have
therefore stated in Sec. 4.85(a) that the Maryland CNC speech
discrimination test and the puretone audiometry test are to be used for
evaluating hearing impairment. The use of the Maryland CNC speech
discrimination test and the puretone threshold average determined by an
audiometry test was established by a regulation on the evaluation of
hearing loss published in the Federal Register on November 18, 1987 (52
FR 44117). That regulation changed the method of evaluating hearing loss
based on a VA study on hearing loss testing methods and assistive
hearing devices that had been requested by Congress in 1984. The results
of the study were published in a VA report titled \`\`Report on Hearing
Loss Study\'\' that was issued on January 6, 1986. Although the
regulation revised the rating schedule to incorporate rating tables
based on the new method of evaluation, it did not add to the schedule
specific details about the new testing methods.

One commenter stated that if only VA examinations or authorized
audiological clinic examinations are to be used, this should be stated
in the proposed regulation. Based on this comment, we have stated in
Sec. 4.85(a) that an examination for hearing impairment for VA purposes
must be conducted by a state-licensed audiologist. This will help to
assure that examinations of veterans will be accurate and consistent
because state licensing agencies require that audiologists meet specific
educational and training requirements and pass a national competency
examination.

Two commenters noted that the meaning of average puretone decibel loss
is not explained in the rating schedule. We agree that this information
should be included in the rating schedule and have added an explanation
in Sec. 4.85(d). For VA purposes, the average puretone decibel loss
means a four-frequency puretone threshold average obtained by adding the
puretone thresholds at four specified frequencies\'1000, 2000, 3000, and
4000 Hertz and dividing by four. This method and the reasons for its
selection were explained in the 1987 regulation referred to above.
Current terminology is \`\`puretone threshold average\'\' rather than
\`\`average puretone decibel loss,\'\' and we have used this language in
Sec. 4.85 and have revised the labels in Tables VI and VIa. For clarity,
we have also titled Table VIa, untitled in the proposed rule,
\`\`Numeric Designation of Hearing Impairment Based Only on Puretone
Threshold Average\'\' and retitled Table VI, titled \`\`Numeric
Designation of Hearing Impairment\'\' in the proposed rule, \`\`Numeric
Designation of Hearing Impairment Based on Puretone Threshold Average
and Speech Discrimination.\'\' In the proposed rule we inadvertently
placed the numeric tables in Sec. 4.86, we have moved them to Sec.
4.85(h) as the more appropriate location. We removed the examples from
Sec. 4.85 because the directions for using the tables are clear enough
without them.

We also proposed to add two new provisions for evaluating veterans with
certain patterns of hearing impairment that cannot always be accurately
assessed under Sec. 4.85, because the speech discrimination test may not
reflect the severity of communicative functioning these veterans
experience. These veterans were identified in review studies carried out
by the Veterans Health Administration\'s (VHA\'s) Audiology and Speech
Pathology Service in 1991. One of the new provisions, proposed as Sec.
4.85(d), stated that if puretone thresholds in any four of the five
frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 55 dB\'s or
more, an evaluation could be based either on Table VI or Table VIa,
whichever results in a higher evaluation. (This provision has been
redesignated Sec. 4.86(a), as discussed below.)

One commenter, although offering no rationale for the comment, suggested
that the level of hearing loss for this provision should be 50 dB
instead of 55.

To conduct a speech discrimination test in someone with hearing
impairment, the sounds must be amplified sufficiently for the individual
to hear the words. The greater the dB threshold level, the higher the
level of amplification that is needed. Up to a 50 dB threshold level,
amplification sufficient to conduct a speech discrimination test is
feasible. However, with a 55 dB threshold level\--the level at which
speech becomes essentially inaudible\--the high level of amplification
needed to attempt to conduct a speech discrimination test would be
painful to most people, and speech discrimination tests may therefore
not be possible or reliable. The new provision will allow evaluation of
hearing impairment in such individuals on the basis of puretone
threshold average only, if that results in a higher evaluation than one
based on a combination of speech discrimination and puretone threshold
average.

The same commenter suggested applying proposed Sec. 4.85(d) if three of
the five specified frequencies have a threshold of 55 dB or more because
the frequencies of 2000 and above are the most important frequencies for
speech discrimination, and precipitous hearing impairment in the high
frequencies is extremely handicapping in the work environment.

The frequencies selected and the dB threshold were chosen because VHA,
through their clinical studies, found that speech discrimination studies
are quite variable in veterans with a 55 dB threshold in four or more
frequencies and may not accurately reflect the true extent of
disability. Also based on the results of their studies, they did not
extend the recommendation for an alternative method of evaluation to
those with that extent of hearing impairment at only three frequencies.
In view of VHA\'s recommendations, based on tests conducted on 1565
individuals, we make no change based on this comment.

The second provision we proposed to add (as Sec. 4.85(e)) was to direct
the rating agency to choose the Roman numeral designation derived from
either table VI or VIa, whichever is higher, when puretone thresholds
are 30 dB or less at frequencies of 1000 Hertz and below, and are 70 dB
or more at 2000 Hertz. It also directed the rating agency to elevate
that Roman numeral designation one level. This provision was meant to
compensate for a pattern of hearing impairment that is an extreme
handicap in the presence of any environmental noise. VHA found that when
this pattern of impairment is present, a speech discrimination test
conducted in a quiet room with amplification of the sounds does not
always reflect the extent of impairment experienced in the ordinary
environment. This provision allows evaluation of hearing impairment in
these individuals on puretone average only, if that results in a higher
evaluation. (This provision has been redesignated Sec. 4.86(b), as
discussed below.)

One commenter said it appears in proposed Sec. 4.85(d) and (e) that 500
Hertz is one of the frequencies to be used in the puretone average,
although when Sec. 4.85 was revised in 1987, the supplementary
information stated that puretone frequencies at 1000, 2000, 3000, and
4000 Hertz were to be used to determine the puretone threshold average.
The commenter also said that the use of four frequencies in some
circumstances and of five or more in others requires an explanation of
why such a methodology does not give rise to disparate treatment.

In the proposed rule, the four frequency puretone threshold average was
the basis of the evaluation for hearing impairment in all cases, and the
500 Hertz frequency was to be used only to help select the veterans to
whom the special provisions would be applied. However, in order to
remove any suggestion of disparate treatment, and after consultation
with VHA, we removed the 500 Hertz stipulations from the two proposed
special provisions. VHA assured us that this change would not affect the
need for the special provisions and would not affect the disability
ratings of any group of veterans.

One commenter suggested that the language for evaluation parallel the
language of 38 CFR 3.385.

The purpose of Sec. 3.385, \`\`Disability due to impaired hearing,\'\'
is to explain the basis for determining whether impaired hearing is a
disability, which is different from the purpose of Sec. 4.85, which is
to explain how to evaluate hearing impairment, once it has been
determined to be a disability, for purposes of disability compensation.
Since these regulations serve different purposes, and different
frequencies are involved, the use of parallel language is neither
necessary nor feasible.

When the puretone threshold average is 105 dB or more, tables VI and VIa
require a numeric designation of XI, the highest level of evaluation.
This is unchanged from the previous schedule. One commenter stated that
a loss of greater than 92 dB, rather than 105 dB, would result in total
impairment in everyone, according to the American Academy of
Otolaryngology and Otolaryngology Guide for the Evaluation of Hearing
Impairment.

Methods of measuring hearing impairment and assessing disability based
on the results vary from one organization to another, making direct
comparisons infeasible. Not all organizations use the same range of
frequencies, for example, to determine a puretone threshold average.
While VA uses 1000, 2000, 3000, and 4000 Hertz for evaluation, based on
the results of the VA study referred to above, the American Medical
Association (AMA), in its \`\`Guides to the Evaluation of Permanent
Impairment\'\' 4th ed., 1993, uses 500, 1000, 2000, and 3000 Hertz. The
National Institute for Occupational Safety and Health proposed using
puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, as has the
American Speech and Hearing Association Task Force, and their rationale
is that these frequencies are most sensitive to discrimination ability
in quiet and in noise. Not all organizations use a speech discrimination
test in evaluating hearing impairment; the AMA, for example, does not.
The guide referred to by the commenter is no longer in existence, but
the AMA Guides states that the criteria it uses are adapted from the
1979 Academy of Otolaryngology-Head and Neck Surgery Guide. The AMA
Guides considers impairment of hearing to be total if the average of the
four puretone frequencies they use is over 91.7 dB. However, total
impairment of hearing under their system does not mean that a
100-percent disability evaluation is assigned. Under the AMA disability
evaluation system, each disability is considered in terms of its effect
on the whole person. The evaluation they would assign for a bilateral
puretone threshold of 91.7 dB (in workers\' compensation claims, for
example) is 35 percent, not 100 percent. With a unilateral puretone
threshold of 91.7 dB (with the other ear normal), the AMA system would
evaluate monaural hearing impairment at 100 percent, and binaural
hearing impairment at approximately 17 percent, but the actual
evaluation they would assign is six percent. Thus, direct comparisons of
different systems of evaluating disability due to hearing loss are not
possible, and we make no change based on this comment.

One commenter pointed out that Sec. 4.86 in the previous schedule stated
that evaluations are intended to make proper allowance for improvement
by hearing aids and that examination to determine the improvement is not
necessary. The commenter further stated that because Table VI appears to
be unchanged in the proposed regulations, it would appear that Table VI
continues to be built on the assumption of improvement with hearing aids
and that performing audiology tests with hearing aids or adjusting the
rating values based on an assumption of improvement with hearing aids
violates the policy of determining impairment of body function without
the use of any prosthetic device.

We are unaware of any general policy which prohibits consideration of
the effect of a prosthetic device in determining the degree of
impairment. In fact, there is a standard method for measuring best
corrected vision, and the rating schedule requires that examinations for
visual impairment include corrected, as well as uncorrected, visual
acuity. However, there is no standard procedure for measuring best
corrected hearing, and the amended instruction (Sec. 4.85(a)) states
that examinations for hearing impairment will be conducted without the
use of hearing aids. Section 4.85(a) is clear enough that, in order to
avoid confusion, we have removed the language in proposed Sec. 4.86(b)
stating that the evaluations are designed to measure the best residual
uncorrected hearing and that examinations comparing hearing with and
without hearing aids are unnecessary. VHA consultants indicated that it
is well accepted in the audiological literature that the better the
speech discrimination score, the better the overall result with hearing
aids, but they also stated that the language in the former rating
schedule about anticipated improvement by a hearing aid did not in any
way affect the method of evaluation or disability ratings themselves,
and that removal of that language would also have no effect on the
method of evaluation or on disability ratings.

The previous Sec. 4.87 and proposed Sec. 4.86(a) defined \`\`impairment
of auditory acuity,\'\' for VA purposes. However, that term is not used
elsewhere in the rating schedule, although the terms \`\`hearing
impairment,\'\' \`\`hearing loss,\'\' and \`\`deafness\'\' are used. We
have therefore removed Sec. 4.86(a) as unnecessary and have, for the
sake of clarity, used \`\`hearing impairment\'\' in all other parts of
the rating schedule to designate a loss of hearing except where the
statutory terms \`\`deafness\'\' or \`\`hearing loss\'\' are required
(by 38 U.S.C. 1114(k)).

Former section 4.86a, \`\`Evidence other than puretone audiometry and
controlled speech,\'\' explained that where claims contain evidence
which predates the use of puretone audiometry and controlled speech,
determination of service connection will be evaluated under the
regulations in effect on December 17, 1987. We proposed to retain this
instruction in Sec. 4.86(c). One commenter suggested that this is not a
rating regulation and that it properly belongs in Part 3 of 38 CFR.

We agree that regulations regarding service connection are not
appropriate in the rating schedule, which is used for the evaluation of
disabilities, and we have removed Sec. 4.86(c). This completes the
removal of the contents of proposed Sec. 4.86. We have, however,
retained Sec. 4.86, retitled it \`\`Exceptional patterns of hearing
impairment,\'\' and added paragraphs (a) and (b) for the two provisions
that were proposed as Sec. 4.85(d) and (e). This change better
highlights the unusual aspects of evaluating these uncommon patterns of
hearing impairment.

The previous schedule did not provide specific instructions on
evaluating bilateral hearing impairment when hearing impairment is
service-connected in only one ear. One commenter suggested that we add a
note indicating that a non-service-connected ear is to be treated as
having normal hearing.

We concur and have added Sec. 4.85(f) to specify that a
non-service-connected ear will be assigned a Roman numeral designation
of I, subject to the provisions of Sec. 3.383, \`\`Special consideration
for paired organs and extremities.\'\' This is consistent with the
manner in which we evaluate other paired organs, where only one of the
pair is service-connected (38 CFR 4.73 (muscle injuries) and 38 CFR
4.124a (diseases of the cranial and peripheral nerves)).

One commenter stated that the regulation should include a specific
effective date and should state whether the regulatory change
constitutes a liberalizing law or issue.

The effective date of the regulation will be 30 days after publication
of this final rule in the Federal Register. The revisions of the
sections addressing ear and other sense organs are part of the overall
revision of the rating schedule based on medical advances, etc., rather
than representing liberalizing interpretations of regulations. We have
explained above the reasons for the provisions of Sec. 4.86. The
preamble erred in discussing these provisions as liberalizations.
Rather, they are an attempt to assure more equitable evaluations in a
small number of veterans with unusual patterns of hearing impairment.

Special monthly compensation (SMC) is a benefit authorized by 38 U.S.C.
1114 that is payable in addition to the compensation payable for
specific disabilities, or combinations of disabilities, based upon the
extent of impairment under the Schedule for Rating Disabilities. We
proposed removing the footnote regarding SMC in Table VII in favor of a
single note at the end of Sec. 4.85 directing the rating agency to refer
to Sec. 3.350 (\`\`Special monthly compensation ratings\'\') to
determine whether a claimant is entitled to SMC. One commenter suggested
that we retain this footnote.

In response to the comment, and for the sake of consistency with
references to SMC that we have made in other revised sections of the
rating schedule, we have added this information as Sec. 4.85(g) and also
restored a footnote to Table VII, Percentage Evaluations for Hearing
Impairment, indicating that the rating agency is to review for
entitlement to special monthly compensation under Sec. 3.350. (We
proposed to put the information now in Sec. 4.85(g) in a footnote
following Sec. 4.86, but moved it to Sec. 4.85 instead to remove
ambiguity about whether it referred only to the provisions of Sec. 4.86
or to all hearing evaluations.) A single footnote to Table VII is
adequate because we have deleted all but one diagnostic code (DC), 6100,
for hearing impairment, since it is unnecessary for any practical
purpose to have multiple diagnostic codes to indicate various evaluation
levels of the same disability. SMC may be warranted not only when
hearing impairment is evaluated at 100 percent, but also for various
levels of deafness (or hearing impairment) when they occur in
combination with blindness, and the single footnote will assure that SMC
is always considered when there is hearing impairment. We believe that
the combination of the footnote and Sec. 4.85(g) is the most effective
method for ensuring complete review for special monthly compensation.

38 U.S.C. 1114(k) authorizes payment of SMC if there is absence of air
and bone conduction in both ears. The implementing regulation, 38 CFR
3.350(a)(5), states that deafness of both ears, having absence of air
and bone conduction, will be held to exist when bilateral hearing loss
is equal to or greater than the minimum bilateral hearing loss required
for a maximum rating (100 percent) under the schedule. One commenter
suggested that we add a footnote to the 80- and 90-percent levels
indicating entitlement to special monthly compensation, because these
evaluations constitute deafness, for all practical purposes.

We do not concur. Complete loss of air and bone conduction would result
in no response on audiometry, even at 105 dB, according to VHA
consultants, and would therefore warrant a 100-percent evaluation. If
there is a response on audiometry, which would necessarily be the case
to establish an 80- or 90-percent evaluation for hearing impairment,
there is not complete absence of air and bone conduction, and the
hearing impairment in those cases would not meet the requirements of 38
U.S.C. 1114(k). Such a footnote would therefore be contrary to statutory
requirements.

The previous schedule listed mastoiditis under its own diagnostic code
(6206), with evaluation based on suppuration and impairment of hearing.
We proposed to combine it with suppurative otitis media under DC 6200.
The previous schedule provided neither diagnostic code nor evaluation
criteria for cholesteatoma; raters have generally evaluated it analogous
to otitis media. We also proposed to include cholesteatoma under DC
6200, because the three conditions are closely related, and their
manifestations may be essentially the same. One commenter suggested that
we assign separate diagnostic codes for cholesteatoma and mastoiditis
because the proposed rule is ambiguous as to whether one of these
conditions must accompany otitis media to assign a 10-percent evaluation
and because mastoiditis and cholesteatoma can exist without forming pus
(suppuration).

Chronic otitis media, mastoiditis, and cholesteatoma may exist with or
without suppuration. However, two or more of these conditions, all of
which are interrelated, commonly coexist, and their manifestations may
be very similar. For example, chronic mastoiditis may develop
simultaneously with otitis media or may occur as a later complication.
Therefore, a single diagnostic code and set of evaluation criteria for
all three conditions is appropriate, and we have revised the title of DC
6200 to clarify that it can apply to any of these conditions. We have
also added aural polyps to the criteria for a 10-percent evaluation
because they are a possible consequence of chronic otitis media. We have
also expanded the note directing that hearing impairment be evaluated
separately to include a list of other possible
complications\--labyrinthitis, tinnitus, facial nerve paralysis, and
bone loss of skull\--that would also warrant separate evaluations. These
criteria better encompass the usual range of impairments that may
develop in this group of conditions. Placing these related conditions
under a single diagnostic code will help assure that the same impairment
is not evaluated twice when more than one of these conditions is present
in an individual.

The previous schedule addressed otitis interna under DC 6203 and
evaluated it based on the extent of hearing loss. We proposed to
eliminate this diagnostic code because otitis interna is an archaic name
for a general ear infection condition which is more accurately
classified as a peripheral vestibular disorder, DC 6204. One commenter
suggested that we provide instructions under peripheral vestibular
disorders explaining how to evaluate otitis interna. We do not concur.
Otitis interna is an obsolete term, and conditions which it formerly
encompassed are best evaluated under the criteria for peripheral
vestibular disorders.

The previous rating schedule provided three evaluation levels for
Meniere\'s syndrome, DC 6205, based on the severity and frequency of
attacks. Among other things, we proposed to provide objective measures
for the frequency of the attacks. One commenter stated that the
prodromal signs, the duration of the episode, and the recovery period
for an attack may last as long as ten days, and therefore suggested that
the frequency of attacks proposed for the 100-percent evaluation (more
than once weekly) and 60-percent evaluation (once a week or less) was
too stringent. The commenter also said that \`\`attacks occurring once a
week or less\'\' should be better defined.

Attacks of vertigo in Meniere\'s syndrome appear suddenly and last from
a few to 24 hours (Boies Fundamentals of Otolaryngology, Sixth Edition,
W.B. Saunders Company, 1989, p.139, and The Merck Manual of Diagnosis
and Therapy, Merck Research Laboratories, 1992, p. 2336). Since the
attacks of vertigo (often accompanied by nausea, vomiting, hearing
impairment, and tinnitus) generally subside within 24 hours, requiring
attacks more than once weekly for a 100-percent level, and one to four
times a month for a 60-percent level, are reasonable requirements, in
our judgment, that are equivalent to, but more objective than, the
requirements of \`\`frequent and typical,\'\' and \`\`less frequent\'\'
in the previous schedule. In response to the comment, however, we better
defined the criteria by changing the requirements for a 60-percent
evaluation from \`\`deafness with attacks of vertigo and cerebellar gait
occurring once a week or less\'\' to \`\`hearing impairment with attacks
of vertigo and cerebellar gait occurring from one to four times a month,
with or without tinnitus,\'\' and by changing the requirements for a
30-percent evaluation from \`\`deafness with occasional vertigo\'\' to
\`\`hearing impairment with vertigo less than once a month, with or
without tinnitus.\'\' Tinnitus is commonly, but not universally, present
in Meniere\'s syndrome. We included the phrase \`\`with or without
tinnitus\'\' in these criteria to emphasize that the overall evaluation
of Meniere\'s syndrome is the same whether or not tinnitus is present.
This will avoid the assignment of a separate evaluation for tinnitus
when evaluating the syndrome under DC 6205, and at the same time,
indicate that the absence of tinnitus in certain cases has no effect on
the evaluation to be assigned under DC 6205.

We proposed to retain \`\`deafness\'\' as one of the criteria at the
100-percent evaluation level of Meniere\'s syndrome (DC 6205). One
commenter suggested that there be a footnote appended to the 100-percent
level, signaling that entitlement to Special Monthly Compensation is
payable.

We do not concur. A particular level of impaired hearing is not a
requirement for the 100-percent level for Meniere\'s syndrome. The term
\`\`deafness\'\' was meant to indicate any level of hearing impairment,
and we have changed \`\`deafness\'\' to \`\`hearing impairment\'\' in
the criteria for Meniere\'s syndrome to make that clear. The
requirements for a 100-percent evaluation of Meniere\'s syndrome are met
if there is any levelof hearing impairment, and vertigo and cerebellar
gait occur more than once weekly. 38 CFR 3.350(a)(5), on the other hand,
requires an absence of air and bone conduction and hearing loss equal to
or greater than the minimum bilateral hearing loss required for a
100-percent rating, for entitlement to SMC on the basis of hearing
impairment. For this reason, a footnote referring to entitlement to SMC
is not appropriate here, and Sec. 4.85(g) and the footnote to Table VII
will assure consideration of SMC in any case of hearing impairment.

Another commenter suggested that we add a note under Meniere\'s syndrome
instructing the rating agency that hearing impairment will be rated
separately and combined. We did not adopt this suggestion because the
evaluation criteria and percentages are based on all of the
manifestations of Meniere\'s syndrome, with attacks often consisting of
hearing impairment, vertigo, tinnitus, and staggering gait. Any of the
symptoms may be intermittent. It would be contrary to 38 CFR 4.14
(Avoidance of pyramiding), which prohibits the evaluation of the same
manifestation under different diagnoses, to evaluate hearing impairment
separately, and also use it to support an evaluation under DC 6205.
However, we have added a note stating that Meniere\'s syndrome may be
evaluated either under DC 6205 or by separately evaluating vertigo (as a
peripheral vestibular disorder), hearing impairment, and tinnitus,
whichever method results in a higher overall evaluation. The note also
prohibits combining an evaluation for hearing impairment, tinnitus, or
vertigo with an evaluation under DC 6205.

The previous schedule provided a minimum 10-percent evaluation for
malignant neoplasms of the ear, DC 6208. We proposed to delete the
minimum evaluation. One commenter suggested that we reinstate the
minimum 10-percent evaluation because it was meant to compensate for
skull loss.

In our judgment, loss of function is the most accurate and equitable
basis for evaluating the residuals of this condition. If a malignant
neoplasm results in skull loss, the skull loss would be separately
evaluated under the skeletal system (DC 5296).

The previous rating schedule provided a 10-percent evaluation for
tinnitus, DC 6260, with the criteria being: \`\`persistent as a symptom
of head injury, concussion or acoustic trauma.\'\' We proposed to remove
the requirement that tinnitus be a symptom of head injury, concussion or
acoustic trauma and that it be persistent and instead provide a
10-percent evaluation for recurrent tinnitus. One commenter suggested
that we add a note following tinnitus instructing that the evaluation
for tinnitus be combined with ratings for hearing impairment,
suppurative otitis media, and peripheral vestibular disorder.

We agree and have added a note under DC 6260 stating that a separate
evaluation for tinnitus under DC 6260 may be combined with an evaluation
under DC\'s 6100, 6200, 6204, or other diagnostic code except when
tinnitus supports an evaluation under one of those diagnostic codes.

We added the word \`\`nonsuppurative\'\' to the proposed title of DC
6201, \`\`chronic nonsuppurative otitis media with effusion (serous
otitis media),\'\' to better distinguish it from DC 6200, \`\`chronic
suppurative otitis media, mastoiditis, or cholesteatoma.\'\' We also
made additional nonsubstantive changes throughout this final rule for
the sake of clarity and succinctness.

he Secretary hereby certifies that this regulatory amendment will not
have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C.
601-612. The reason for this certification is that this amendment would
not directly affect any small entities. Only VA beneficiaries could be
directly affected. Therefore, pursuant to 5 U.S.C. 605 (b), this
amendment is exempt from the initial and final regulatory flexibility
analysis requirements of sections 603 and 604.

This regulatory action has been reviewed by the Office of Management and
Budget under Executive Order 12866.

The Catalog of Federal Domestic Assistance numbers are 64.104 and
64.109.

List of Subjects in 38 CFR Part 4

Disability benefits, Individuals with disabilities, Pensions, Veterans.

For the reasons set out in the preamble, 38 CFR part 4 is amended as set
forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155.

Subpart B\--Disability Ratings

2\. Section 4.85 is revised to read as follows:

Sec. 4.85 Evaluation of hearing impairment.

\(a\) An examination for hearing impairment for VA purposes must be
conducted by a state-licensed audiologist and must include a controlled
speech discrimination test (Maryland CNC) and a puretone audiometry
test. Examinations will be conducted without the use of hearing aids.

\(b\) Table VI, \`\`Numeric Designation of Hearing Impairment Based on
Puretone Threshold Average and Speech Discrimination,\'\' is used to
determine a Roman numeral designation (I through XI) for hearing
impairment based on a combination of the percent of speech
discrimination (horizontal rows) and the puretone threshold average
(vertical columns). The Roman numeral designation is located at the
point where the percentage of speech discrimination and puretone
threshold average intersect.

\(c\) Table VIa, \`\`Numeric Designation of Hearing Impairment Based
Only on Puretone Threshold Average,\'\' is used to determine a Roman
numeral designation (I through XI) for hearing impairment based only on
the puretone threshold average. Table VIa will be used when the examiner
certifies that use of the speech discrimination test is not appropriate
because of language difficulties, inconsistent speech discrimination
scores, etc., or when indicated under the provisions of Sec. 4.86.

\(d\) \`\`Puretone threshold average,\'\' as used in Tables VI and VIa,
is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000
Hertz, divided by four. This average is used in all cases (including
those in Sec. 4.86) to determine the Roman numeral designation for
hearing impairment from Table VI or VIa.

\(e\) Table VII, \`\`Percentage Evaluations for Hearing Impairment,\'\'
is used to determine the percentage evaluation by combining the Roman
numeral designations for hearing impairment of each ear. The horizontal
rows represent the ear having the better hearing and the vertical
columns the ear having the poorer hearing. The percentage evaluation is
located at the point where the row and column intersect.

\(f\) If impaired hearing is service-connected in only one ear, in order
to determine the percentage evaluation from Table VII, the
non-service-connected ear will be assigned a Roman Numeral designation
for hearing impairment of I, subject to the provisions of Sec. 3.383 of
this chapter.

\(g\) When evaluating any claim for impaired hearing, refer to Sec.
3.350 of this chapter to determine whether the veteran may be entitled
to special monthly compensation due either to deafness, or to deafness
in combination with other specified disabilities.

\(h\) Numeric tables VI, VIA\*, and VII.

3\. Section 4.86 is revised to read as follows:

Sec. 4.86 Exceptional patterns of hearing impairment.

\(a\) When the puretone threshold at each of the four specified
frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more,
the rating specialist will determine the Roman numeral designation for
hearing impairment from either Table VI or Table VIa, whichever results
in the higher numeral. Each ear will be evaluated separately.

\(b\) When the puretone threshold is 30 decibels or less at 1000 Hertz,
and 70 decibels or more at 2000 Hertz, the rating specialist will
determine the Roman numeral designation for hearing impairment from
either Table VI or Table VIa, whichever results in the higher numeral.
That numeral will then be elevated to the next higher Roman numeral.
Each ear will be evaluated separately.

(Authority: 38 U.S.C. 1155)

Sec. 4.86a \[Removed\]

4\. Section 4.86a is removed.

5\. Section 4.87 is revised to read as follows:

Sec. 4.87 Schedule of ratings\--ear.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

DISEASES OF THE EAR

6200 Chronic suppurative otitis media, mastoiditis, or

cholesteatoma (or any combination):

During suppuration, or with aural
polyps\...\...\...\...\...................................................................10

Note: Evaluate hearing impairment, and complications such as
labyrinthitis, tinnitus, facial nerve paralysis, or bone loss of skull,
separately.

6201 Chronic nonsuppurative otitis media with effusion (serous otitis
media):

Rate hearing impairment

6202 Otosclerosis:

Rate hearing impairment

6204 Peripheral vestibular disorders:

Dizziness and occasional
staggering\...\...\...\...\...\...\................................................................\....30

Occasional
dizziness\...\...\...\...\...\...\...\...\...\...\...\........................................................................\...10

Note: Objective findings supporting the diagnosis of vestibular
disequilibrium are required before a compensable evaluation can be
assigned under this code. Hearing impairment or suppuration shall be
separately rated and combined.

6205 Meniere\'s syndrome (endolymphatic hydrops):

Hearing impairment with attacks of vertigo and cerebellar

gait occurring more than once weekly, with or without

tinnitus\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............................................................................100

Hearing impairment with attacks of vertigo and cerebellar

gait occurring from one to four times a month, with or

without
tinnitus\...\...\...\...\...\...\...\...\...\...\...\...\..............................................................................60

Hearing impairment with vertigo less than once a month,

with or without
tinnitus\...\...\...\...\...\...\...\...\...\...........................................................................30

Note: Evaluate Meniere\'s syndrome either under these criteriaor by
separately evaluating vertigo (as a peripheral vestibular disorder),
hearing impairment, and tinnitus, whichever method results in a higher
overall evaluation. But do not combine an evaluation for hearing
impairment, tinnitus, or vertigo with an evaluation under diagnostic
code 6205.

6207 Loss of auricle:

Complete loss of
both\...\...\...\...\...\...\...\...\...\...\...\.......................................................................
50

Complete loss of
one\...\...\...\...\...\...\...\...\...\...\...\........................................................................
30

Deformity of one, with loss of one-third or more of the

substance\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...............................................................................10

6208 Malignant neoplasm of the ear (other than skin
only)..................................................... 100

Note: A rating of 100 percent shall continue beyond the cessation of any
surgical, radiation treatment, antineoplastic chemotherapy or other
therapeutic procedure. Six months after discontinuance of such
treatment, the appropriate disability rating shall be determined by
mandatory VA examination. Any change in evaluation based on that or any
subsequent examination shall be subject to the provisions of
Sec.3.105(e) of this chapter. If there has been no local recurrence or
metastasis, rate on residuals.

6209 Benign neoplasms of the ear (other than skin only):

Rate on impairment of function.

6210 Chronic otitis externa:

Swelling, dry and scaly or serous discharge, and itching

requiring frequent and prolonged
treatment\...\...\...\..............................................................10

6210. Tympanic membrane, perforation of
      ....................................................................0

```{=html}
<!-- -->
```
6260. Tinnitus,
      recurrent\...\...\...\...\...\...\...\.........................................................................10

Note: A separate evaluation for tinnitus may be combined with an
evaluation under diagnostic codes 6100, 6200, 6204, or other diagnostic
code, except when tinnitus supports an evaluation under one of those
diagnostic codes.

(Authority: 38 U.S.C. 1155)

6\. Section 4.87a is revised to read as follows:

Sec. 4.87a Schedule of ratings\--other sense organs.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

6275 Sense of smell, complete
loss\...\...\...\...\...\...\...\.....................................................................10

6276 Sense of taste, complete
loss\...\...\...\...\...\...\...\...................................................................10

Note: Evaluation will be assigned under diagnostic codes 6275 or 6276
only if there is an anatomical or pathological basis for the condition.

(Authority: 38 U.S.C. 1155)

Sec. 4.87b \[Removed\]

7\. Section 4.87b is removed.

<table style="width:100%;">
<colgroup>
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><p>TABLE VI</p>
<p>NUMERIC DESIGNATION OF HEARING IMPAIRMENT BASED ON PURETONE THRESHOLD
AVERAGE AND SPEECH DISCRIMINATION</p>
<p>Puretone Threshold Average</p></td>
</tr>
<tr class="even">
<td><p>% of</p>
<p>discrim-ination</p></td>
<td>0-41</td>
<td>42-49</td>
<td>50-57</td>
<td>58-65</td>
<td>66-73</td>
<td>74-81</td>
<td>82-89</td>
<td>90-97</td>
<td>98+</td>
</tr>
<tr class="odd">
<td>92-100</td>
<td>I</td>
<td>I</td>
<td>I</td>
<td>II</td>
<td>II</td>
<td>II</td>
<td>III</td>
<td>III</td>
<td>IV</td>
</tr>
<tr class="even">
<td>84-90</td>
<td>II</td>
<td>II</td>
<td>II</td>
<td>III</td>
<td>III</td>
<td>III</td>
<td>IV</td>
<td>IV</td>
<td>IV</td>
</tr>
<tr class="odd">
<td>76-82</td>
<td>III</td>
<td>III</td>
<td>IV</td>
<td>IV</td>
<td>IV</td>
<td>V</td>
<td>V</td>
<td>V</td>
<td>V</td>
</tr>
<tr class="even">
<td>68-74</td>
<td>IV</td>
<td>IV</td>
<td>V</td>
<td>V</td>
<td>VI</td>
<td>VI</td>
<td>VII</td>
<td>VII</td>
<td>VII</td>
</tr>
<tr class="odd">
<td>60-66</td>
<td>V</td>
<td>V</td>
<td>VI</td>
<td>VI</td>
<td>VII</td>
<td>VII</td>
<td>VIII</td>
<td>VIII</td>
<td>VIII</td>
</tr>
<tr class="even">
<td>52-58</td>
<td>VI</td>
<td>VI</td>
<td>VII</td>
<td>VII</td>
<td>VIII</td>
<td>VIII</td>
<td>VIII</td>
<td>VIII</td>
<td>IX</td>
</tr>
<tr class="odd">
<td>44-50</td>
<td>VII</td>
<td>VII</td>
<td>VIII</td>
<td>VIII</td>
<td>VIII</td>
<td>IX</td>
<td>IX</td>
<td>IX</td>
<td>X</td>
</tr>
<tr class="even">
<td>36-42</td>
<td>VIII</td>
<td>VIII</td>
<td>VIII</td>
<td>IX</td>
<td>IX</td>
<td>IX</td>
<td>X</td>
<td>X</td>
<td>X</td>
</tr>
<tr class="odd">
<td>0-34</td>
<td>IX</td>
<td>X</td>
<td>XI</td>
<td>XI</td>
<td>XI</td>
<td>XI</td>
<td>XI</td>
<td>XI</td>
<td>XI</td>
</tr>
</tbody>
</table>

TABLE VIA\*

NUMERIC DESIGNATION OF HEARING IMPAIRMENT BASED ONLY ON PURETONE
THRESHOLD AVERAGE

Puretone Threshold Average

  ------ ------- ------- ------- ------- ------- ------- ------- ------- -------- ------
  0-41   42-48   49-55   56-62   63-69   70-76   77-83   84-90   91-97   98-104   105+

  I      II      III     IV      V       VI      VII     VIII    IX      X        XI
  ------ ------- ------- ------- ------- ------- ------- ------- ------- -------- ------

\* This table is for use only as specified in §§ 4.85 and 4.86.

<table>
<colgroup>
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"></td>
<td colspan="11"><p>TABLE VII</p>
<p>PERCENTAGE EVALUATION FOR HEARING IMPAIRMENT</p>
<p>(DIAGNOSTIC CODE 6100)</p>
<p>Poorer Ear</p></td>
</tr>
<tr class="even">
<td>XI</td>
<td colspan="2">100*</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>X</td>
<td colspan="2">90</td>
<td>80</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>IX</td>
<td colspan="2">80</td>
<td>70</td>
<td>60</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>VIII</td>
<td colspan="2">70</td>
<td>60</td>
<td>50</td>
<td>50</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>VII</td>
<td colspan="2">60</td>
<td>60</td>
<td>50</td>
<td>40</td>
<td>40</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>VI</td>
<td colspan="2">50</td>
<td>50</td>
<td>40</td>
<td>40</td>
<td>30</td>
<td>30</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>V</td>
<td colspan="2">40</td>
<td>40</td>
<td>40</td>
<td>30</td>
<td>30</td>
<td>20</td>
<td>20</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>IV</td>
<td colspan="2">30</td>
<td>30</td>
<td>30</td>
<td>20</td>
<td>20</td>
<td>20</td>
<td>10</td>
<td>10</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>III</td>
<td colspan="2">20</td>
<td>20</td>
<td>20</td>
<td>20</td>
<td>20</td>
<td>10</td>
<td>10</td>
<td>10</td>
<td>0</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>II</td>
<td colspan="2">10</td>
<td>10</td>
<td>10</td>
<td>10</td>
<td>10</td>
<td>10</td>
<td>10</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td></td>
</tr>
<tr class="even">
<td>I</td>
<td colspan="2">10</td>
<td>10</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">XI</td>
<td>X</td>
<td>IX</td>
<td>VIII</td>
<td>VII</td>
<td>VI</td>
<td>V</td>
<td>IV</td>
<td>III</td>
<td>II</td>
<td>I</td>
</tr>
</tbody>
</table>

\* Review for entitlement to special monthly compensation under §3.350
of this chapter.

REGULATORY AMENDMENT

3-99-2

Regulations Affected: 38 C.F.R. §3.381 and §3.382; 38 C.F.R. §4.149

Effective Date of the Regulation: June 8, 1999

Date Secretary Approved Regulation: April 21, 1999

Federal Register Citation: 64 FR 30392-93 (June 8, 1999)

The purpose of the following comments on the changes included in this
amendment of VA regulations is to inform all concerned why the changes
are being made. These comments are not regulatory.

38 CFR Part 4, the Schedule for Rating Disabilities, provides
evaluations for dental conditions considered disabling in nature. There
are, however, other dental conditions which are not considered disabling
and consequently do not fall under the purview of the rating schedule.
The issue of service connection for these conditions arises only for the
purpose of determining eligibility to outpatient dental treatment. These
conditions include carious teeth, replaceable missing teeth, dental or
alveolar abscesses, periodontal disease, and Vincent\'s stomatitis (also
referred to as Vincent\'s disease, Vincent\'s infection, or acute
necrotizing gingivitis). These conditions were listed in the former 38
CFR §4.149, in the Schedule for Rating Disabilities. Because these
conditions are not evaluated for compensation, but only to determine
eligibility for treatment, it is more appropriate to list them in 38 CFR
Part 3, which contains general rules for determining service connection.
Therefore, §4.149 has been deleted.

Prior to the current revision, §3.381 provided that service connection
will be granted for certain dental conditions shown after a \"reasonable
period of service\"; however, this subjective term was not defined. The
new rule replaces this subjective term with the objective requirement of
180 days or more of active service in decisions pertaining to service
connection for dental conditions that develop over a period of time.
Such conditions include dental caries, periodontal disease, and disease
of pathology of third molars or teeth in which an existing filling
requires replacement. Because these conditions take time to develop,
(often a year or two in permanent teeth), it is more likely than not
that caries or pathology that become apparent within the first 180 days
of service pre-existed that service.

The new rule also eliminates overlapping provisions in 38 CFR §§ 3.381
and 3.382 which did not clearly state requirements for service
connection or which appeared to be possibly conflicting. Section
3.381(d) now includes specific rules for determining whether dental
conditions that are noted at entry into service and treated during
active duty are service connected for treatment purposes. These
provisions provide concrete guidelines for decisions related to tooth
extractions and restorations, as well as for missing teeth.

Former §3.381(c) which addressed the principle of secondary service
connection for dental diseases and injuries was deleted because it was
superfluous given the provisions governing secondary service connection
already contained in §3.310. Likewise, paragraphs (a) and (b) of §3.382
were deleted because its statements related to the types of evidence
needed to establish service connection were redundant of provisions
contained elsewhere in the regulations which adequately describe
evidence requirements for establishing service connection. (*See* 38 CFR
§3.303, §3.304)

Former §3.381(d) specifically stated that the presumption of soundness
does not apply to non-compensable dental conditions. While no longer
explicitly stated in the revised regulation, the presumption of
soundness is clearly inapplicable based on 38 U.S.C. §1110 and §1111.
Section 1111 requires VA to consider every veteran

to have been in sound condition at the time of entry except as to
defects noted at that time. It specifically references §1110 of Title 38
which applies only to payment of compensation for disability. Section
1111 is therefore not applicable to determining eligibility to
outpatient dental treatment under 38 U.S.C. §1712. In addition, §1153 of
Title 38 U.S.C. applies only to disabilities. Because non-compensable
dental conditions are not considered to be disabilities, §1153 is also
not applicable to 38 U.S.C. §1712 determinations.

The revised rule retains the general principle contained in former
§3.381(b) which stated that treatment during service is not considered
*per se* aggravation of a dental condition noted as present at the time
of entry because such treatment is considered ameliorative. However, the
phrase \"*per se\"* has been deleted and is replaced with a statement
that treatment in service is not evidence that a condition noted at
entry has been aggravated unless additional pathology developed after
180 days or more of service. This is consistent with the change
reflected in §3.381(d) requiring 180 days of active duty service as a
prerequisite to considering specified dental conditions as service
connected for purposes of treatment.

Paragraph 3.381(e) lists conditions that will not be service connected
for treatment purposes, replacing former §3.382(c). Current medical
terminology has been used to describe these conditions with \"calculus\"
replacing \"salivary deposits,\" and \"periodontal disease\" replacing
\"gingivitis,\" \"Vincent\'s disease,\" and \"pyorrhea.\" Impacted or
malposed teeth are considered developmental defects as is the presence
of third molars (wisdom teeth). These conditions are not service
connected unless separate pathology develops after 180 days of active
service. The use of the 180-day time period has been explained above.
Periodontal disease is related to dental hygiene and can be affected by
other factors such as diet, abnormal stress, other disease processes,
and reaction to certain drugs or chemicals. With proper treatment, most
periodontal disease resolves with no residuals. Therefore, service
connection for acute periodontal disease is not subject to service
condition in the former rule and remains not subject to service
connection in the present rule. However, chronic periodontal disease
(formerly described as \"Pyorrhea\"), which may result in tooth
extraction, will warrant service connection for the lost teeth.

For the reasons set forth in the preamble, 38 CFR Part 3 is amended as
follows:

1\. The Authority citation for part 3 continues to read as follows:

AUTHORITY: 38 U.S. C. 501 (a), unless otherwise noted.

2\. Section 3.381 is amended by revising the heading and text to read as
follows:

§ 3.381 Service connection of dental conditions for treatment purposes.

(a) Treatable carious teeth, replaceable missing teeth, dental or
    alveolar abscesses, and

periodontal disease will be considered service-connected solely for the
purpose of establishing eligibility for

outpatient dental treatment as provided in section 17.161 of this
chapter.

\(b\) The rating activity will consider each defective or missing tooth
and each disease of the teeth and periodontal tissues separately to
determine whether the condition was incurred or aggravated in line of
duty during active service. When applicable, the rating activity will
determine whether the condition is due to combat or other in-service
trauma, or whether the veteran was interned as a prisoner of war.

\(c\) In determining service connection, the condition of teeth and
periodontal tissues at the time of entry into active duty will be
considered. Treatment during service, including filling or extraction of
a tooth, or placement

of a prosthesis, will not be considered evidence of aggravation of a
condition that was noted at entry, unless additional pathology developed
after 180 days or more of active service.

\(d\) The following principles apply to dental conditions noted at entry
and treated during service:

\(1\) Teeth noted as normal at entry will be service-connected if they
were filled or extracted after 180 days or more of active service.

\(2\) Teeth noted as filled at entry will be service-connected if they
were extracted, or if the existing filling was replaced, after 180 days
or more of active service.

\(3\) Teeth noted as carious but restorable at entry will not be service
connected on the basis that they were filled during service. However,
new caries that developed 180 days or more after such a tooth was filled
will be service-connected.

\(4\) Teeth noted as carious but restorable at entry, whether or not
filled, will be service-connected if extraction was required after 1 80
days or more of active service.

\(5\) Teeth noted at entry as non-restorable will not be
service-connected, regardless of treatment during service.

\(6\) Teeth noted as missing at entry will not be service connected,
regardless of treatment during service.

\(e\) The following will not be considered service-connected for
treatment

purposes:

\(1\) calculus;

\(2\) acute periodontal disease;

\(3\) third molars, unless disease or pathology of the tooth developed
after

180 days or more of active service, or was due to combat or in-service
trauma;

\(4\) impacted or malposed teeth, and other developmental defects,
unless disease or pathology of these teeth developed after 180 days or
more of active service.

\(f\) Chronic periodontal disease. Teeth extracted because of chronic
periodontal disease will be service-connected only if they were
extracted after 180 days or more of active service.

(Authority: 38 U.S.C. 1712)

§ 3.382 Evidence to establish service connection for dental
disabilities.

\[Removed\]

3\. Section 3.382 is removed and reserved.

PART 4 SCHEDULE FOR RATING DISABILITIES

Dental and Oral Conditions

4\. The Authority citation for part 4 continues to read as follows:

AUTHORITY: 38 U.S.C. 11 55.

§ 4.149 Rating diseases of the teeth and gums. \[Removed\]

5\. Section 4.149 is removed and reserved.

REGULATORY AMENDMENT

4-99-2

Regulation affected: 38 CFR 4.71a.

EFFECTIVE DATE OF REGULATION: June 17, 1999

Date Secretary approved regulation: March 24, 1999

Federal Register Citation: 64 FR 32410 (June 17, 1999)

In the [Federal Register]{.underline} of May 7, 1996 (61 FR 20438), we
published an interim final rule adding a new diagnostic code, 5025, and
evaluation criteria for fibromyalgia to § 4.71a of 38 CFR part 4, the
rating schedule. This final rule responds to comments received in
response to the interim final rule and adopts the interim final rule
without change.

The [Federal Register]{.underline} document follows.

=======================================================================

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AH05

Schedule for Rating Disabilities; Fibromyalgia

AGENCY: Department of Veterans Affairs.

ACTION: Final
rule.\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

SUMMARY: This document adopts as a final rule without change an interim
final rule adding a diagnostic code and evaluation criteria for
fibromyalgia to the Department of Veterans Affairs\' (VA\'s) Schedule
for Rating Disabilities. The intended effect of this rule is to insure
that veterans diagnosed with this condition meet uniform criteria and
receive consistent evaluations.

DATES: Effective Date: This final rule is effective June 17, 1999. The
interim rule adopted as final by this document was effective May 7,
1996.

FOR FURTHER INFORMATION CONTACT: Vickie Milton, M.D., Consultant, Policy
and Regulations Staff (211B), Compensation and Pension Service, Veterans
Benefits Administration, Department of Veterans Affairs, 810 Vermont
Avenue, NW, Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: On May 7, 1996, VA published in the Federal
Register an interim final rule with request for comments (61 FR 20438).
The rule added a diagnostic code, 5025, and evaluation criteria for
fibromyalgia to the section of the VA Schedule for Rating Disabilities
(38 CFR part 4) that addresses the musculoskeletal system (38 CFR
4.71a). A 60-day comment period ended July 8, 1996, and we received
three comments, one from two physicians in the Department of Medicine at
The Oregon Health Sciences University, and two from VA employees.

The evaluation criteria for fibromyalgia under diagnostic code 5025 have
one requisite that applies to all levels: \`\`\[w\]ith widespread
musculoskeletal pain and tender points, with or without associated
fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable
bowel symptoms, depression, anxiety, or Raynaud\'s-like symptoms.\'\'
The 40-, 20-, and 10-percent evaluation levels are additionally based on
whether these findings are constant, or nearly so, and refractory to
therapy; are episodic, but present more than one-third of the time; or
require continuous medication for control. One commenter felt that the
use of the phrase \`\`with or without\'\' as used in diagnostic code
5025 is confusing and might be interpreted as rendering the symptoms
that follow the phrase as superfluous and unnecessary in the evaluation
of fibromyalgia.

Some individuals with fibromyalgia have only pain and tender points;
others have pain and tender points plus stiffness; still others have
pain and tender points plus stiffness and sleep disturbance; etc. As a
shorter way of stating this, we have used the phrase \`\`with or
without,\'\' followed by a list of symptoms, to indicate that any or all
of these symptoms may be part of fibromyalgia, but none of them is
necessarily present in a particular case. When symptoms in addition to
pain and tenderness are present, they may be used as part of the
assessment of whether fibromyalgia symptoms are episodic or constant.
When none of the symptoms on the list is present, the determination of
whether the condition is episodic or constant must be based solely on
musculoskeletal pain and tender points. The term \`\`with or without\'\'
is also used in Sec. 4.116 (Schedule of ratings\--gynecological
conditions and disorders of the breast) of the rating schedule under
diagnostic code 7619, \`\`Ovary, removal of,\'\' where the criterion for
a zero-percent evaluation is \`\`removal of one with or without partial
removal of the other.\'\' We believe that in both cases the phrase
\`\`with or without,\'\' rather than adding confusion, better defines
the potential scope of the condition under evaluation. We therefore make
no change based on this comment.

The same commenter questioned whether the intent is to place a ceiling
of 40 percent on the evaluation of fibromyalgia despite the presence of
one or more of the symptoms following the phrase \`\`with or
without.\'\' As the evaluation criteria indicate, there may be
multi-system complaints in fibromyalgia. If signs and symptoms due to
fibromyalgia are present that are not sufficient to warrant the
diagnosis of a separate condition, they are evaluated together with the
musculoskeletal pain and tender points under the criteria in diagnostic
code 5025 to determine the overall evaluation. The maximum schedular
evaluation for fibromyalgia in such cases is 40 percent. If, however, a
separate disability is diagnosed, e.g., dysthymic disorder, that is
determined to be secondary to fibromyalgia, the secondary condition can
be separately evaluated (see 38 CFR 3.310(a)), as long as the same signs
and symptoms are not used to evaluate both the primary and the secondary
condition (see 38 CFR 4.14 (Avoidance of pyramiding)). In such cases,
fibromyalgia and its complications may warrant a combined evaluation
greater than 40 percent. Since these rules are for general application,
they need not be specifically referred to under diagnostic code 5025.

Another commenter referred to a statement in the supplementary
information to the interim final rule that indicated that fibromyalgia
is a benign disease that does not result in loss of musculoskeletal
function. The commenter said that while it is not a malignant disease
which leads to anatomic crippling, the result of persistent chronic pain
is often musculoskeletal dysfunction.

The statement regarding the lack of loss of musculoskeletal function is
supported by medical texts which state, for example, that objective
musculoskeletal function is not impaired in fibromyalgia (\`\`The Manual
of Rheumatology and Outpatient Orthopedic Disorders\'\' 349 (Stephen
Padgett, Paul Pellicci, John F. Beary, III, eds., 3rd ed. 1993)); that
the syndrome is not accompanied by abnormalities that are visible,
palpable, or measurable in any traditional sense; and that the patient
must recognize the physical benignity of the problem (\`\`Clinical
Rheumatology\'\' 315 (Gene V. Ball, M.D. and William J. Koopman, M.D.,
1986)). These medical texts confirm that fibromyalgia does not result in
objective musculoskeletal pathology. The criteria we have established to
evaluate disability due to fibromyalgia are therefore based on the
symptoms of\[\[Page 32411\]\]fibromyalgia rather than on objective loss
of musculoskeletal function.

The same commenter said that more could have been said about the wide
clinical spectrum of fibromyalgia and the associated stress response
which may lead to clinical problems of psychopathology, inappropriate
behavior, deconditioning, hormonal imbalance, and sleep disorder.

The evaluation criteria do include a broad spectrum of possible
symptoms, and sleep disturbance is one of them. As discussed above, any
disability, including a mental disorder, that is medically determined to
be secondary to fibromyalgia, can be separately evaluated. The rating
schedule is, however, a guide to the evaluation of disability for
compensation, not treatment (see 38 CFR 4.1), and it is unnecessary for
that purpose to include a broad discussion of the clinical aspects of
fibromyalgia. We therefore make no change based on this comment.

The same commenter said that it is important to stress that fibromyalgia
may co-exist with other rheumatic disorders and have an additive effect
on disability. If two conditions affecting similar functions or anatomic
areas are present, and one is service-connected and one is not (a
situation that is not unique to rheumatic disorders), the effects of
each are separately evaluated, if feasible.

When it is not possible to separate the effects of the conditions, VA
regulations at 38 CFR 3.102, which require that reasonable doubt on any
issue be resolved in the claimant\'s favor, dictate that the effects be
attributed to the service-connected condition. Since there is an
established method of evaluating co-existing conditions, there is no
need to stress the point that other diseases may co-exist with
fibromyalgia, resulting in additive effects, and we make no change based
on this comment.

The commenter also stated that the correct diagnosis of fibromyalgia and
the exclusion of other rheumatic conditions are of paramount importance
in ensuring a successful treatment program.

The diagnosis of fibromyalgia and exclusion of other rheumatic disorders
are functions of the examiner and outside the scope of the rating
schedule, which, as noted earlier, is a guide for the evaluation of
disability for purposes of compensation, not treatment. We therefore
make no change based on this comment.

One commenter stated that claimants with fibromyalgia will present with
limitation of motion of various joints of the body, and the rating
agency will have to take into consideration pain on movement and
functional loss due to pain (see 38 CFR 4.40 and 4.45). The commenter
felt that the proposed scheme invites separate ratings for limitation of
motion of each joint.

Fibromyalgia is a \`\`nonarticular\'\' rheumatic disease (\`\`The Merck
Manual\'\' (1369, 16th ed. 1992)), and objective impairment of
musculoskeletal function, including limitation of motion of the joints,
is not present, in contrast to the usual findings in \`\`articular\'\'
rheumatic diseases. Joint examinations in fibromyalgia are necessary
only to exclude other rheumatic diseases because physical signs other
than tender points at specific locations are lacking. The pain of
fibromyalgia is not joint pain, but a deep aching, or sometimes burning
pain, primarily in muscles, but sometimes in fascia, ligaments, areas of
tendon insertions, and other areas of connective tissue (Ball and
Koopman, 315). The evaluation criteria require that the pain be
widespread, and that the symptoms be assessed based on whether they are
constant or episodic, or require continuous medication, but they are not
based on evaluations of individual joints or other specific parts of the
musculoskeletal system. We believe the evaluation criteria make clear
the basis of evaluation, and we therefore make no change based on this
comment.

> REGULATORY AMENDMENT

4-01-1

Regulation affected: 38 CFR 4.112 and 4.114

EFFECTIVE DATE OF REGULATION: July 2, 2001

Date Secretary approved regulation: March 5, 2001

Federal Register Citation: 66 FR 29486-89

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

This document amends 38 CFR 4.112 and certain diagnostic codes in 38 CFR
4.114, in order to address hepatitis C and its sequelae, and to update
evaluation criteria for other liver disabilities.

We have made the information in § 4.112 more specific by stating that
the term \"substantial weight loss,\" for purposes of evaluating
conditions in § 4.114, means a loss of greater than 20 percent of the
individual\'s baseline weight, sustained for three months or longer;
that the term \"minor weight loss\" means a loss of 10 to 20 percent of
the individual\'s baseline weight, sustained for three months or longer;
and that the term "inability to gain weight" means "substantial" (rather
than the current term "significant") weight loss with inability to
regain it despite appropriate therapy. We have also defined \"baseline
weight\" as the average weight for the two-year-period preceding onset
of the disease.

We revised the evaluation criteria for Injury of the liver (diagnostic
code 7311) to have them include not only adhesions of peritoneum
(diagnostic code 7301), but also cirrhosis of liver (diagnostic code
7312) or chronic liver disease without cirrhosis (diagnostic code 7345)
as options for evaluation.

We broadened the scope of diagnostic code 7312 so that the criteria
apply not only to cirrhosis of the liver but also to primary biliary
cirrhosis and the cirrhotic phase of sclerosing cholangitis, two
conditions that are not in the current rating schedule but that have
disabling effects similar to cirrhosis. We deleted the subjective and
outdated terms in the evaluation criteria for diagnostic code 7312, but
retained the same evaluation levels, except for adding a 10-percent
level to provide an appropriate evaluation level for individuals who
have symptoms due to cirrhosis but do not meet the criteria for a
30-percent evaluation, as might occur in the early stages of the
disease. We have provided evaluation criteria that are similar to those
formerly in the schedule, but updated. They include the presence or
history of ascites, hemorrhage from varices or portal gastropathy,
hepatic encephalopathy, portal hypertension, splenomegaly, jaundice, and
substantial weight loss, as well as symptoms of generalized weakness,
anorexia, abdominal pain, and malaise. We have also added a add a note
stating that evaluation under this diagnostic code requires
documentation of cirrhosis (by biopsy or imaging) and abnormal liver
function tests.

We deleted diagnostic code 7313 because abscesses of the liver now
ordinarily resolve without residual disability.

We updated the titles of diagnostics 7343 and 7344 and made changes in
the evaluation of malignant neoplasms similar to those we have made in
other sections of the rating schedule.

We changed the title of diagnostic code 7345, formerly infectious
hepatitis, to chronic liver disease without cirrhosis (including
hepatitis B, chronic active hepatitis, autoimmune hepatitis,
hemochromatosis, drug induced hepatitis, etc., but excluding bile duct
disorders and hepatitis C). This code will now encompass many chronic
liver diseases that were not named in the former schedule, most
importantly hepatitis B, and will exclude hepatitis A (formerly called
infectious hepatitis), which is an acute disease that heals without
long-term residuals. We added new diagnostic code 7354 for hepatitis C
(or non-A, non-B hepatitis), a disease of rising importance in veterans.

We provided the same evaluation criteria for diagnostic codes 7345 and
7354. The evaluation of both is based either on the signs and symptoms
of chronic liver disease, such as fatigue, malaise, and anorexia, or on
the total duration of incapacitating episodes (defined as a period of
acute signs and symptoms severe enough to require bed rest and treatment
by a physician). We changed the evaluation levels under 7345 from 100,
60, 30, 10, and zero percent to 100, 60, 40, 20, 10, and zero percent.
This change was made in order to maintain internal consistency in the
rating schedule, because they correspond to the levels that we proposed
for the evaluation of intervertebral disc syndrome, another condition
for which we proposed to use the total duration of periods of
incapacitation as an alternative means of evaluation. Because chronic
liver disease may in some cases be nonsymptomatic even when not healed,
and would still not be disabling and therefore warrant no more than a
zero-percent evaluation, we changed the evaluation criteria for the
zero-percent level from \"healed, nonsymptomatic\" to
\"nonsymptomatic\". This will assure that all nonsymptomatic veterans
who have serologic evidence of having had a hepatitis B or C virus will
be service-connected at 0% in order to assure appropriate handling of
later-developing sequelae of hepatitis B and C. We removed "depression"
and "anxiety" as criteria under diagnostic code 7345 because they are
not prominent symptoms of chronic liver disease, and, if a mental
disorder is medically determined to be secondary to liver disease, it
would be separately evaluated under the mental disorders portion of the
rating schedule. We added a note under diagnostic codes 7345 and 7354
directing that sequelae of these conditions, such as cirrhosis or
malignancy of the liver, be evaluated under an appropriate diagnostic
code, as long as the same signs and symptoms are not used as the basis
for evaluation under both 7345 or 7354 and under another diagnostic
code. We added another note under 7345 to indicate that the diagnosis of
hepatitis B infection must be confirmed by serologic testing. The
hepatitis C criteria indicate that it too requires serologic evidence of
infection.

We added new diagnostic code 7351 for liver transplants, which requires
a 100-percent evaluation for an indefinite period from the date of
hospital admission for transplant surgery, with a mandatory VA
examination one year following hospital discharge. We also provided a
minimum evaluation of 30 percent following transplant, because of the
need for long-term immunosuppressive medication and its associated
problems.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

7311 7313 7354

7312 7351

7343

7344

7345

PART 4\--SCHEDULE FOR RATING DISABILITIES

1.  The authority citation for part 4 continues to read as follows:
    Authority: 38 U.S.C. 1155, unless otherwise noted.

2.  Section 4.112 is revised to read as follows:

    Sec. 4.112 Weight Loss.

    For purposes of evaluating conditions in Sec. 4.114, the term
    \`\`substantial weight loss\'\' means a loss of greater than 20
    percent of the individual\'s baseline weight, sustained for three
    months or longer; and the term \`\`minor weight loss\'\' means a
    weight loss of 10 to 20 percent of the individual\'s baseline
    weight, sustained for three months or longer. The term \`\`inability
    to gain weight\'\' means that there has been substantial weight loss
    with inability to regain it despite appropriate therapy.
    \`\`Baseline weight\'\' means the average weight for the
    two-year-period preceding onset of the disease. (Authority: 38
    U.S.C. 1155)

3.  Section 4.114 is amended by:

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A.  Revising diagnostic codes 7311, 7312, 7343, 7344, and 7345.

B.  Removing diagnostic code 7313.

C.  Adding diagnostic codes 7351 and 7354.

D.  Adding a new authority citation at the end of the section.

The revisions and additions read as follows:

Sec. 4.114 Schedule of ratings-digestive system.

-   \* \*

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

7311 Residuals of injury of the liver:

> Depending on the specific residuals, separately evaluate as adhesions
> of peritoneum (diagnostic code 7301), cirrhosis of liver (diagnostic
> code 7312), and chronic liver disease without cirrhosis (diagnostic
> code 7345).
>
> 7312 Cirrhosis of the liver, primary biliary cirrhosis, or cirrhotic
> phase of sclerosing cholangitis:
>
> Generalized weakness, substantial weight loss, and persistent
> jaundice,
>
> or; with one of the following refractory to treatment: ascites,

hepatic encephalopathy, hemorrhage from varices or

portal gastropathy (erosive
gastritis)\...\...\...\...\............................................................\...100

> History of two or more episodes of ascites, hepatic encephalopathy,
>
> or hemorrhage from varices or portal gastropathy (erosive gastritis),
>
> but with periods of remission between attacks
> .............................................................70
>
> History of one episode of ascites, hepatic encephalopathy,
>
> or hemorrhage from varices or portal gastropathy (erosive
> gastritis)...................................50
>
> Portal hypertension and splenomegaly, with weakness, anorexia,
>
> abdominal pain, malaise, and at least minor weight
> loss...............................................30
>
> Symptoms such as weakness, anorexia, abdominal pain, and
> malaise...............................10

Note: For evaluation under diagnostic code 7312, documentation of
cirrhosis (by biopsy or imaging) and abnormal liver function tests must
be present.

> \* \* \* \* \*
>
> 7343 Malignant neoplasms of the digestive system, exclusive of skin
> growths...............................100
>
> Note: A rating of 100 percent shall continue beyond the cessation of
> any surgical, X-ray, antineoplastic chemotherapy or other therapeutic
> procedure. Six months after discontinuance of such treatment, the
> appropriate disability rating shall be determined by mandatory VA
> examination. Any change in evaluation based upon that or any
> subsequent examination shall be subject to the provisions of Sec.
> 3.105(e) of this chapter. If there has been no local recurrence or
> metastasis, rate on residuals.
>
> 7344 Benign neoplasms, exclusive of skin growths:
>
> Evaluate under an appropriate diagnostic code, depending on the
> predominant disability or the specific residuals after treatment.
>
> 7345 Chronic liver disease without cirrhosis (including hepatitis B,
>
> chronic active hepatitis, autoimmune hepatitis, hemochromatosis,
>
> drug-induced hepatitis, etc., but excluding bile duct disorders and
> hepatitis C):
>
> Near-constant debilitating symptoms (such as fatigue, malaise, nausea,
> vomiting, anorexia, arthralgia, and right upper quadrant
> pain)\...\...\.............................................................100
>
> Daily fatigue, malaise, and anorexia, with substantial weight loss
>
> (or other indication of malnutrition), and hepatomegaly,
>
> or; incapacitating episodes (with symptoms such as fatigue,
>
> malaise, nausea, vomiting, anorexia, arthralgia, and right
>
> upper quadrant pain) having a total duration of at least six
>
> weeks during the past 12- month period, but not occurring constantly
> .......................... 60
>
> Daily fatigue, malaise, and anorexia, with minor weight loss
>
> and hepatomegaly, or; incapacitating episodes (with symptoms
>
> such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia,
>
> and right upper quadrant pain) having a total duration of at least
>
> four weeks, but less than six weeks, during the past 12-month
> period...............................40
>
> Daily fatigue, malaise, and anorexia (without weight loss or
>
> hepatomegaly), requiring dietary restriction or continuous medication,
>
> or; incapacitating episodes (with symptoms such as fatigue, malaise,
>
> nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)
>
> having a total duration of at least two weeks, but less than four
> weeks,
>
> during the past 12-month
> period\........................................................................\...20
>
> Intermittent fatigue, malaise, and anorexia, or; incapacitating
> episodes
>
> (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia,
>
> arthralgia, and right upper quadrant pain) having a total duration of
>
> at least one week, but less than two weeks, during the past 12-month
> period....................10
>
> Nonsymptomatic\...\...\...\...\...\...\...\...\.............................................................................0

Note (1): Evaluate sequelae, such as cirrhosis or malignancy of the
liver, under an appropriate diagnostic code, but do not use the same
signs and symptoms as the basis for evaluation under DC 7354 and under a
diagnostic code for sequelae. (See Sec. 4.14.).

Note (2): For purposes of evaluating conditions under diagnostic code
7345, \`\`incapacitating episode\'\' means a period of acute signs and
symptoms severe enough to require bed rest and treatment by a physician.

Note (3): Hepatitis B infection must be confirmed by serologic testing
in order to evaluate it under diagnostic code 7345.

\* \* \* \* \*

7351 Liver transplant:

> For an indefinite period from the date of hospital admission for
> transplant surgery....... .......100
>
> Minimum\...\...\...\...\...\...\...\...\...\...\...\...\...\.........................................................................\...30

Note: A rating of 100 percent shall be assigned as of the date of
hospital admission for transplant surgery and shall continue. One year
following discharge, the appropriate disability rating shall be
determined by mandatory VA examination. Any change in evaluation based
upon that or any subsequent examination shall be subject to the
provisions of Sec. 3.105(e) of this chapter.

7354 Hepatitis C (or non-A, non-B hepatitis):

With serologic evidence of hepatitis C infection and the following signs
and

symptoms due to hepatitis C infection:

> Near-constant debilitating symptoms (such as fatigue, malaise,
>
> nausea, vomiting, anorexia, arthralgia, and right upper quadrant
>
> pain)\...\...\...\...\...\...\..........................................................\.....................................100
>
> Daily fatigue, malaise, and anorexia, with substantial weight loss
>
> (or other indication of malnutrition), and hepatomegaly, or;
>
> incapacitating episodes (with symptoms such as fatigue, malaise,
>
> nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)
>
> having a total duration of at least six weeks during the past 12-
> month
>
> period, but not occurring constantly ..............................
> .......................................60
>
> Daily fatigue, malaise, and anorexia, with minor weight loss and
>
> hepatomegaly, or; incapacitating episodes (with symptoms such as
>
> fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right
>
> upper quadrant pain) having a total duration of at least four weeks,
>
> but less than six weeks, during the past 12-month
> period..................\.............................40

Daily fatigue, malaise, and anorexia (without weight loss or

hepatomegaly), requiring dietary restriction or continuous

medication, or; incapacitating episodes (with symptoms such

as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and

right upper quadrant pain) having a total duration of at least

two weeks, but less than four weeks, during the past 12-month
period...........................\.... 20

> Intermittent fatigue, malaise, and anorexia, or; incapacitating
>
> episodes (with symptoms such as fatigue, malaise, nausea,
>
> vomiting, anorexia, arthralgia, and right upper quadrant pain)
>
> having a total duration of at least one week, but less than two
>
> weeks, during the past 12-month
> period...................................................................10
>
> Nonsymptomatic\...\...\...\...\...\...\...\...\...\...\...\.................................................................\......
> 0

Note (1): Evaluate sequelae, such as cirrhosis or malignancy of the
liver, under an appropriate diagnostic code, but do not use the same
signs and symptoms as the basis for evaluation under DC 7354 and under a
diagnostic code for sequelae. (See Sec. 4.14.).

Note (2): For purposes of evaluating conditions under diagnostic code
7354, \`\`incapacitating episode\'\' means a period of acute signs and
symptoms severe enough to require bed rest and treatment by a physician.

(Authority: 38 U.S.C. 1155)

REGULATORY AMENDMENT

4-02-1

3-02-3

Regulations affected: 38 CFR 3.350(a) and 38 CFR 4.116, note two and
diagnostic code 7626.

Effective Date of Regulation: March 18, 2002.

Date Secretary Approved Regulation: January 9, 2002.

Federal Register Citation: 67 FR 6872-6874 (February 14, 2002).

67 FR 37695 (May 30, 2002)(Correction)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

The Veterans Benefits and Health Care Improvement Act of 2000, Public
Law 106-419, 114 Stat. 1822, amended section 1114(k) by making
anatomical loss of one or both breasts (including loss by mastectomy) as
a result of a service-connected disability by a woman veteran a
condition warranting this special monthly compensation. This regulation
implements this legislation by 1) revising 38 CFR 3.350(a) to add the
provision concerning anatomical loss of one or both breasts (including
loss by mastectomy) in a woman veteran and to define what anatomical
loss of one or both breasts means for this purpose, 2) revising note two
under 38 CFR 4.116 to include anatomical loss of one or both breasts as
a condition for which a rater should refer to 38 CFR 3.350(a) to
determine whether special monthly compensation is warranted, and 3)
annotating diagnostic code 7626 in 38 CFR 4.116 to refer to a footnote
directing the rater to review for entitlement to special monthly
compensation under 38 CFR 3.350.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

7626 None None

NOTE: A correction to this final rule was published in 67 FR 37695 on
May 30, 2002, to correct typographical errors in the "Note" at the end
of diagnostic code 7626 in 38 CFR 4.116.

REGULATORY AMENDMENT

4-02-2

Regulation affected: 38 CFR 4.71a

EFFECTIVE DATE OF REGULATION: August 26, 2002

Date Secretary approved regulation: May 16, 2002

Federal Register Citation: 67 FR 48784-48787 (July 26, 2002)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

This document amends 38 CFR 4.71a to clarify the method of evaluation of
ankylosis and limitation of motion of single and multiple digits by
revising and reorganizing the diagnostic codes and explanatory notes
that address the evaluation of these conditions in order to assure fair
and consistent evaluations of these disabilities.

We relocated the interpretive notes regarding evaluations of ankylosis
and limitation of motion of the digits of the hands into a single set of
instructions preceding diagnostic code 5216 and deleted notes (1), (2),
(3), and (4) preceding diagnostic code 5216; notes (a), (b), and (c)
following diagnostic code 5219; notes (1), (2), (3) and (4) preceding
diagnostic code 5220; notes (a) and (b) following diagnostic code 5223;
and the note following diagnostic code 5227.

We changed the term used for the third digit from \"middle finger\" to
\"long finger,\" changed \"median transverse fold of the palm\" to
\"proximal transverse crease of the palm,\" an anatomic landmark where
the fingertips normally meet the palm when they are in full flexion, and
added descriptions of the position of function of the hand and of the
normal range of motion of the index, long, ring, and little fingers.

We revised the evaluation criteria under diagnostic codes 5216 through
5227 so that they address ankylosis only and added three new diagnostic
codes, 5228, 5229, and 5230, for the evaluation of limitation of motion
of the thumb, the index or long finger, and the ring or little finger,
respectively. The evaluation criteria for the newly added conditions are
derived from the material contained in former note (3) preceding
diagnostic code 5216, former note (3) preceding diagnostic code 5220,
and former note (a) following diagnostic code 5223. Limitation of motion
of the index, long, ring, and little fingers is evaluated based on
either the number of degrees by which extension is limited, or on a
measurement of the gap between the fingertip and the palm when the
finger is flexed to the extent possible. Limitation of motion of the
thumb is evaluated based on its most important function, opposing the
fingers, as measured by the gap between the thumb pad and the fingers
with the thumb attempting to oppose the fingers. These criteria are
consistent with § 4.71, \"Measurement of ankylosis and joint motion\".

An ankylosed digit is evaluated as amputation when both joints are
ankylosed, and either is in extension or \"full\" flexion (flexion of
the fingers is not possible beyond \"full,\" or complete, flexion). We
simplified diagnostic codes 5217 through 5223 by combining certain
combinations of fingers or fingers and thumb.

In response to a comment on the proposed rule stating that the proposed
ratings did not adequately provide for the disability that occurs when a
finger ankylosed in flexion obstructs the other fingers and reduces the
strength of the hand in gripping or grasping motions, we added notes
following the diagnostic codes for ankylosis of individual digits
directing raters to consider whether evaluation as amputation is
warranted and whether an additional evaluation is warranted for
resulting limitation of motion of other digits or interference with
overall function of the hand.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

5216. 5228

5217. 5229

5218. 5230

5219

5221

5222

5223

5224

5225

5226

5227

The pertinent portions of the final rule are as follows:

SUMMARY: This document amends the Department of Veterans Affairs (VA)
Schedule for Rating Disabilities by revising the evaluation criteria for
ankylosis and limitation of motion of the fingers and thumb in order to
assure that veterans diagnosed with these conditions receive consistent
evaluations.

SUPPLEMENTARY INFORMATION: As part of its review of the Schedule for
Rating Disabilities (38 CFR part 4), VA published a proposal to amend
that portion of the Schedule pertaining to ankylosis and limitation of
motion of the fingers and thumb. The proposed rule was published in the
Federal Register on November 2, 2001 (66 FR 55614). Interested persons
were invited to submit written comments on or before January 2, 2002. We
received one comment, from the Disabled American Veterans.

We proposed to change the name of the \`\`middle finger\'\' to \`\`long
finger\'\' in the diagnostic codes pertaining to digit ankylosis and
limitation of motion. The commenter suggested that we make the same
change in diagnostic codes for finger amputations. In response, we have
made that change. In addition, in current Plate III, one finger is
labeled \`\`middle finger,\'\' and we will be revising that as part of
the overall revision of the orthopedic system to \`\`long finger\'\'.
Similarly, the commenter suggested that we change \`\`median transverse
fold of palm\'\' to \`\`proximal transverse crease of palm\'\' in 38 CFR
4.71, as we proposed to do in Sec. 4.71a. We have also made that change.

We proposed to evaluate an ankylosed digit as amputation when both
joints are ankylosed, and either is in extension or \`\`full\'\'
flexion. The commenter felt that the proposed ratings do not adequately
provide for the disability that occurs when a finger ankylosed in
flexion obstructs the other fingers and reduces the strength of the hand
in gripping or grasping motions. The commenter expressed the belief that
this disability is worse than an amputation and should receive a higher
evaluation.

Digits that inhibit the use of other fingers are sometimes amputated if
they inhibit hand function. Since 38 CFR 4.68, \`\`Amputation rule,\'\'
however, prohibits an evaluation exceeding that which would be assigned
if the finger were amputated, we have adopted another way of addressing
this problem. In our judgment, if finger flexion deformity interferes
with the function of other fingers or hand function overall, assessment
of the other fingers or the hand overall should be taken into account in
rating. This is both more appropriate than providing a higher evaluation
for the ankylosed finger itself and consistent with the requirements of
Sec. 4.68. Provisions #2 and #5 of this portion of the rating schedule
would apply in this situation. However, to assure that raters address
any additional disability due to ankylosis of a single digit, we have
revised the notes following the diagnostic codes for ankylosis of
individual digits, which currently direct raters to consider rating as
amputation, to read \`\`Also consider whether evaluation as amputation
is warranted and whether an additional evaluation is warranted for
resulting limitation of motion of other digits or interference with
overall function of the hand\'\'. In our judgment, this will be
sufficient to alert raters to the possibility of additional disability
due to a single ankylosed digit. VA appreciates the comment submitted in
response to the proposed rule. Based on the rationale stated in the
proposed rule and in this document, the proposed rule is adopted with
the changes noted.

\* \* \*

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

Subpart B\--Disability Ratings

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

2\. In Sec. 4.71, last sentence, remove \`\`median transverse fold of

the palm\'\' and add, in its place, \`\`proximal transverse crease of
palm\'\'.

3\. In Sec. 4.71a under the tables MULTIPLE FINGER AMPUTATIONS and
SINGLE FINGER AMPUTATIONS, remove \`\`middle\'\' every place it occurs
and add in each place \`\`long\'\'.

4\. Section 4.71a is amended by removing the tables \`\`MULTIPLE
FINGERS: UNFAVORABLE ANKYLOSIS\'\'; MULTIPLE FINGERS: FAVORABLE
ANKYLOSIS\'\'; and ANKYLOSIS OF INDIVIDUAL FINGERS\'\' and adding, in
their place, the following table to read as follows:

Sec. 4.71a Schedule of ratings\--musculoskeletal system.

\* \* \* \* \*

Evaluation of Ankylosis or Limitation of Motion of Single or Multiple
Digits of the Hand

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Major Minor

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\(1\) For the index, long, ring, and little fingers \...\...\.....
\...\...\...

(digits II, III, IV, and V), zero degrees of flexion represents the
fingers

fully extended, making a straight line with the rest of the hand.

The position of function of the hand is with the wrist dorsiflexed

20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal

joints flexed to 30 degrees, and the thumb (digit I) abducted and
rotated

so that the thumb pad faces the finger pads. Only joints in these

positions are considered to be in favorable position. For digits II

through V, the metacarpophalangeal joint has a range of zero to

90 degrees of flexion, the proximal interphalangeal joint has a

range of zero to 100 degrees of flexion, and the distal (terminal)

interphalangeal joint has a range of zero to 70 or 80 degrees of
flexion\...\...\...\...\...\..........

\(2\) When two or more digits of the same hand are affected by any
\...\...\.... \...\...\...

combination of amputation, ankylosis, or limitation of motion that

is not otherwise specified in the rating schedule, the evaluation level

assigned will be that which best represents the overall disability
(i.e.,

amputation, unfavorable or favorable ankylosis, or limitation of
motion),

assigning the higher level of evaluation when the level of disability

is equally balanced between one level and the next higher
level......\...\...\...\...\...\...\...\...\...\...

\(3\) Evaluation of ankylosis of the index, long, ring, and little
fingers:

\(i\) If both the metacarpophalangeal and proximal interphalangeal
\...\...\... \...\...\...

joints of a digits are ankylosed, and either is in extension or full
flexion,

or there is rotation or angulation of a bone, evaluate as amputation

without metacarpal resection, at proximal interphalangeal joint or

proximal thereto.

\(ii\) If both the metacarpophalangeal and proximal interphalangeal
......... ......\...

joints of a digit are ankylosed, evaluate as unfavorable ankylosis,

even if each joint is individually fixed in a favorable
position\...\...\..........................\...

\(iii\) If only the metacarpophalangeal or proximal interphalangeal
\...\...\... \...\...\...

proximal interphalangeal joint is ankylosed, and there is a gap of

more than two inches (5.1 cm.) between the fingertip(s) and the

proximal transverse crease of the palm, with the finger(s) flexed to

the extent possible, evaluate as unfavorable ankylosis.

\(iv\) If only the metacarpophalangeal or proximal interphalangeal
\...\...\... \...\...\...

is ankylosed, and there is a gap of two inches (5.1 cm.) or less

between the fingertip(s) and the proximal transverse crease of the palm,

with the finger(s) flexed to the extent possible, evaluate as favorable
ankylosis\...\...\..........\...

\(4\) Evaluation of ankylosis of the thumb:

\(i\) If both the carpometacarpal and interphalangeal joints
\...\...\... \...\...\...

are ankylosed, and either is in extension or full flexion, or

there is rotation or angulation of a bone, evaluate as amputation

at metacarpophalangeal joint or through proximal
phalanx.................................\...\...\.....

\(ii\) If both the carpometacarpal and interphalangeal joints
\......\... \...\...\...

interphalangeal joints are ankylosed, evaluate as unfavorable ankylosis,

even if each joint is individually fixed in a favorable
position...............\...\...\...\...\...\...\...\...\...\...

\(iii\) If only the carpometacarpal or interphalaneal joint is
\...\...\... \...\...\...

ankylosed, and there is a gap of more than two inches (5.1 cm.)

between the thumb pad and the fingers, with the thumb attempting

to oppose the fingers, evaluate as unfavorable
ankylosis....................................\...\...\.....

\(iv\) If only the carpometacarpal or interphalangeal joint is
\...\...\... \...\...\...

ankylosed, and there is a gap of two inches (5.1 cm.) or less

between the thumb pad and the fingers, with the thumb attempting

to oppose the fingers, evaluate as favorable
ankylosis....................................\...\...\...\...\...

\(5\) If there is limitation of motion of two or more digits, evaluate
each \...\...\... \...\...\...

more digits, evaluate each digit separately and combine the
evaluations\...\...\...\..........\...\...\...\...

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

I. Multiple Digits: Unfavorable Ankylosis

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

5216 Five digits of one hand, unfavorable ankylosis of
................................................60........50

Note: Also consider whether evaluation as amputation is warranted.

5217 Four digits of one hand, unfavorable ankylosis of:

Thumb and any three
fingers\...\...\...\.......................................................................
60........ 50

Index, long, ring, and little
fingers.........................................................\...\.............50........40

Note: Also consider whether evaluation as amputation is warranted.

5218 Three digits of one hand, unfavorable ankylosis of:

Thumb and any two
fingers\...\...\...\...\...\.....................................................................50........40

Index, long, and ring; index, long, and little; or index, ring and
little fingers......................40........30

Long, ring, and little
fingers\...\...\...\.......................................................................\...30........20

Note: Also consider whether evaluation as amputation is warranted.

5219 Two digits of one hand, unfavorable ankylosis of:

Thumb and any
finger\...\...\...\...\...\...\...\.......................................................................40........30

Index and long; index and ring; or index and little
fingers............................................30........20

Long and ring; long and little; or ring and little
fingers.............................................\...20........20

Note: Also consider whether evaluation as amputation is warranted.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

II\. Multiple Digits: Favorable Ankylosis

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

5220 Five digits of one hand, favorable ankylosis of
.................................................. 50........ 40

5221 Four digits of one hand, favorable ankylosis of:

Thumb and any three
fingers\...\...\...\...\.....................................................................50......\...40

Index, long, ring, and little
fingers\...\.....................................................................
40........30

5222 Three digits of one hand, favorable ankylosis of:

Thumb and any two
fingers\...\...\...\...\...\....................................................................
40........30

Index, long, and ring; index, long, and little; or index, ring, and
little finger......................30........20

Long, ring and little
fingers\...\...\...\...\......................................................................
20........20

5223 Two digits of one hand, favorable ankylosis of:

Thumb and any
finger\...\...\...\...\...\...\.........................................................................30........20

Index and long; index and ring; or index and little
fingers...........................................20........20

Long and ring; long and little; or ring and little
fingers...............................................10........10

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

III\. Ankylosis of Individual Digits

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

5224 Thumb, ankylosis of:

Unfavorable\...\...\...\...\...\...\...\...\...\..............................................................................20........20

Favorable\...\...\...\...\...\...\...\...\...\...\...............................................................................10........10

Note: Also consider whether evaluation as amputation is warranted and
whether an additional evaluation is warranted for resulting limitation
of motion of other digits or interference with overall function of the
hand.

5225 Index finger, ankylosis of:

Unfavorable or
favorable\...\...\...\...\...\........................................................................10........10

Note: Also consider whether evaluation as amputation is warranted and
whether an additional evaluation is warranted for resulting limitation
of motion of other digits or interference with overall function of the
hand.

5226 Long finger, ankylosis of:

Unfavorable or
favorable\...\...\...\...\.......................................................................\....10........10

Note: Also consider whether evaluation as amputation is warranted and
whether an additional evaluation is warranted for resulting limitation
of motion of other digits or interference with overall function of the
hand.

5227 Ring or little finger, ankylosis of:

Unfavorable or
favorable\...\...\...\...\...\.........................................................................
0.........0

Note: Also consider whether evaluation as amputation is warranted and
whether an additional evaluation is warranted for resulting limitation
of motion of other digits or interference with overall function of the
hand.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

IV\. Limitation of Motion of Individual Digits

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

5228 Thumb, limitation of motion:

With a gap of more than two inches (5.1 cm.) between the thumb

pad and the fingers, with the thmb attempting to oppose the
fingers...............................20........20

With a gap of one to two inches (2.5 to 5.1 cm.) between

thumb pad and the fingers, with the thumb attempting

to oppose the
fingers......................................................................................10......\...10

With a gap of less than one inch (2.5 cm.) between the thumb pad

and the fingers, with the thumb attempting to oppose the
fingers..................................\...0.........0

5229 Index or long finger, limitation of motion:

With a gap of one inch (2.5 cm.) or more between the fingertip and

the proximal transverse crease of the palm, with the finger flexed to

the extent possible, or; with extension limited by more than 30

degrees......................................................................................................10........10

With a gap of less than one inch (2.5 cm.)between the fingertip and

the proximal transverse crease of the palm, with the finger flexed to

to the extent possible, and; extension is limited by no more than 30

degrees........................................................................................................0.........0

5230 Ring or little finger, limitation of motion:

Any limitation of
motion\...\...\...\...\...\..........................................................................0.........0

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\* \* \* \* \*

(Authority: 38 U.S.C. 1155)

REGULATORY AMENDMENT

4-02-3

Regulation affected: 38 CFR 4.118

EFFECTIVE DATE OF REGULATION: August 30, 2002.

Date Secretary approved regulation: May 17, 2002.

Federal Register Citation: 67 FR 49590-49599 (July 31, 2002)

Correction: 67 FR 58448 (September 16, 2002)

Correction : 67 FR 62889 (October 9, 2002)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

As part of VA's ongoing revision of the Schedule for Rating
Disabilities, we have amended section 4.118 of 38 CFR, Part 4, the
section of the rating schedule that addresses disabilities of the skin.
The purpose is to update this portion of the rating schedule to ensure
that it uses current medical terminology and unambiguous criteria, and
that it reflects medical advances that have occurred since the last
review. Numerous editorial changes have also been made. More detailed
explanations for substantive changes are included in the "Supplementary
Information" section of both the final regulatory amendment document,
which is enclosed, and the notice of proposed rulemaking, which was
published in the [Federal Register]{.underline} on January 19, 1993 (58
FR 4969).

We revised the evaluation criteria for diagnostic code (DC) 7800 by
basing them on how many of eight objective characteristics of
disfigurement are present (scar 5 or more inches (13 or more cm.) in
length; scar at least one-quarter inch (0.6 cm.) wide at widest part;
surface contour of scar elevated or depressed on palpation; scar
adherent to underlying tissue; skin hypo- or hyper-pigmented in an area
exceeding six square inches (39 sq. cm.); skin texture abnormal
(irregular, atrophic, shiny, scaly, etc.) in an area exceeding six
square inches (39 sq. cm.); underlying soft tissue missing in an area
exceeding six square inches (39 sq. cm.); and skin indurated and
inflexible in an area exceeding six square inches (39 sq. cm.)) and
whether there is asymmetry or gross distortion of features. We provided
evaluation levels of 10, 30, 50 and 80 percent for this condition.

We changed the scope of DC\'s 7801 and 7802 from being limited to burn
scars to include scars from other causes, such as chemical injury, with
DC 7801 now for evaluating scars of a certain size other than face,
head, or neck that are deep (meaning there is underlying soft tissue
damage) or that cause limited motion and DC 7802 for evaluating scars of
a certain size other than face, head, or neck that are superficial
(meaning not associated with underlying soft tissue damage) and do not
cause limited motion. The range of evaluations for DC 7801 is 10 to 40
percent. There is a single 10-percent evaluation under DC 7802.

We retitled DC 7803 as \"Scars, superficial, unstable\" and defined an
unstable scar as meaning one where there is frequent loss of covering of
skin over the scar. We retitled DC 7804 as \"Scars, superficial, painful
on examination\" and defined a superficial scar as meaning one that is
not associated with underlying soft tissue damage. Evaluations under DC
7803 and 7804 are limited to 10 percent.

We retitled DC 7806 as \"Dermatitis or eczema,\" changed the evaluation
levels to zero, 10, 30, and 60 percent, and provided identical
evaluation criteria for this condition as for DC\'s 7815 (bullous
disorders), 7816 (psoriasis), 7821 (cutaneous manifestations of
collagen-vascular diseases not listed elsewhere (a newly added
condition), and 7822 (papulosquamous disorders not listed elsewhere).
Evaluation is now based on the extent (in percentage) to which the
entire body or exposed areas are affected by the condition or on the
treatment required. Alternatively, these conditions can be evaluated as
disfigurement of the head, face, or neck or as scars.

Discoid lupus (DC 7809) is now evaluated as disfigurement or dermatitis,
depending on the predominant disability. Exfoliative dermatitis (DC
7817, formerly dermatitis exfoliativa) is now evaluated at levels of
zero, 10, 30, 60, or 100 percent based on the extent of involvement of
the skin, whether there are also systemic manifestations, and the type
and duration of treatment.

We revised the evaluation criteria for benign skin neoplasms, DC 7819,
to base them on impairment of function as well as on scars or
disfigurement. We added DC 7820, Infections of the skin not listed
elsewhere (including bacterial, fungal, viral, treponemal and parasitic
diseases), with evaluation based on disfigurement of the head, face, or
neck or dermatitis, depending on the predominant disability. Vitiligo
(DC 7823), a new code, is evaluated at zero or ten percent based on
whether or not exposed areas are affected.

Another condition we added to the Schedule, diseases of keratinization
(DC 7824) is evaluated at zero, 10, 30, or 60 percent based on therapy
requirements, the extent of cutaneous involvement, and whether the skin
involvement is constant or episodic.

Leishmaniasis, both American (DC 7807) and Old World (DC 7808), are now
evaluated based on disfigurement, scars, or dermatitis, whichever is the
predominant disability.

We made changes in the evaluation of malignant neoplasms of the skin (DC
7818). They were formerly rated as scars, disfigurement, etc., on the
extent of constitutional symptoms, physical impairment. Now they are
evaluated based on disfigurement of the head, face, or neck, on scars,
or on impairment of function. However, malignancies of the skin
sometimes require systemic treatment that is comparable to that given
for other types of malignancies. Therefore, we added a note indicating
that if a skin malignancy undergoes treatment that is similar to that
used for internal malignancies, such as chemotherapy or radiation
therapy more extensive than to the skin, or if surgery more extensive
than wide local excision is used, a 100-percent evaluation will be
assigned from onset of treatment and will continue with a mandatory VA
examination six months following the completion of antineoplastic
treatment, and any change in evaluation based upon that or any
subsequent examination subject to the provisions of 38 CFR 3.105(e). If
treatment is confined to the skin, the provisions for a 100-percent
evaluation do not apply. We added a separate diagnostic code, 7833, to
the rating schedule for malignant melanoma of the skin with the same
evaluation criteria as for other skin malignancies.

We also added urticaria to the rating schedule under DC 7825, with
evaluation levels of 10, 30, and 60 percent based on frequency and
severity of episodes and treatment. We added DC 7826, primary cutaneous
vasculitis, and DC 7827, erythema multiforme (toxic epidermal
necrolysis), with identical evaluation criteria and evaluation levels of
10, 30, and 60 percent based on the frequency of debilitating episodes
and the type and frequency of treatment. Alternatively, these conditions
can be evaluated as disfigurement of the head, face, or neck or as
scars, depending on the predominant disability.

We added DC 7828 for the evaluation of acne and DC 7829 for the
evaluation of chloracne with identical evaluation criteria and
evaluation levels of zero, 10 and 30 percent based on the extent of
involvement by acne, its location, and whether it is deep or
superficial. Alternatively, these conditions can be evaluated as
disfigurement of the head, face, or neck or as scars, depending on the
predominant disability.

We added DC 7830, scarring alopecia, with evaluation levels of zero, 10,
and 20 percent based on the percent of scalp affected. We also added DC
7831, alopecia areata, with evaluation levels of zero and 10 percent
based on the extent of hair loss.

We revised the title of DC 7813, Dermatophytosis, to include "(ringworm:
of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis;
of beard area, tinea barbae; of nails, tinea unguium; of inguinal area
(jock itch), tinea cruris)" to clarify what is included.

We added DC 7832, hyperhidrosis (which is excessive sweating) with
evaluation levels of zero and 30 percent based on whether or not an
individual can handle paper or tools and response to therapy.

Diagnostic codes Diagnostic codes Diagnostic codes

revised removed added

7800 7810 7820

7801 7812 7821

7802 7814 7822

7803. 7823

7804. 7824

7806 7825

7807. 7826

7808. 7827

7809. 7828

7811 7829

7813. 7830

7815 7831

7816. 7832

7817. 7833

7818

7819

Note: A correction published on September 16, 2002 made corrections to
diagnostic codes 7802, 7807, 7808, 7809, 7811, 7818, 7819, 7820, and
7833.

Note: A correction published on October 9, 2002 made a correction to the
language of the preamble.

The pertinent portions of the final rule are as follows:

SUMMARY: This document amends that portion of the Department of Veterans
Affairs (VA) Schedule for Rating Disabilities that addresses the Skin.
The intended effect of this action is to update the portion

of the rating schedule that deals with skin to ensure that it uses
current medical terminology and unambiguous criteria, and that it
reflects medical advances that have occurred since the last review.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of the
rating schedule, VA published a proposal to amend 38 CFR 4.118, which
addresses disabilities of the skin, in the Federal Register of January
19, 1993 (58 FR 4969). Comments were received from the American Legion,
Paralyzed Veterans of America, Veterans of Foreign Wars, Disabled
American Veterans, and VA employees.

One commenter suggested that VA withdraw the proposed regulations and
reissue them based on more objective standards, and also made specific
suggestions for changes to many diagnostic codes.

We do not agree that the proposed regulations should be withdrawn

.

We made the process of revision as open as possible. For example, prior
to publication of the proposed amendment, we published an advance notice
of proposed rulemaking in the Federal Register to receive public
comments about the revision. We also contracted with an outside
consultant, who convened a panel of non-VA physician specialists in skin
diseases to make recommendations for revisions of this section of the
rating schedule. We asked the Veterans Health Administration to review
our proposed changes. We published the proposed revision only after
reviewing all of these sources of information. We received several other
comments on the proposed rule after it was published in the Federal
Register, but none of the commenters suggested withdrawing the proposed
revision. In response to comments, we have however, made further
revisions to some of the criteria for the sake of clarity and more
objectivity and have added definitions and explanatory notes under some
conditions. These added changes are discussed in more detail below. The
same commenter who suggested withdrawing the proposed revision also made
specific suggestions for changes to many diagnostic codes. With the
additional changes we have made in the final revision, we believe we
have made the evaluation criteria for skin conditions reasonably clear
and objective

.

Under diagnostic code (DC) 7800, disfigurement of the head, face, or
neck, the former rating schedule provided evaluation levels of 50, 30,
10, and zero percent based on whether there is repugnant deformity of
one or both sides of the face, whether the disfigurement is
\`\`severe,\'\' producing a marked and unsightly deformity of eyelids,
lips, or auricles, and on whether the disfigurement is \`\`moderate\'\'
or \`\`slight.\'\' Following these criteria was a note stating that each
level could be increased to the next higher evaluation level on the
basis of marked discoloration or color contrast and that the most
repugnant, disfiguring conditions, including scars and diseases of the
skin, could be submitted with photographs for central office rating. The
proposed amendment added an 80-percent evaluation level and deleted the
part of the note that provided authority to elevate evaluations in the
presence of marked discoloration or color contrast based on the
rationale that these criteria are subject to inconsistent
interpretations. The proposed evaluation criteria were based at 80
percent on whether disfigurement is so disfiguring as to preclude
occupational interaction with the public, at 50 percent on whether it is
repugnant on casual inspection, at 30 percent on whether it is
disagreeable on casual inspection, at 10 percent on whether it is
noticeable on casual inspection, and at zero percent on whether it is
noticeable, but only on close inspection.

One commenter felt that the deleted note should be retained. Another
commenter, while offering no alternative language for us to consider,
stated that the words \`\`repugnant,\'\' disagreeable,\'\' and
\`\`noticeable,\'\' used to describe degrees of disfigurement, are too
subjective to be useful and are not based on medical criteria. In a
similar vein, another commenter said that we should establish objective
criteria for rating scars that should include evaluation of size,
configuration, color,etc. One commenter felt that the difference between
casual and close inspection, part of the criteria used to determine
disfigurement, is a distinction that is difficult to understand.

In response to these comments, we have further revised the evaluation
criteria for DC 7800 by basing them on the number of objective
characteristics of disfigurement that are present and whether there is
asymmetry or gross distortion of the features. We provided a new note
following DC 7800 describing the eight specific characteristics of
disfigurement, for purposes of evaluation under Sec. 4.118: Scar 5 or
more inches (13 or more cm.) in length; scar at least one-quarter inch
(0.6 cm.) wide at widest part; surface contour of scar elevated or
depressed on palpation; scar adherent to underlying tissue; skin hypo-
or hyper-pigmented in an area exceeding six square inches (39 sq. cm.);
skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an
area exceeding six square inches (39 sq. cm.); underlying soft tissue
missing in an area exceeding six square inches (39 sq. cm.); and skin
indurated and inflexible in an area exceeding six square inches (39 sq.
cm.). For an 80-percent evaluation, there must be visible or palpable
tissue loss and either gross distortion or asymmetry of three or more
features or paired sets of features (nose, chin, forehead, eyes
(including eyelids), ears (auricles), cheeks, lips), or six or more
characteristics of disfigurement must be present. For a 50-percent
evaluation, there must be visible or palpable tissue loss and either
gross distortion or asymmetry of two features or paired sets of
features, or four or more haracteristics of disfigurement must be
present. For a 30-percent evaluation, there must be visible or palpable
tissue loss and either gross distortion or asymmetry of one feature or
set of paired features, or two or three characteristics of disfigurement
must be present. For a 10-percent evaluation, one characteristic of
disfigurement must be present. In our judgment, these further revised
criteria are sufficiently clear and objective to assure that evaluations
take into account the most significant characteristics of disfigurement
and will be consistent from veteran to veteran. We have provided two
additional notes under DC 7800, one directing the rater to rate tissue
loss of the auricle under DC 6207 (loss of auricle) and anatomical loss
of the eye under DC 6061 (anatomical loss of both eyes) or DC 6063
(anatomical loss of one eye), as appropriate; and the second directing
the rater to take into consideration unretouched color photographs.

The former rating schedule designated DC 7801 as \`\`scars, burns, third
degree,\'\' and DC 7802 as \`\`scars, burns, second degree.\'\' We
proposed to revise these codes so that they additionally addressed scars
from causes other than burns and so that the conditions would be
evaluated based on actual residual disability, i.e., the size of the
area of underlying soft tissue damage or limitation of motion, rather
than on the initial assessment of the severity of a burn. We proposed to
redesignate DC 7801 as \`\`scars, other than head, face, or neck, with
underlying soft tissue damage causing deep contour defect or limited
motion\'\' and DC 7802 as \`scars, other than head, face, or neck, that
are superficial and that do not cause limited motion.\'\' We proposed
that under DC 7801 scars with an area or areas exceeding 144 square
inches (929 sq. cm.) receive a 40-percent evaluation; with area or areas
exceeding 72 square inches (465 sq. cm.) a 30-percent evaluation; with
area or areas exceeding 12 square inches (77 sq. cm.) a 20-percent
evaluation; and with area or areas exceeding 6 square inches (39 sq.
cm.) a 10-percent evaluation. We proposed that under DC 7802 scars with
area or areas approximating 144 square inches (929 sq. cm.) receive a
10-percent evaluation. A commenter felt that historical precedent
requires continuation of the wording \`\`third degree\'\' and \`\`second
degree\'\' under DC\'s 7801 and 7802, formerly burn scars.

We disagree. One objective of the rating schedule revision is to
incorporate medical advances and to delete obsolete concepts and
conditions. Our consultants, a panel of non-VA physician specialists in
skin diseases, as well as medical textbooks such as \`\`Christopher\'s
Textbook of Surgery\'\' 140-41 (Loyal Davis, M.D., ed., 9th ed. 1968),
indicate that the clinical estimation of the degree of a burn is not
always accurate and does not necessarily relate to long-term disability.
The severity of residual scarring from burns of all depths varies.
Furthermore, burn scars that are not caused by thermal injury, but by
chemical, electrical, or friction injury, as well as scars resulting
from non-burn injuries that permanently alter the skin, can lead to
comparable residuals. For these reasons, a determination of disability
that is based on the extent of the scarring itself and its effects,
rather than on the etiology of the scarring, is preferable because it
will result in wider application of these criteria and afford
consistency in the evaluation of comparable scarring, whatever the
etiology. For more clarity and consistency of language, we have,
however, modified the titles slightly, for better differentiation of
superficial and deep scars, as discussed below.

We proposed that DC 7801 (formerly titled \`\`scars, burns, third
degree\'\') be retitled \`\`scars, other than head, face, or neck, with
underlying soft tissue damage causing deep contour defect or limited
motion.\'\' According to one commenter, the term \`\`deep contour
defect\'\' is confusing. When there is soft tissue damage beneath the
skin, in addition to scarring of the skin, the overlying scar shows a
greater anatomical change in contour than when there is skin damage
alone. The defect that appears in a scarred area when there is
underlying soft tissue damage is known as a deep contour defect and
could also be called a deep scar. The lesser change that results in a
scarred area when there is skin damage alone, without soft tissue damage
beneath the skin, is known as a superficial contour defect and could
also be called a superficial scar. A superficial scar may have an
irregular surface that is either raised or depressed, but the abnormal
contour goes no deeper than the skin. To make the distinction between
the scars to be evaluated under DC\'s 7801 and 7802 clearer, we have
removed the term \`\`deep contour defect\'\' and have retitled DC 7801
\`\`scars, other than head, face, or neck, that are deep or that cause
limited motion\'\' and retitled DC 7802 \`\`scars, other than head,
face, or neck, that are superficial and that do not cause limited
motion.\'\' We have also added a definition of deep scar, as one
associated with underlying soft tissue damage, in a note under DC 7801
and of superficial scar, as one not associated with underlying soft
tissue damage, in a note under DC 7802.

We proposed to retitle DC 7803 (formerly titled \`\`scars, superficial,
poorly nourished, with repeated ulceration\'\') \`\`scars, superficial,
unstable with frequent loss of epidermal covering.\'\' One commenter
felt that the meaning of \`\`unstable\'\' under DC 7803 is unclear, and
wondered whether this means that the wound is infected or unhealed.

The term \`\`unstable\'\' in the title of DC 7803 does not imply a
specific etiology but only indicates that there is frequent loss of
covering of the skin over the scar. An unstable scar may result from
anumber of causes, including poor healing or infection. For further
clarity, we have added a note under DC 7803 defining unstable scar as
one where, for any reason, there is frequent loss of covering of skin
over the scar. We have also removed the term \`\`with frequent loss of
epidermal covering\'\' from the title and repeated the definition of
superficial scar under this code.

One commenter suggested that we not repeat identical criteria when
several different conditions are evaluated using the same criteria.

While it is feasible to use general rating formulas when related
conditions are listed consecutively, we have repeated criteria under a
number of diagnostic codes in this section for several reasons. First,
conditions evaluated under identical criteria in this section are not
consecutive diagnostic codes. The repetition of criteria will save time
by eliminating the need to seek the appropriate evaluation criteria,
lessen the chance of error by eliminating the need to search other pages
of the rating schedule, and eliminate the \`\`double references\'\' that
are present under some diagnostic codes (where the schedule says to see
a certain diagnostic code and there is a reference under that diagnostic
code to see yet another diagnostic code). Additionally, while rating
specialists may readily locate the appropriate rating criteria, others
who use the schedule may find it more difficult. While eliminating the
repetition of criteria would save space, we believe that the advantages
gained favor their repetition in this case. Where a general rating
formula applies to several diagnostic codes that are listed
consecutively, the proximity of the conditions and the rating formula
eliminates most of the potential problems discussed above.

In the former schedule, DC 7806 (dermatitis or eczema) was evaluated at
levels of 50, 30, 10, or zero percent. The criteria called for a
50-percent evaluation for ulceration or extensive exfoliation or
crusting, with systemic or nervous manifestations, or being
exceptionally repugnant; a 30-percent evaluation for constant exudation
or itching, with extensive lesions, or with marked disfigurement; a
10-percent evaluation for exfoliation, exudation or itching, if
involving an exposed surface or extensive area; and a zero-percent
evaluation for slight, if any, exfoliation, exudation or itching, if on
a nonexposed surface or small area. DC\'s 7809 (discoid lupus
erythematosus), 7815 (bullous disorders), 7816 (psoriasis), and 7817
(exfoliative dermatitis) did not include specific evaluation criteria,
but were ordinarily rated as analogous conditions, using the same
criteria as for DC 7806. We proposed to evaluate all five of these
conditions, plus four new conditions-cutaneous manifestations of
collagen-vascular diseases not listed elsewhere (DC 7821),
papulosquamous disorders not listed elsewhere (DC 7822), vitiligo (DC
7823), and diseases of keratinization (DC 7824)\--under identical
criteria, with evaluation levels of 100, 50, 30, 10, and zero percent.
We proposed a 100-percent evaluation for generalized scaling, crusting,
systemic manifestations, pruritus and for being so disfiguring as to
preclude interaction with the public; a 50-percent evaluation for
ulceration or extensive exfoliation or crusting, and systemic
manifestations, or being so disfiguring as to be repugnant on casual
inspection; a 30-percent evaluation for exudation or constant itching,
or extensive lesions, or being so disfiguring as to be disagreeable on
casual inspection; a 10-percent evaluation for exfoliation, exudation,
or itching, if involving an exposed surface or extensive area; and a
zero-percent evaluation for minimal exfoliation, exudation or itching,
if on a nonexposed surface or small area. We proposed to evaluate a
second group of skin disorders-disfigurement of the head, face, or neck
(DC 7800), acne (DC 7828), chloracne (DC 7829), scarring alopecia (DC
7830), and alopecia areata (DC 7831)\--solely on the basis of
disfigurement, as described above under the discussion of DC 7800, and
made 80 percent the maximum evaluation for this group based on
disfigurement that precludes occupational interaction with the public.
There were several comments regarding similarities between the proposed
criteria for a 100-percent evaluation for the first group (DC 7806 and
conditions rated under the same criteria) and the criterion for an
80-percent evaluation for the second group (DC 7800 and conditions rated
under the same criteria).

One commenter objected to the fact that when interaction with the public
is precluded, one group of skin conditions may be assigned an evaluation
of 100 percent and another group may be assigned no more than 80
percent. Another commenter suggested that we add an intermediate
evaluation level between 50 and 100 percent for the skin conditions for
which we proposed evaluation levels of 100, 50, 30, 10, and zero
percent. An evaluation of 60 percent or more for a single disability
would allow a veteran to advance a claim under 38 CFR 4.16(a), which
allows a claim for individual unemployability in cases where there is a
service-connected disability rating that is less than total but which
renders an individual unable to secure or follow a substantially gainful
occupation.

In response to these comments, and because the more specific criteria we
have provided for DC 7800 are not as readily applicable to other skin
conditions as those we proposed, we have further revised the criteria
for DC\'s 7806, 7809, 7815, 7816, 7817, 7821, 7822, 7823, and 7824. We
have removed the proposed criteria, which were the same for all these
conditions and have provided criteria that are more objective and more
specific for each condition.

For dermatitis or eczema, DC 7806, instead of the proposed evaluation
levels of 100, 50, 30, 10, and zero percent based on the presence of
scaling, crusting, whether there are systemic manifestations, itching,
exudation, exfoliation, etc., or, alternatively, on the extent of
disfigurement, we have now provided evaluation levels of 60, 30, 10, and
zero percent, as the commenter suggested. As part of the more
condition-specific criteria we have provided, we have also removed the
100-percent evaluation level because dermatitis is rarely totally
disabling. However, since a 60-percent evaluation level may now be
assigned, a claim for individual unemployability, when appropriate, is
feasible under 38 CFR 4.16 (a) for those individuals unable to secure or
follow a substantially gainful occupation as a result of
service-connected skin disease. The criteria are based on the extent (in
percentage) to which the entire body or exposed areas are affected by
the condition or on the treatment required. For a 60-percent evaluation
for dermatitis, more than 40 percent of the entire body or more than 40
percent of exposed areas must be affected, or constant or near-constant
systemic therapy such as corticosteroids or other immunosuppressive
drugs is required. For a 30-percent evaluation, 20 to 40 percent of the
entire body or 20 to 40 percent of exposed areas must be affected, or
systemic therapy for a total duration of six weeks or more, but not
constantly, during the past 12-month period is required. For a
10-percent evaluation, at least 5 percent, but less than 20 percent, of
the entire body, or at least 5 percent, but less than 20 percent, of
exposed areas must be affected, or intermittent systemic therapy for a
total duration of less than six weeks during the past 12-month period is
required. For a zero-percent evaluation, less than 5 percent of the
entire body or less than 5 percent of exposed areas must be affected,
with no more than topical therapy required during the past 12-month
period. We also added analternative direction to rate as disfigurement
of the head, face, or neck(DC 7800) or scars (DC\'s 7801, 7802, 7803,
7804, or 7805), depending upon the predominant disability. This will
provide an alternative means of evaluation in cases, for example, where
the active disease has been controlled but there are significant
residuals, such as scarring. These criteria are much more objective than
the proposed criteria and will assuremore consistent evaluations. We had
proposed criteria identical to those for DC 7806 for DC\'s 7815 (Bullous
disorders (including pemphigus vulgaris, pemphigus foliaceous, bullous
pemphigoid, dermatitis herpetiformis, epidermolysis bullosa acquisita,
benign chronic familial pemphigus (Hailey-Hailey), and porphyria cutanea
tarda)); 7816 (Psoriasis); 7821 (Cutaneous manifestations of
collagen-vascular diseases not listed elsewhere (including scleroderma,
calcinosis cutis, and dermatomyositis)); and 7822 (Papulosquamous
disorders not listed elsewhere (including lichen planus, large or small
plaque parapsoriasis, pityriasis lichenoides et varioliformis acuta
(PLEVA), lymphomatoid papulosus, and pityriasis rubra pilaris (PRP))).
The further revised evaluation criteria we have provided for DC 7806
remain appropriate for those four conditions, and we have provided
identical criteria under each diagnostic code.

We also proposed to provide evaluation criteria identical to those for
DC 7806 for the evaluation of DC\'s 7809 (Discoid lupus erythematosus or
subacute cutaneous lupus erythematosus), 7817 (Exfoliative dermatitis
(erythroderma)), 7823 (Vitiligo), and 7824 (Diseases of keratinization).
However, the proposed criteria were not specific enough to these
conditions to assure consistent evaluations, and the revised criteria
for DC 7806 are also not appropriate for their evaluation. We have
therefore provided more disease-specific evaluation criteria for these
conditions, and also revised the evaluation levels in order to make them
appropriate for the usual range of severity of each individual
condition. The evaluation criteria for each of these conditions is
discussed in more detail below.

Discoid lupus erythematosus (DC 7809) can present in a number of
different ways (scaling, plaques, atrophy, erythema, scars, etc.), and
we have therefore directed that it be rated as disfigurement (DC 7800),
scars (DC\'s 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806),
depending upon the predominant disability.

Exfoliative dermatitis (DC 7817) is a disease that may be very severe,
and its treatment is different from that of most other skin conditions.
It may require the use of corticosteroids, immunosuppressive retinoids,
PUVA (psoralen with long-wave ultraviolet-A light) or UVB (ultraviolet-B
light) treatments, or electron beam therapy. It may also be associated
with systemic manifestations, such as fever, weight loss, and
hypoproteinemia (low level of protein in the blood, often associated
with edema). We have provided evaluation levels of 100, 60, 30, 10, and
zero percent for this condition, based on the extent of involvement of
the skin, whether there are also systemic manifestations, and the type
and duration of treatment. For a 100-percent evaluation, generalized
involvement of the skin, plus systemic manifestations (such as fever,
weight loss, and hypoproteinemia) must be present, and constant or
near-constant systemic therapy such as therapeutic doses of
corticosteroids, immunosuppressive retinoids, PUVA (psoralen with
long-wave ultraviolet-A light) or UVB (ultraviolet-B light) treatments,
or electron beam therapy during the past 12-month period is required.
For a 60-percent evaluation, generalized involvement of the skin without
systemic manifestations must be present, and constant or near-constant
systemic therapy during the past 12-month period is required. For a
30-percent evaluation, there can be any extent of involvement of the
skin, and systemic therapy for a total duration of six weeks or more,
but not constantly, during the past 12-month period is required. For a
10-percent evaluation, there can be any extent of involvement of the
skin, and systemic therapy for a total duration of less than six weeks
during the past 12-month period is required. For a zero-percent
evaluation, there can be any extent of involvement of the skin with no
more than topical therapy required during the past 12-month period.
These criteria are specific to this condition and are more objective
than the proposed criteria.

We proposed to evaluate vitiligo (DC 7823) under the same evaluation
criteria as those we proposed for DC 7806 (dermatitis or eczema).
Vitiligo is a condition in which the only abnormal finding is
hypopigmented skin; the only treatment for it is cosmetic. The proposed
criteria, however, included findings such as ulceration, itching,
crusting, exfoliation, and systemic manifestations, none of which is
specific to, or even occurs in, vitiligo. It is unlikely that an
evaluation higher than zero percent could have been assigned for
vitiligo using those criteria. Disfigurement was another of the proposed
criteria under DC 7806. Of the characteristics of disfigurement
described under DC 7800, only one\--hypopigmentation\--is present in
vitiligo, and that is its only disabling effect. For one characteristic
of disfigurement of the head, face, or neck under DC 7800, a 10-percent
evaluation is assigned. We have therefore provided evaluation levels for
vitiligo of ten and zero percent, providing ten percent if exposed areas
are affected, and zero percent if they are not. These criteria will
assure consistent evaluations for vitiligo, and they are internally
consistent with the evaluations for disfigurement of the head, face, or
neck, where the maximum evaluation based on the presence of
hypopigmentation alone is 10 percent.

We also proposed to evaluate DC 7824, diseases of keratinization
(including icthyoses, Darier\'s disease, and palmoplantar keratoderma)
under the same evaluation criteria as those we proposed for DC 7806
(dermatitis or eczema). The further revised criteria for DC 7806 are not
entirely appropriate for evaluating diseases of keratinization. We have
therefore provided evaluation levels of 60, 30, 10, and zero percent for
diseases of keratinization, based on requirements for therapy, the
extent of cutaneous involvement, whether there are systemic
manifestations, and whether the skin involvement is constant or
episodic. A 60-percent evaluation requires either generalized cutaneous
involvement or systemic manifestations and constant or near-constant
systemic medication, such as immunosuppressive retinoids, during the
past 12-month period. A 30-percent evaluation requires either
generalized cutaneous involvement or systemic manifestations and
intermittent systemic medication, such as immunosuppressive retinoids,
for a total duration of six weeks or more, but not constantly, during
the past 12-month period. A 10-percent evaluation requires localized or
episodic cutaneous involvement and intermittent systemic medication,
such as immunosuppressive retinoids, for a total duration of less than
six weeks during the past 12-month period. A zero-percent evaluation is
assigned if no more than topical therapy was required during the past
12-month period. These criteria are more appropriate for the evaluation
of diseases of keratinization. In addition, we have added to the title
some of the specific diseases that make up the category of diseases of
keratinization-icthyoses, Darier\'s disease, and palmoplantar
keratoderma. Under the former schedule, leishmaniasis, both American (DC
7807) and Old World (DC 7808), were ordinarily evaluated under the same
criteria as DC 7806 (eczema). We proposed to evaluate leishmaniasis as
disfigurement, scars, or dermatitis, depending upon the predominant
disability. One commenter suggested that we include evaluation criteria
for systemic manifestations of the disease under these codes. In our
judgment, there is no need to include criteria for the systemic forms of
leishmaniasis here, because evaluation criteria for visceral
leishmaniasis are provided under DC 6301, in the section of the rating
schedule on infectious diseases, immune disorders and nutritional
deficiencies (38 CFR 4.88b). However, as a reminder to rating
specialists, we have added a note under each of these codes directing
that non-cutaneous (visceral) leishmaniasis be evaluated under DC 6301
(visceral leishmaniasis).

In the former schedule and in the proposed rule, DC 7811 (tuberculosis
luposa (lupus vulgaris), active or inactive) was directed to be rated
under Secs. 4.88b or 4.89. Section 4.88b was redesignated Sec. 4.88c in
a separate rulemaking, so we have corrected the reference under DC 7811
to codes to be used for the evaluation of tuberculosis of the skin to
Secs. 4.88c and 4.89.

Malignant neoplasms of the skin (DC 7818) were evaluated on scars,
disfigurement, etc., on the extent of constitutional symptoms, and on
physical impairment, in the former schedule. We proposed to evaluate
based on impairment of function, disfigurement, or scars. One commenter
stated that these criteria are inadequate for malignant melanoma because
the condition is potentially lethal.

On further consideration, we have added a separate diagnostic code,
7833, to the rating schedule for malignant melanoma of the skin because
it is a common malignancy and often behaves differently, particularly
more aggressively, than other skin malignancies. All residuals that
might occur from any skin malignancy can be evaluated under the proposed
criteria for malignant neoplasms of the skin because \`\`impairment of
function\'\' covers virtually any disability that might result, and we
propose to provide the same evaluation criteria for malignant melanoma
as for other skin malignancies. However, malignant melanoma, and at
times other malignancies of the skin, may require a level of
antineoplastic treatment that is similar to that used for internal
malignancies. We have therefore added a note under DC\'s 7818 and 7833
stating that if a skin malignancy requires therapy that is comparable to
that used for internal malignancies, i.e., systemic chemotherapy, X-ray
therapy more extensive than to the skin, or surgery more extensive than
wide local excision, a 100-percent evaluation will be assigned from the
date of onset of treatment, and will continue, with a mandatory VA
examination six months following the completion of such antineoplastic
treatment, and any change in evaluation based upon that or any
subsequent examination subject to the provisions of 38 CFR 3.105(e).
Those provisions require a 60-day notice before VA reduces an evaluation
and an additional 60-day notice before the reduced evaluation takes
effect. The revision requires a current examination to assure that all
residuals are documented, and also offers the veteran more
contemporaneous notice of any proposed action and expands the veteran\'s
opportunity to present evidence showing that the proposed action should
not be taken. If there has been no local recurrence or metastasis,
evaluation will then be made on residuals. This will assure that the
evaluation of these neoplasms, when they require treatment that is
comparable to the treatment of internal malignancies, is commensurate
with that type of treatment and is consistent with the method of
evaluating malignancies in other systems. If treatment is confined to
the skin, the provisions for a 100-percent evaluation do not apply.
Since we have provided a separate diagnostic code for malignant
melanoma, we added to the title of malignant skin neoplasms (DC 7818)
for clarity, \`\`other than malignant melanoma.\'\' We proposed to add
urticaria to the rating schedule as DC 7825, with evaluation levels of
40, 20, and zero percent. We proposed to call for a 40-percent
evaluation if there is either a need for regular immunosuppressive
therapy or the presence of uncontrollable episodes despite therapy; a
20-percent evaluation if there is a need for frequent immunosuppressive
therapy; and a zero-percent evaluation if the condition is occasional or
asymptomatic. We received two comments about these criteria. One
commenter said that urticaria should be evaluated at 60 percent if it is
uncontrollable despite any therapy, and at 50 percent if it requires
frequent treatment. The other said that urticaria should be evaluated
higher than 40 percent if it is uncontrolled by systemic
immunosuppressive therapy and that we should replace the words
\`\`frequent,\'\' \`\`regular,\'\' and \`\`occasional\'\' with more
objective criteria.

We agree that a higher level of evaluation is warranted and have
therefore added a 60-percent evaluation level for urticaria when there
are at least four debilitating episodes during the past 12-month period
despite continuous immunosuppressive therapy. In conjunction with this
change, we made the next lower evaluation level 30 percent instead of 40
percent, and based it on debilitating episodes occurring at least four
times during the past 12-month period but requiring only intermittent
systemic immunosuppressive therapy for control, and made the level below
that 10 percent instead of 20 percent, and based it on recurrent
episodes occurring at least four times during the past 12-month period
and that respond to treatment with antihistamines or sympathomimetics.
These evaluation levels are consistent with the ranges for other skin
diseases, and these criteria respond to the comments by providing a
higher evaluation level for the most severe cases of urticaria, and by
providing more objective criteria. The more objective criteria will
assure more consistent evaluations. We proposed to add primary cutaneous
vasculitis as DC 7826, to be evaluated on the basis of disfigurement,
scars, or urticaria, depending upon the predominant disability. Because
the revised evaluation criteria for disfigurement (DC 7800) and
urticaria (DC 7825) are more specific to those conditions than the
proposed criteria were, they are less appropriate for the evaluation of
primary cutaneous vasculitis, which is a chronic, but episodic,
condition. We have therefore provided a separate set of more objective
criteria with evaluation levels of 60, 30, and 10 percent for primary
cutaneous vasculitis, based on the frequency of debilitating episodes
and the type and frequency of treatment. A 60-percent evaluation calls
for recurrent debilitating episodes occurring at least four times during
the past 12-month period despite continuous immunosuppressive therapy; a
30-percent evaluation calls for recurrent debilitating episodes
occurring at least four times during the past 12-month period and
requiring intermittent systemic immunosuppressive therapy for control;
and a ten-percent evaluation calls for recurrent episodes occurring one
to three times during the past 12-month period and requiring
intermittent systemic immunosuppressive therapy for control. These
criteria are more specificto this condition and will result in more
consistent evaluations. We have also provided an alternative direction
to rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC\'s 7801, 7802, 7803, 7804, or 7805), depending upon the predominant
disability. These are consistent with the criteria recommended by our
consultants.

Similarly, we proposed to add erythema multiforme (toxic
epidermal.necrolysis) as DC 7827, with evaluation based on
disfigurement, scars, or urticaria, depending upon the predominant
disability. Because the revised evaluation criteria for disfigurement
(DC 7800) and urticaria (DC 7825) are more specific to those conditions
than the proposed criteria were, they are less appropriate for the
evaluation of erythema multiforme. We have therefore provided a separate
set of more objective criteria for erythema multiforme, which is an
episodic condition, with levels of 60, 30, and 10 percent, based on the
frequency of debilitating episodes and the type and frequency of
treatment. A 60-percent evaluation calls for recurrent debilitating
episodes at least four times during the past 12-month period despite
ongoing immunosuppressive therapy; a 30-percent evaluation calls for
recurrent debilitating episodes at least four times during the past
12-month period despite ongoing immunosuppressive therapy; and a
ten-percent evaluation calls for recurrent episodes that respond to
treatment with antihistamines or sympathomimetics. We also provided an
alternative direction to rate as disfigurement of the head, face, or
neck (DC 7800) or scars (DC\'s 7801, 7802, 7803, 7804, or 7805),
depending upon the predominant disability. These criteria are identical
to the criteria for DC 7826, since both conditions are episodic and
require similar treatment, and they are consistent with the criteria
recommended by our consultants.

We proposed that acne (DC 7828) and chloracne (DC 7829), which have
similar manifestations, be evaluated under the same criteria as DC 7800
(disfigurement of the head, face, or neck). One commenter suggested that
acne on nonexposed areas may warrant a compensable evaluation if there
are extensive painful cysts. The proposed criteria did not provide for a
compensable evaluation for such manifestations.

We agree that acne involving nonexposed areas may be disabling, more
because of the inflammatory aspects than the disfiguring aspects. We
have therefore established evaluation criteria for acne and chloracne
that are based on the extent of involvement by acne, its location, and
whether it is deep or superficial. We have provided a 30-percent
evaluation for deep acne (meaning deep inflamed nodules and pus-filled
cysts) affecting 40 percent or more of the face and neck; a 10-percent
evaluation for deep acne affecting less than 40 percent of the face and
neck, or deep acne other than on the face and neck; and a zero-percent
evaluation for superficial acne (comedones, papules, pustules,
superficial cysts) of any extent. We have provided an alternative
direction to rate acne and chloracne as disfigurement of the head, face,
or neck (DC 7800) or scars (DC\'s 7801, 7802, 7803, 7804, or 7805),
depending upon the predominant disability. This change will allow more
leeway in assessing which type of disability best represents the
findings in a particular case of acne or chloracne.

We proposed to evaluate scarring alopecia (DC 7830) and alopecia areata
(DC 7831) on the basis of disfigurement. One commenter suggested that
the criteria for DC\'s 7830 and 7831 take into account the ability or
inability to improve appearance with a hairpiece or wig. We have
reconsidered the criteria for these types of alopecia in view of our
changed disfigurement criteria, which are not appropriate for these
conditions, and have provided evaluation criteria based instead on the
extent of involvement by alopecia. We have provided evaluation levels of
20, 10, and zero percent for scarring alopecia and ten and zero percent
for alopecia areata. These levels are commensurate with the range of
disability these conditions produce, according to our contract
consultant specialists, who reviewed the rating schedule and made
recommendations for changes to help fulfill the goals of revising and
updating the medical criteria. For scarring alopecia, which usually
follows injury, infection, burns, etc., and shows tissue loss and
scarring, we have provided a 20-percent evaluation if the condition
affects more than 40 percent of the scalp; a 10-percent evaluation if it
affects 20 to 40 percent of the scalp; and a zero-percnt evaluation if
it affects less than 20 percent of the scalp. For alopecia areata, where
scarring and atrophic changes are not present, we have provided a
10-percent evaluation for generalized involvement of the body, and a
zero-percent evaluation if the condition is limited to the scalp and
face. These criteria are clear and objective and will assure consistency
in evaluation. They do not take into account the potential improvement
of appearance with a hairpiece or wig, which would require a subjective
assessment, but are based instead on the objectively determinable
effects of the condition and are consistent with the recommendations of
our consultants.

We edited the language of the note regarding under painful superficial
scars (DC 7804) for clarity, and the notes under DC\'s 7801 and 7802
regarding scars in widely separated areas for the same reason, but these
are not substantive changes.

For more clarity and objectivity, we have revised the language in DC
7802 from \`\`area or areas approximating 144 square inches (929 sq.
cm.)\'\' to \`\`area or areas of 144 square inches (929 sq. cm.) or
greater.\'\' We revised the title of DC 7813, Dermatophytosis, to
include \`\`(ringworm: of body, tinea corporis; of head, tinea capitis;
of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea
unguium; of inguinal area (jock itch), tinea cruris)\'\' to clarify what
is included.

VA appreciates the comments submitted in response to the proposed rule,
which is now adopted with the amendments noted above.

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

Subpart B\--Disability Ratings

2\. Section 4.118 is revised to read as follows:

Sec. 4.118 Schedule of ratings\--skin.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7800 Disfigurement of the head, face, or neck:

With visible or palpable tissue loss and either gross distortion or
asymmetry

of three or more features or paired sets of features (nose, chin,
forehead, eyes

(including eyelids), ears (auricles), cheeks, lips), or; with six or
more

characteristics of
disfigurement....................................................................................80

With visible or palpable tissue loss and either gross distortion or
asymmetry

of two features or paired sets of features (nose, chin, forehead, eyes
(including

eyelids), ears (auricles), cheeks, lips), or; with four or five
characteristics of disfigurement..............50

With visible or palpable tissue loss and either gross distortion or
asymmetry

of one feature or paired set of features (nose, chin, forehead, eyes
(including

eyelids), ears (auricles), cheeks, lips), or; with two or three
characteristics of disfigurement.............30

With one characteristic of
disfigurement........................................................................\...10

Note (1):The 8 characteristics of disfigurement, for purposes of
evaluation under Sec. 4.118, are:

Scar 5 or more inches (13 or more cm.) in length.

Scar at least one-quarter inch (0.6 cm.) wide at widest part.

Surface contour of scar elevated or depressed on palpation.

Scar adherent to underlying tissue.

Skin hypo-or hyper-pigmented in an area exceeding six square inches (39
sq. cm.).

Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an
area exceeding six square inches

(39 sq. cm.).

Underlying soft tissue missing in an area exceeding six square inches
(39 sq. cm.).

Skin indurated and inflexible in an area exceeding six square inches (39
sq. cm.).

Note (2): Rate tissue loss of the auricle under DC 6207 (loss of
auricle) and anatomical loss of the eye

under DC 6061 (anatomical loss of both eyes) or DC 6063 (anatomical loss
of one eye), as appropriate.

Note (3): Take into consideration unretouched color photographs when
evaluating under these criteria.

7801 Scars, other than head, face, or neck, that are deep or that cause
limited motion:

Area or areas exceeding 144 square inches (929
sq.cm.)........................................................ 40

Area or areas exceeding 72 square inches (465 sq.
cm.).........................................................30

Area or areas exceeding 12 square inches (77 sq.
cm.).......................................................... 20

Area or areas exceeding 6 square inches (39 sq.
cm.)............................................................ 10

Note (1): Scars in widely separated areas, as on two or more extremities
or on anterior and posterior surfaces of extremities or trunk, will be
separately rated and combined in accordance with Sec. 4.25 of this part.

Note (2): A deep scar is one associated with underlying soft tissue
damage.

7802 Scars, other than head, face, or neck, that are superficial and
that do not

limited motion: Area or areas of 144 square inches (929 sq. cm.) or
greater..................................10

Note (1): Scars in widely separated areas, as on two or more extremities
or on anterior and posterior surfaces of extremities or trunk, will be
separately rated and combined in accordance with Sec. 4.25 of this part.

Note (2): A superficial scar is one not associated with underlying soft
tissue damage.

7803 Scars, superficial,
unstable\...\...\...\...\...\...\..........................................................................10

Note (1): An unstable scar is one where, for any reason, there is
frequent loss of covering of skin

over the scar.

Note (2): A superficial scar is one not associated with underlying soft
tissue damage.

7804 Scars, superficial, painful on
examination\...\...\...............................................................\...10

Note (1): A superficial scar is one not associated with underlying soft
tissue damage.

Note (2): In this case, a 10-percent evaluation will be assigned for a
scar on the tip of a finger or toe even

though amputation of the part would not warrant a compensable
evaluation.

(See Sec. 4.68 of this part on the amputation rule.)

7805 Scars, other;

Rate on limitation of function of affected part.

7806 Dermatitis or eczema.

More than 40 percent of the entire body or more than 40 percent of
exposed

of exposed areas affected, or; constant or near-constant systermic
therapy

such as corticosteroids or other immunosuppressive drugs required during

the past 12-month
period..........................................................................................60

20 to 40 percent of the entire body or 20 to 40 percent of exposed areas

affected, or; systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of six weeks

more, but not constantly, during the past 12-month
period...................................................30

At least 5 percent, but less than 20 percent, of the entire body, or at
least

5 percent, but less than 20 percent, of exposed areas affected, or;
intermittent

systemic therapy such as corticosteroids or other immunosuppressive

drugs required for a total duration of less than six weeks during the
past

12-month
period.......................................................................................................10

Less than 5 percent of the entire body or less than 5 percent of exposed
areas

affected, and; no more than topical therapy required during the past

12-month
period........................................................................................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars

(DC\'s 7801, 7802, 7803, 7804, or 7805), depeding upon the

predominant disability.

7807 American (New World) leishmaniasis (mucocutaneous, espundia): Rate
as disfigurement of the head, face, or neck (DC 7800), scars (DC\'s
7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending
upon the predominant disability.

Note: Evaluate non-cutaneous (visceral) leishmaniasis under DC 6301
(visceral leishmaniasis).

7808 Old World leishmaniasis (cutaneous, Oriental sore):

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC\'s
7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending
upon the predominant disability.

Note: Evaluate non-cutaneous (visceral) leishmaniasis under DC 6301
(visceral leishmaniasis).

7809 Discoid lupus erythematosus or subacute cutaneous lupus
erythematosus: Rate as disfigurement of the head, face, or neck (DC
7800), scars (DC\'s 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC
7806), depending upon the predominant disability. Do not combine with
ratings under DC 6350.

7811 Tuberculosis luposa (lupus vulgaris), active or inactive: Rate
under Secs. 4.88c or 4.89, whichever is

appropriate.

7813 Dermatophytosis (ringworm: of body, tinea corporis; of head, tinea
capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails,
tinea unguium; of inguinal area (jock itch), tinea cruris): Rate as
disfigurement of the head, face, or neck (DC 7800), scars (DC\'s 7801,
7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the
predominant disability.

7815 Bullous disorders (including pemphigus vulgaris, pemphigus
foliaceous, bullous pemphigoid, dermatitis herpetiformis, epidermolysis
bullosa acquisita, benign chronic familial pemphigus (Hailey-Hailey),
and porphyria cutanea tarda):

More than 40 percent of the entire body or more than 40 percent of
exposed

areas affected, or; constant or near-constant systemic therapy

such as corticosteroids or other immunosuppressive drugs required during
the

past 12-month
period...............................................................................................60

20 to 40 percent of the entire body or 20 to 40 percent of exposed areas

affected, or; systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of six weeks or

or more, but not constantly, during the past 12-month
period................................................\...30

At least 5 percent, but less than 20 percent, of the entire body, or at
least

5 percent, but less than 20 percent or exposed areas affected, or;

intermittent systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of less than

six weeks during the past 12-month
period.....................................................................10

Less than 5 percent of the entire body or exposed areas affected, and;
no

more than topical therapy required during the past 12-month
period...........................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC\'s 7801, 7802, 7803,

7804, or 7805), depending upon the predominant disability.

7816 Psoriasis:

More than 40 percent of the entire body or more than 40 percent or
exposed

areas affected, or; constant or near-constant systermic therapy

such as corticosteroids or other immunosuppressive drugs required

during the past 12-month
period.................................................................................\....60

20 to 40 percent of the entire body or 20 to 40 percent of exposed areas

affected, or; systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of six

weeks or more, but not constantly, during the past 12-month
period..........................................30

At least 5 percent, but less than 20 percent, of the entire body,

or at least 5 percent, but less than 20 percent, of exposed areas
affected,

or; intermittent systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of less than six
weeks

during the past 12-month
period....................................................................................10

Less than 5 percent of the entire body or exposed areas affected, and;
no...................................... 0

more than topical therapy required during the past 12-month period.

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC\'s 7801, 7802, 7803,

7804, or 7805), depending upon the predominant disability.

7817 Exfoliative dermatitis (erythroderma):

Generalized involvement of the skin, plus systemic manifestations

(such as fever, weight loss, and hypopreteinemia), and; constant or

near-constant systemic therapy such as therapeutic doses of

systemic therapy such as therapeutic doses of costicosteroids,

immunosuppressive retinoids, PUVA (psoralen with long-wave ultraviolet-A
light)

or UVB (ultraviolet-B light) treatments, or electron beam therapy

required during the past 12-month
period.....................................................................100

Generalized involvement of the skin without systemic manifestations,
and;

constant or near-constant systemic therapy such as therapeutic doses of

corticosteroids, immunosuppressive retinoids, PUVA

(psoralen with long-wave ultraviolet-A light) or UVB (ultraviote-B
light)

treatments, or electron beam therapy required during the past 12-month
period............................60

Any extent of involvement of the skin, and; systemic therapy such as

as therapeutic doses of corticosteroids, immunosuppressive retinoids,

PUVA (psoralen with long- wave ultraviolet-A light) or

UVB (ultraviolet-B light) treatments, or electron beam therapy required

for a total duration of six weeks or more, but not constantly, during

the past 12-month
period.............................................................................................30

Any extent of involvement of the skin, and; systemic therapy such as

therapeutic doses of corticosteroids, immunosuppressive

retinoids, PUVA (psoralen with long-wave ultraviolet-A light)

or UVB (ultraviolet-B light) treatments, or UVB treatments,

or electron beam therapy required for a total duration of less

than six weeks during the past 12-month
period...............................................................10

Any extent of involvement of the skin, and; no more than topical

therapy required during the past 12-month
period.................................................................0

7818 Malignant skin neoplasms (other than malignant melanoma):

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC\'s
7801, 7802, 7803, 7804, or

7805), or impairment of function.

Note: If a skin malignancy requires therapy that is comparable to that
used for systemic malignancies,

i.e., systemic chemotherapy, X-ray therapy more extensive than to the
skin, or surgery more extensive

than wide local excision, a 100-percent evaluation will be assigned from
the date of onset of treatment,

and will continue, with a mandatory VA examination six months following
the completion of such

antineoplastic treatment, and any change in evaluation based upon that
or any subsequent examination

will be subject to the provisions of Sec. 3.105(e) of this chapter. If
there has been no local recurrence or

metastasis, evaluation will then be made on residuals. If treatment is
confined to the skin, the provisions

for a 100-percent evaluation do not apply.

7819. Benign skin neoplasms: Rate as disfigurement of the head, face, or
      neck (DC 7800), scars (DC\'s

7801, 7802, 7803, 7804, or 7805), or impairmeny of function.

7820 Infections of the skin not listed elsewhere (including bacterial,
fungal, viral, treponemal and

parasitic diseases): Rate as disfigurement of the head, face, or nect
(DC 7800), scars (DC's 7801,

7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the
predominant disability.

7821 Cutaneous manifestations of collagen-vascular diseases not listed
elsewhere (including

scleroderma, calcinosis cutis, and dermatomyositis):

More than 40 percent of the entire body or more than 40 percent of
exposed

areas affected, or; constant or near-constant systemic therapy such as

corticosteroids or other immunosuppressive drugs required during the

past 12-month
period.................................................................................................60

20 to 40 percent of the entire body or 20 to 40 percent of exposed areas

affected, or; systemic therapy such as conrticosteroids or other

immunosuppressive drugs required for a total duration of six weeks or

more, but not constantly, during the past 12-month
period.....................................................30

At least 5 percent, but less than 20 percent, of the entire body, or at
least

5 percent, but less than 20 percent, of exposed areas affected, or;

intermittent systemic therapy such as corticosteroids or other

immunosuppressive drugs required for a total duration of less than six

weeks during the past 12-month
period............................................................................10

Less than 5 percent of the entire body or exposed areas affected, and;

no more than topical therapy required during the past 12-month
period.......................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars

(DC\'s 7801, 7802, 7803, 7804, or 7805), depending upon the predominant
disability.

7822 Papulosquamous disorders not listed elsewhere (including lichen
planus, large or

small plaque parapsoriasis, pityriasis lichenoides et varioliformis

acuta (PLEVA), lymphomatoid papulosus, and pityriasis rubra pilaris
(PRP)):

More than 40 percent of the entire body or more than 40 percent of
exposed

areas affected, and; constant or near-constant systemic medications or

intensive light therapy required during the past 12-month
period..............................................60

20 to 40 percent of the entire body or 20 to 40 percent of exposed areas

affected, or; systemic therapy or intensive light therapy required for a

total duration of six weeks or more, but not constantly, during the

past 12-month
period.................................................................................................30

At least 5 percent, but less than 20 percent, of the entire body, or at

least 5 percent, but less than 20 percent, of exposed areas affected,

or; systemic therapy or intensive light therapy required for a total

total duration of less than six weeks during the past 12-month
period........................................10

Less than 5 percent of the entire body or exposed areas

affected, and; no more than topical therapy required

during the past 12-month
period\...\...\...\...\...\...\........................................................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC's 7801, 7802,

7803, 7804, or 7805), depending upon the predominant disability.

7823 Vitiligo:

With exposed areas
affected\...\...\...\...\...\...\...\...........................................................................10

With no exposed areas
affected\...\...\...\...\...\...\..........................................................................
0

7824 Diseases of keratinization (including icthyoses, Darier\'s disease,
and palmoplantar keratoderma):

With either generalized cutaneous involvement or systemic

manifestations, and; constant or near-constant systemic medication,

such as immunosuppressive retinoids, required during the past

12-month
period.......................................................................................................60

With either generalized cutaneous involvement or systemic
manifestations,

and; intermittent systemic medication, such as immunosuppressive

retinoids, required for a total duration of six weeks or more, but not

but not constantly, during the past 12-month
period.............................................................30

With localized or episodic cutaneous involvement and intermittent

systemic medication, such as immunosuppressive retinoids,

required for a total duration of less than six weeks during the past

12- month
period......................................................................................................10

No more than topical therapy required during the past 12-month
period....................................... 0

7825 Urticaria:

Recurrent debilitating episodes occurring at least four times during

the past 12-month period despite continuous immunosuppressive
therapy...................................60

Recurrent debilitating episodes occurring at least four times during the

past 12-month period, and; requiring intermittent systemic

immunosuppressive therapy for
control.........................................................................30

Recurrent episodes occurring at least four times during the past

12-month period, and; responding to treatment with antihistamines

or
sympathomimetics.................................................................................................10

7826 Vasculitis, primary cutaneous:

Recurrent debilitating episodes occurring at least four times during

the past 12-month period despite continuous immunosuppressive

therapy..................................................................................................................60

Recurrent debilitating episodes occurring at least four times during the

past 12-month period, and; requiring intermittent systemic

immunosuppressive therapy for
control............................................................................30

Recurrent episodes occurring one to three times during the past

12-month period, and; requiring intermittent systemic

immunosuppressive therapy for
control............................................................................10

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC's 7801, 7802, 7803

7804, or 7805), depending upon the predominant disability.

7827 Erythema multiforme; Toxic epidermal necrolysis:

Recurrent debilitating episodes occurring at least four times during

the past 12-month period despite ongoing immunosuppressive
therapy.................................60

Recurrent episodes occurring at least four times during the past

12-month period, and; requiring intermittent systemic

immunosuppressive
therapy.................................................................................\...30

Recurrent episodes occurring during the past 12-month period

that respond to treatment with antihistamines or sympathomimetics,

or; one to three episodes occurring during the past 12-monht period

requiring intermittent systemic immunosuppressive
therapy.................................................10

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC's 7801, 7802,

7803, 7804, or 7805), depending upon the predominant disability.

7828 Acne:

Deep acne (deep inflamed nodules and pus-filled cysts) affecting

40 percent or more of the face and
neck...........................................................................30

Deep acne (deep inflamed nodules and pus-filled cysts)affecting

less than 40 percent of the face and neck, or; deep acne other

than on the face and
neck..........................................................................................\...10

Superficial acne (comedones, papules, pustules, superficial cysts)

of any
extent.............................................................................................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC's 7801, 7802,

7803, 7804, or 7805), depending upon the predominant disability.

7829 Chloracne:

Deep acne (deep inflamed nodules and pus-filled cysts) affecting 40

percent or more of the face and
neck\................................................................................30

Deep acne (deep inflamed nodules and pus-filled cysts) affecting

less than 40 percent of the face and neck, or; deep acne other than

on the face and
neck................................................................................................\...10

Superficial acne (comedones, papules, pustules, superficial cysts

of any
extent............................................................................................................0

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars
(DC's 7801,

7802, 7803, 7804, or 7805), depending upon the predominant disability.

7830 Scarring alopecia:

Affecting more than 40 percent of the
scalp\...\...\...................................................................
20

Affecting 20 to 40 percent of the
scalp\...\...\...\........................................................................10

Affecting less than 20 percent of the
scalp\...\...\.......................................................................0

7831 Alopecia areata:

With loss of all body
hair\...\...\...\...\...\...\...\...\............................................................................10

With loss of hair limited to scalp and
face\...\......................................................................\...0

7832 Hyperhidrosis:

Unable to handle paper or tools because of moisture, and unresponsive

to
therapy...............................................................................................................30

Able to handle paper or tools after
therapy\...\...\......................................................................
0

7833 Malignant melanoma: Rate as scars (DC\'s 7801, 7802, 7803, 7804 0r
7805),

disfigurement of the head, face, or neck (DC 7800), or impairment of
function

(under the appropriate body system).

Note: If a skin malignancy requires therapy that is comparable to that
used for systemic malignancies,

i.e., systemic chemotherapy, X-ray therapy more extensive than to the
skin, or surgery more extensive

than wide local excision, a 100-percent evaluation will be assigned from
the date of onset of treatment,

and will continue, with a mandatory VA examination six months following
the completion of such

antineoplastic treatment, and any change in evaluation based upon that
or any subsequent examination

will be subject to the provisions of Sec. 3.105(e). If there has been no
local recurrence or metastasis,

evaluation will then be made on residuals. If treatment is confined to
the skin, the provisions for a 100-

percent evaluation do not apply.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

(Authority: 38 U.S.C. 1155)

**Correction, published September 16, 2002:**

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AF00

Schedule for Rating Disabilities; the Skin

Correction

In rule document 02-19331 beginning on page 49590 in the issue of
Wednesday, July 31, 2002 make the following correction:

Sec. 4.118 \[Corrected\]

1\. On page 49596, the Rate Schedule for 7802 is corrected to read as
follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7802 Scars, other than head, face, or neck, that are superficial and
that

do not cause limited motion:

Area or areas of 144 square inches (929 sq. cm.) or
greater...................................................10

Note (1): Scars in widely separated areas, as on two or more extremities
or on anterior and posterior

surfaces of extremities or trunk, will be separately rated and combined
in accordance with Sec. 4.25 of this part.

Note (2): A superficial scar is one not associated with underlying soft
tissue damage.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

2\. On the same page, the Rate Schedule for 7807, 7808 and 7809 is
corrected to read as follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7807 American (New World) leishmaniasis (mucocutaneous, espundia):

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC's
7801, 7802,

7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the

predominant disability.

Note: Evaluate non-cutaneous (visceral) leishmaniasis under DC 6301
(visceral leishmaniasis).

7808 Old World leishmaniasis (cutaneous, Oriental sore):

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC's
7801, 7802, 7803,

7804, or 7805), or dermatitis (DC 7806), depending upon the

predominant disability.

Note: Evaluate non-cutaneous (visceral) leishmaniasis under DC 6301
(visceral leishmaniasis).

7809 Discoid lupus erythematosus or subacute cutaneous lupus
erythematosus:

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC's
7801, 7802, 7803,

7804, or 7805), or dermatitis (DC 7806), depending upon the predominant
disability.

Do not combine with ratings under DC 6350.

3\. On page 49597, the Rate Schedule for 7811 is corrected to read as
follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7811 Tuberculosis luposa (lupus vulgaris), active or inactive

Rate under Sec. Sec. 4.88c or 4.89, whichever is appropriate.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\[\[Page 58449\]\]

4\. On the same page, the Rate Schedule for 7813 is corrected to read as
follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7813 Dermatophytosis (ringworm: of body, tinea corporis; of head, tinea
capitis; of feet, tinea pedis; of

beard area, tinea barbae; of nails, tinea unguium; of inguinal area
(jock itch), tinea cruris):

Rate as disfigurement of the head, face, or neck (DC 7800),

scars (DC\'s 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806),

depending upon the predominant disability.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

5\. On the same page, the Rate Schedule for 7818, 7819, and 7820 is
corrected to read as follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7818 Malignant skin neoplasms (other than malignant melanoma):

Rate as disfigurement of the head, face, or neck (DC 7800),

scars (DC\'s 7801, 7802, 7803, 7804, or 7805), or impairment of
function.

Note: If a skin malignancy requires therapy that is comparable to that
used for systemic malignancies,

i.e., systemic chemotherapy, X-ray therapy more extensive than to the
skin, or surgery more extensive

than wide local excision, a 100-percent evaluation will be assigned from
the date of onset of treatment,

and will continue, with a mandatory VA examination six months following
the completion of such

antineoplastic treatment, and any change in evaluation based upon that
or any subsequent examination

will be subject to the provisions of Sec. 3.105(e) of this chapter. If
there has been no local recurrence or

metastasis, evaluation will then be made on residuals. If treatment is
confined to the skin, the provisions

for a 100-percent evaluation do not apply.

7819 Benign skin neoplasms:

Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC's
7801,

7802, 7803, 7804, or 7805), or impairment of function.

7820. Infections of the skin not listed elsewhere (including bacterial,
      fungal,

> viral, treponemal and parasitic diseases):

Rate as disfigurement of the head, face, or neck (DC7800), scars

(DC\'s 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806),
depending upon the

predominant disability.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

6\. On page 49599, the Rate Schedule for 7833 is corrected to read as
follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

7833 Malignant melanoma:

Rate as scars (DC\'s 7801, 7802, 7803, 7804, or 7805), disfigurement of
the head,

face, or neck (DC 7800), or impairment of function (under the
appropriate body

system).

Note: If a skin malignancy requires therapy that is comparable to that
used for systemic malignancies,

i.e., systemic chemotherapy, X-ray therapy more extensive than to the
skin, or surgery more extensive

than wide local excision, a 100-percent evaluation will be assigned from
the date of onset of treatment,

and will continue, with a mandatory VA examination six months following
the completion of such

antineoplastic treatment, and any change in evaluation based upon that
or any subsequent examination

will be subject to the provisions of Sec. 3.105(e). If there has been no
local recurrence or metastasis,

evaluation will then be made on residuals. If treatment is confined to
the skin, the provisions for a 100-

percent evaluation do not apply.

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

REGULATORY AMENDMENT

4-02-4

Regulation affected: 38 CFR 4.71a

EFFECTIVE DATE OF REGULATION: September 23, 2002.

Date Secretary approved regulation: June 24, 2002.

Federal Register Citation: 67 FR 54345-49 (August 22, 2002).

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

This document amends diagnostic code 5293 of 38 CFR 4.71a in order to
update and clarify the evaluation of intervertebral disc syndrome to
assure consistent evaluations. For more detailed information, review the
preambles to the attached final regulatory amendment and the notice of
proposed rulemaking, which was published in the [Federal
Register]{.underline} on February 24, 1997 (62 FR 8204).

Intervertebral disc syndromes, both pre-operative and post-operative,
are now evaluated in one of two ways. Those that are primarily disabling
because of periods of acute symptoms that require bedrest are evaluated
according to the cumulative amount of time over the course of a year
that the patient is incapacitated, i.e., requires bed rest and treatment
by a physician. Those that are disabling primarily because of chronic
orthopedic manifestations (e.g., painful muscle spasm or limitation of
motion), chronic neurologic manifestations (e.g., footdrop, muscle
atrophy, or sensory loss), or a combination of both, are evaluated by
assigning separate evaluations for the orthopedic and neurologic
manifestations. There are evaluation levels of 60, 40, 20, and 10
percent. When an intervertebral disc syndrome is disabling both because
of incapacitating episodes and chronic orthopedic or neurologic
manifestations, evaluation will be based on whichever alternative method
of evaluation results in a higher evaluation.

If intervertebral disc syndrome is present in more than one spinal
segment, provided that the effects in each spinal segment are clearly
distinct, each affected segment may be separately evaluated based on:
(1) incapacitating episodes, (2) chronic manifestations; or (3) one
affected segment may be evaluated based on incapacitating episodes and
another segment may be evaluated based on chronic manifestations,
whichever method results in a higher evaluation for that segment.

# Diagnostic code revised

5293

The pertinent portion of the final rule is as follows:

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

SUMMARY: This document amends that portion of the Department of Veterans
Affairs (VA) Schedule for Rating Disabilities that addresses
intervertebral disc syndrome. The effect of this action is to clarify
the criteria to ensure that veterans diagnosed with this condition meet
uniform criteria and receive consistent evaluations.

SUPPLEMENTARY INFORMATION: VA published a proposal to amend the
evaluation criteria for diagnostic code 5293, intervertebral disc
syndrome (IVDS), in the Federal Register of February 24, 1997 (62 FR
8204). Interested persons were invited to submit written comments on or
before April 25, 1997. We received comments from the Vietnam Veterans of
America, Disabled American Veterans, Paralyzed Veterans of America, and
two concerned individuals.

We proposed to evaluate IVDS either on its chronic neurologic and
orthopedic manifestations or on the total annual duration of
incapacitating episodes, whichever would result in a higher evaluation.
One commenter recommended that the final rule specify whether there
could be separate evaluations of the chronic manifestations of each
spinal segment with IVDS; whether there could be separate evaluations

based on incapacitating episodes of each spinal segment; and whether one
spinal segment could be evaluated based on incapacitating episodes and
another on chronic manifestations.

In response to this comment, we have added a third note specifying that
IVDS in separate spinal segments will be separately evaluated as long as
the effect on each segment is clearly distinct. Inherent in the rule is
the concept that each affected spinal segment will be evaluated under
the method that results in the highest overall evaluation. This means
that affected segments may be separately evaluated based on: (1)

Incapacitating episodes, (2) chronic manifestations; or (3) one affected
segment may be evaluated based on incapacitating episodes and another
segment may be evaluated based on chronic manifestations.

One commenter stated that acute incapacitating symptoms are distinct
from chronic symptoms involving persistent orthopedic and neurological
manifestations because each has a different effect on functionality. The
commenter stated that IVDS should be rated on both acute and chronic
symptoms, as long as the manifestations are different, and then the
ratings should be combined. The commenter stated that, if for example a
veteran has foot drop as a result of IVDS that interferes with earning
capacity and also requires frequent bed rest due to IVDS that affects
earning capacity, the veteran has separate disabilities that should be
evaluated separately and then combined, rather than rating based on the
higher of the two respective evaluations.

Acute incapacitating symptoms and chronic symptoms do not necessarily
represent different manifestations of IVDS. For example, IVDS may result
in chronic back pain and limitation of motion (a

chronic orthopedic manifestation); back pain and limitation of motion
may also cause periods of acute incapacitation. Some individuals present
predominantly or exclusively with acute symptoms, some with

chronic symptoms, and some with both. We have provided alternative
methods of evaluation that allow the use of either the chronic
manifestations or the total duration of incapacitating episodes for
evaluation, whichever results in a higher evaluation. But, in our view,
assigning an evaluation under both methods for functional impairment due
to IVDS would clearly result in duplicate evaluations of a single
disability, and therefore would constitute pyramiding, which is
prohibited by 38 CFR 4.14. We therefore make no change in response to
this comment.

Another commenter noted that, in some individuals both IVDS and
residuals of a vertebral fracture in the same spinal segment are
service-connected. Diagnostic code 5285, which applies to fractures of
vertebral bodies, directs that ten percent be added to a spinal
evaluation if it is less than 60 percent disabling and if there is
demonstrable deformity of the vertebral body. The commenter suggested
that the evaluation criteria indicate whether ten percent should be
added to a rating for IVDS for either chronic residuals or
incapacitating episodes.

When vertebral fracture and IVDS are present in the same spinal segment,
the signs and symptoms of each condition commonly overlap and may be
inseparable. For example, both conditions may cause pain and limitation
of motion of the spine and neurologic disability. In such cases, a
single overall evaluation for the manifestations of both disabilities
would be assigned, since evaluating the same disability under two
diagnoses is prohibited (see 38 CFR 4.14). Ten percent would be added to
the single overall evaluation, if it is less than 60 percent disabling,
when there is demonstrable vertebral deformity, because the x-ray
finding that is the basis for the added ten percent does not duplicate
or overlap any other evaluation criteria for either condition. This is
true whether the evaluation is based on the criteria for residuals of
vertebral fracture, on the total duration of incapacitating episodes of
IVDS, or on the chronic orthopedic and neurologic manifestations of
IVDS. There may be some cases where the effects of IVDS and vertebral
fracture are clearly separable. When that happens, the fracture
residuals would be evaluated under diagnostic code 5285, with ten
percent added for deformity of the vertebral body when appropriate, and
the IVDS would be evaluated under either alternative method, as
directed. As with other complex rating issues, if the situation arises,
raters may request an advisory review opinion from the Compensation and
Pension Service, but we do not believe this situation arises frequently
enough to warrant the addition of specific regulatory instructions. We
therefore make no change based on this comment.

The same commenter asked if bed rest because of spasm warrants the added
10 percent.

The instruction under diagnostic code 5285 specifies that ten percent is
to be added on the basis of demonstrable vertebral deformity due to
fracture. Bed rest because of spasm therefore does not warrant

an additional 10 percent.

Another commenter recommended that the rule specify whether the
evaluation for incapacitating episodes is to be compared with the
neurologic and orthopedic evaluations, once combined pursuant to 38 CFR
4.25, or with the higher of those evaluations if both are present.

In response to this comment, we have revised the language under
diagnostic code 5293 to direct that IVDS be evaluated based either on
the total duration of incapacitating episodes or on the combination of
separate evaluations of its chronic orthopedic and neurologic
manifestations, whichever method results in the higher evaluation.

One commenter suggested that VA increase the proposed percentage
evaluations for incapacitating episodes having a total duration of at
least four to six weeks during the past 12 months because, in the
commenter\'s view, veterans who are incapacitated for four to six weeks
or more over the course of a year are unemployable. Another commenter
also suggested that the evaluation criteria for IVDS should include a
100-percent level.

IVDS is characterized by periods of exacerbation and remission, with a
tendency toward recovery over time (\`\`Practical Orthopedic
Medicine\'\' (Brian Corrigan and G.D. Maitland) 312, 1983). When IVDS
first appears, with few exceptions, the preferred treatment is
conservative and includes bed rest of approximately two to four weeks.
The majority of patients with IVDS recover from the acute symptoms and
have minimal residual functional or work capacity impairments
(\`\`Disability Evaluation\'\' (Stephen L. Demeter, M.D., Gunnar B.J.
Anderson, M.D., and George M, Smith, M.D.) 288, 1996). The minority in
whom conservative treatment fails; or who have repeated, disabling
attacks resulting in prolonged loss of time from work; or who have
intractable pain or severe or progressive neurological signs, will
undergo surgery (\`\`Fundamentals of Orthopedics\'\' (John J. Gartland,
M.D.) 334, 1987). Only an occasional patient has disabling back pain and
radicular symptoms after surgery (\`\`Campbell\'s Operative
Orthopaedics\'\') 2114, 1980). Therefore, except for short periods of
treatment, or periods of convalescence following surgery, IVDS is rarely
totally disabling.

The percentage ratings in the schedule \`\`represent as far as can
practicably be determined the average impairment in earning capacity
resulting from such diseases and injuries and their residual conditions
in civil occupations,\'\' 38 CFR 4.1; 38 U.S.C. 1155, and, in our view,
a 100 percent evaluation level for IVDS is not warranted. If a veteran
has permanent neurological or orthopedic residuals following back
surgery, those residuals could alternatively be rated under other
appropriate rating formula. Also, an individual who is shown by the
evidence to be unemployable may be assigned a total evaluation (even

though the schedule does not provide a 100-percent evaluation) under the
provisions of 38 CFR 4.16, 4.17, and 4.18. In view of this fact, and the
information regarding the course and outcome of IVDS after treatment, we
make no change based on this comment.

Another commenter suggested that the rule clarify the meaning of
incapacitating episodes \`\`per year\'\' in order to assure that the
calendar year is not used.

In response to this comment, we have revised diagnostic code 5293, for
the sake of clarity, to specify total duration of incapacitating
symptoms \`\`during the past 12 months\'\' rather than \`\`per year.\'\'

We proposed to define the term \`\`incapacitating episode of
intervertebral disc syndrome\'\' to mean a period of acute symptoms
(orthopedic, neurologic, or both), requiring bed rest prescribed by a
physician and treatment by a physician. Such treatment by a physician
would not require a visit to a physician\'s office or hospital but would
include telephone consultation with a physician. One commenter suggested
that we revise the definition to require bed rest \`\`prescribed by a
physician,\'\' but eliminate the requirement for treatment.

A physician prescribing bed rest will ordinarily prescribe treatment,
e.g., analgesics, muscle relaxants, or traction, as well. In our view,
the requirement for treatment by a physician makes the criteria clearer,
more objective, and more likely to promote consistent evaluations. We
therefore make no change in response to this comment. However, in order
to clarify note (1), we have added \`\`prescribed by a physician\'\'
following \`\`bed rest.\'\'

The same commenter suggested that we waive the requirement for medical
verification of the veteran\'s previous episodes of incapacitating back
pain in original claims for IVDS because in such cases there would
otherwise be a one-year waiting period from the date of claim. Although
in an original compensation claim, an award will be effective from the
date of claim or the date entitlement arose, whichever is later (38 CFR
3.400(b)(2)(i)), nothing in the regulations precludes VA from
considering medical evidence establishing the total duration of
incapacitating episodes during the twelve-month period preceding the
date of claim when evaluating the disability. Existing medical records
documenting incapacitating episodes of IVDS, as defined in the
regulation, during the twelve months before the veteran filed a claim,
would be sufficient to establish the severity of the condition without a
one-year waiting period. If there are no records of the need for bed
rest and treatment, by regulation there were no incapacitating episodes.
Chronic manifestations, on the other hand, could be evaluated based on
an examination, regardless of whether there were any prior
incapacitating episodes. We therefore make no change based on this
comment.

Another commenter objected to the proposal to evaluate IVDS based only
on doctor-ordered periods of bed rest and suggested that objective
findings of IVDS provide a basis for evaluation and should be
incorporated into the schedular criteria.

Objective findings, when present, may be used to evaluate IVDS based on
chronic orthopedic and neurologic manifestations that are rating
criteria under other diagnostic codes. However, some individuals with
disabling IVDS exhibit few, if any, objective findings between
incapacitating episodes. We have therefore provided alternative
evaluation criteria based on periods of incapacitating episodes. Since
we will evaluate IVDS under whichever method would result in the higher
overall evaluation, we make no change based on this comment.

One commenter assumed that VA will issue companion regulations on how to
rate each neurologic and orthopedic manifestation of IVDS, since chronic
symptoms are not assigned evaluations in the proposed regulation. The
commenter urged that such criteria accurately reflect impairment of
earning capacity.

VA plans no separate regulation to address each neurologic and
orthopedic manifestation of IVDS. There are existing criteria for
evaluating neurologic and orthopedic disabilities, whether they result
from IVDS, stroke, or other condition, in the neurologic and
musculoskeletal portions of the rating schedule. Additional neurologic
manifestations are addressed under diagnostic codes in the schedule for
rating genitourinary or digestive systems. For further clarity, we have
revised note (2) to indicate that the chronic orthopedic and neurologic
manifestations of IVDS are to be evaluated under the most appropriate
code or codes. Evaluating disabilities due to IVDS that are identical to
disabilities of other etiology under the same criteria will assure
consistency and fairness of evaluations.

Proposed note (2) stated that, when evaluating IVDS on the basis of
chronic manifestations, orthopedic manifestations, such as limitation of
motion of lumbar or cervical spine, paravertebral muscle spasm, or
scoliosis of the spine, are to be evaluated under diagnostic code 5293
(IVDS), using evaluation criteria for an appropriate diagnostic code,
and neurologic manifestations, such as footdrop, muscle atrophy, sensory
loss, or neurogenic bladder, are to be evaluated separately under
diagnostic code 5293, using evaluation criteria for an appropriate
diagnostic code. One commenter said the note does not provide clear or
objective guidance on the degree of disability to be assigned for these
manifestations.

There are so many potential neurologic and orthopedic manifestations of
IVDS that it would be impractical to incorporate all of them into a
single set of criteria. It is not only more practical, but also
consistent with the manner in which VA evaluates other conditions that
may affect more than one body system, to use evaluation criteria for
existing orthopedic and neurologic diagnostic codes to evaluate the
specific manifestations of IVDS. We therefore make no change based on
this comment.

The same commenter suggested additional chronic manifestations of IVDS
that the commenter believes are more objective than the proposed
criteria.

The criteria suggested by the commenter would require subjective
interpretations of terms such as \`\`light\'\' or \`\`heavy\'\' labor,
\`\`moderate\'\' activity, etc. In our view this language is less
objective than that in the proposed criteria, and we make no change
based on this comment.

One commenter asserted that proposed note (2) conflicts with Esteban v.
Brown, 6 Vet. App. 259 (1994), because it precludes an evaluation for
the orthopedic manifestations of the spine in addition to an evaluation
for IVDS under diagnostic code 5293.

In Esteban, a case that concerned the evaluation of a facial injury,
with residuals of painful scars, injury to the facial muscles, and
disfigurement, the Court of Appeals for Veterans Claims (CAVC) pointed
out that each of the three disabling effects of the injury could be
separately evaluated unless they constitute the \`same disability\'\' or
the \`\`same manifestation\'\' under 38 CFR 4.14 (see above), or unless
any of the diagnostic codes in question state that a veteran may not be
rated separately for the described conditions. None of the three
diagnostic codes at issue precluded separate ratings for the described
conditions and the CAVC stated that the critical element in the case was
that none of the symptomatology for any one of the three conditions is
duplicative of, or overlapping with, the symptomatology of the other two
conditions.

Diagnostic code 5293 allows for separate evaluations of chronic
orthopedic and chronic neurologic manifestations of IVDS because these
manifestations are separate and distinct, and do not constitute the
\`\`same disability\'\' or the \`\`same manifestation\'\' under 38 CFR
4.14. However, virtually all acute incapacitating episodes rated under
diagnostic code 5293 for IVDS would be the result of chronic orthopedic
and/or chronic neurologic findings. We therefore believe that, if
ratings for orthopedic and chronic manifestations were combined with a
rating for incapacitating episodes under diagnostic code 5293, it would
result in evaluation of the same disability under multiple diagnostic
codes, a result which is to be avoided per 38 CFR 4.14. Also providing
alternative methods for evaluating IVDS is consistent with the manner in
which we evaluate other conditions. For example, lupus erythematosus,
diagnostic code 6350, may be evaluated based either on an overall
evaluation under 6350 or on an evaluation of its residuals under other
diagnostic codes in an appropriate system or systems, whichever method
results in a higher evaluation. As a result, there is no conflict with
Esteban, and we make no change based on this comment.

One commenter stated that the rule is inconsistent with the manner in
which IVDS and orthopedic and/or neurologic manifestations were rated
under the prior version of diagnostic code 5293. According to the
commenter, prior diagnostic code 5293 allowed the maximum 60-percent
rating for disability attributable to IVDS plus a separate rating for
disability affecting other body parts or functions. In support of this
comment, the commenter cited Bierman v. Brown, 6 Vet. App. 125, 129
(1994).

Evaluations of zero to 40 percent under the previous version of
diagnostic code 5293 were based on recurring attacks and the extent of
relief between attacks. The maximum evaluation of 60 percent required
\`\`persistent symptoms compatible with sciatic neuropathy with
characteristic pain and demonstrable muscle spasm, absent ankle jerk, or
other neurological findings appropriate to site of diseased disc, little
intermittent relief.\'\' In Bierman, the Board of Veterans\' Appeals
(BVA) denied a separate rating for neurological deficits because the
veteran\'s 60 percent for IVDS under diagnostic code 5293 already
compensated him for neurological deficits and their effects for which he
was seeking a separate rating. The CAVC stated that, because the BVA
failed to articulate a satisfactory statement of reasons or bases for
its rating, the Court could not determine why this veteran\'s IVDS was
not rated separately for foot drop under DC 8521, pertaining to
paralysis of the popliteal nerve. The CAVC also stated that it was
unclear from the rating schedule itself which functional disabilities
were compensated as part of a 60-percent rating for IVDS.

Notwithstanding the commenter\'s interpretation of the prior evaluation
criteria, a memorandum issued by the BVA Chairman, Memorandum, No.
01-92-23, dated August 10, 1992, did not interpret prior diagnostic code
5293 to allow a full 60 percent in addition to a separate evaluation for
other body parts. Rather, it stated that, except for exceptional cases,
a single rating of 60 percent will ordinarily be assigned when a
veteran\'s footdrop is the result of radiculopathy attributable to IVDS.
By specifying in this rulemaking that a rating for IVDS may be based
either on the combined severity of the chronic neurological and
orthopedic findings, or on the extent of incapacitating episodes
resulting from all manifestations of the disease under diagnostic code
5293, we clarify how functional manifestations of IVDS are to be
evaluated, and we make no further changes based on this comment.

The same commenter stated that the rating criteria in the proposed rule
are not consistent with other ratings in the schedule because the design
of the proposed rule does not provide a rating that corresponds to
functional impairment.

We disagree. On the contrary, the revised rule will assure consistency
with other ratings in the schedule because the same rating criteria will
be used to evaluate identical disabilities, regardless of etiology. The
functional impairment due to footdrop or limitation of motion of the
spine, for example, will be evaluated using the same criteria, whether
due to IVDS or any other cause. If both footdrop and limitation of
motion of the spine are present, the combined evaluation will be the
same, whether due to IVDS or any other cause. These provisions are
clearly consistent with the approach and manner in which we assess
functional impairment in similar disabilities, and we make no change
based on this comment.

The same commenter stated that the rule must \`\`continue\'\' to
recognize that secondary disabilities involving separate anatomical
segments or body parts and separate functions are separately ratable and
may be rated in combination with a 60-percent rating for disc syndrome
itself.

As discussed above, the commenter\'s interpretation of the previous
evaluation criteria for IVDS is not consistent with VA\'s
interpretation. Under the new criteria, all orthopedic and neurologic
disabilities that are part of IVDS, whether affecting the spine, the
extremities, the bladder, or other areas, will be evaluated under one or
the other of the alternative methods of evaluation. However, the revised
regulation is also clear that IVDS cannot be evaluated under both sets
of criteria for a single spinal segment. If the evaluation is based on
the chronic orthopedic and neurologic manifestations, there will be no
evaluation for ncapacitating episodes. We therefore make no change based
on this comment.

We have edited the definition of incapacitating episodes for clarity and
have defined \`\`chronic manifestations\'\' to mean \`\`orthopedic and
neurologic signs and symptoms resulting from IVDS that are present
constantly, or nearly so.\'\' These are not substantive changes.

We have also simplified note (2) by editing for clarity and by removing
specific examples of chronic manifestations, which we believe are
unnecessary.

VA appreciates the comments submitted in response to the proposed rule,
which is now adopted with the amendments noted above.

For the reasons set forth in the preamble, 38 CFR part 4 is amended

as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

Subpart B\--Disability Ratings

2\. Section 4.71a is amended by revising diagnostic code 5293 and adding
an authority citation at the end of the section to read as follows:

Sec. 4.71a Schedule of ratings\--musculoskeletal system.

-   \* \* \* \*

The Spine

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Rating

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\* \* \* \* \*

5293 Intervertebral disc syndrome:

Evaluate intervertebral disc syndrome (preoperatively or
postoperatively)

either on the total duration of incapacitating episodes over the past 12
months

or by combining under Sec. 4.25 separate evaluations of its chronic

orthopedic and neurologic manifestations along with evaluations for all
other

disabilities, whichever method results in the higher evaluation.

With incapacitating episodes having a total duration of at

least six weeks during the past 12
months.........................................................................60

With incapacitating episodes having a total duration of at

least four weeks but less than six weeks during the past 12
months.......................................\...40

With incapacitating episodes having a total duration of at least two

weeks but less than four weeks during the past 12
months...............................................................................................20

With incapacitating episodes having a total duration of at least

one week but less than two weeks during the past 12
months.................................................\...10

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--.

Note (1): For purposes of evaluations under 5293, an incapacitating
episode is a period of acute signs and symptoms due to intervertebral
disc syndrome that requires bed rest prescribed by a physician and
treatment by a physician. \`\`Chronic orthopedic and neurologic
manifestations\'\' means orthopedic and neurologic signs

and symptoms resulting from intervertebral disc syndrome that are
present constantly, or nearly so.

Note (2): When evaluating on the basis of chronic manifestations,
evaluate orthopedic disabilities using evaluation criteria for the most
appropriate orthopedic diagnostic code or codes. Evaluate neurologic
disabilities separately using evaluation criteria for the most
appropriate neurologic diagnostic code or

codes.

Note (3): If intervertebral disc syndrome is present in more than one
spinal segment, provided that the effects in each spinal segment are
clearly distinct, evaluate each segment on the basis of chronic
orthopedic and neurologic manifestations or incapacitating episodes,
whichever method results in a higher evaluation for that segment.

\* \* \* \* \*

(Authority: 38 U.S.C. 1155)

REGULATORY AMENDMENT

4-03-1

Regulation affected: 38 CFR 4.87

EFFECTIVE DATE OF REGULATION: June 13, 2003

Date Secretary approved regulation: April 14, 2003

Federal Register Citation: 68 FR 25822, 25823 (May 14, 2003)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

Recently, VA has received claims for two separate evaluations for
tinnitus in the same individual, one for each side, when recurrent
tinnitus is perceived bilaterally.

This document amends 38 CFR 4.87 to explicitly state the method of
evaluation of (true) tinnitus under diagnostic code 6260 in the portion
of the rating schedule that addresses evaluation of disabilities of the
ear. The document does this through "Note (2)" under diagnostic code
6260 which reads, as follows: "Assign only a single evaluation for
recurrent tinnitus, whether the sound is perceived in one ear, both
ears, or in the head."

The intended effect of this action is to codify current standard VA
practice by stating that recurrent tinnitus will be assigned only a
single 10-percent evaluation whether it is perceived in one ear, both
ears, or somewhere in the head.

Tinnitus is classified either as subjective or "true" tinnitus or
objective tinnitus. Over 95% of tinnitus cases are true tinnitus. In
true tinnitus, the sound is audible only to the patient.

VA's Audiology and Speech Pathology Service recently wrote a booklet
titled Hearing Impairment, an Independent Study Course for health care
providers. The section on tinnitus states that the fact that most
tinnitus appears to be coming from the ear led to a belief that tinnitus
was generated in the inner ear, but that this is not the case. It states
that damage in the inner ear may be a precursor for subjective tinnitus,
but that subjective tinnitus is generated within the central auditory
pathways. It discusses current research that suggests tinnitus is
similar to phantom limb syndrome where the brain creates phantom
sensation (pain, or other sensation) to replace missing inputs from the
amputated limb; with damage to the inner ear, the brain creates phantom
sensations (true tinnitus) to replace missing inputs from the damaged
inner ear.

Unlike true tinnitus where the sound is audible only to the patient, in
the much rarer objective tinnitus (sometimes called extrinsic tinnitus
or "pseudo-tinnitus"), the sound is audible to other people. Other
people can hear the sound either simply by listening or by listening
with a stethoscope. Objective tinnitus commonly has a definite cause
that generates the sound, such as vascular or muscular disorders.
Objective tinnitus may also be due to such nonpathologic causes as noise
from the temporomandibular joints, opening of the Eustachian tubes, or
repetitive muscle contractions.

With regard to objective tinnitus, this document further amends 38 CFR
4.87 to direct raters not to evaluate objective tinnitus under
diagnostic code 6260, but to evaluate it as part of any underlying
condition causing it. The document does this through "Note (3)" under
diagnostic code 6260 which reads as follows: "Do not evaluate objective
tinnitus (in which the sound is audible to other people and has a
definable cause that may or may not be pathologic) under this diagnostic
code, but evaluate it as part of any underlying condition causing it."

Diagnostic code (s) revised: 6260

Diagnostic code (s) removed: None

Diagnostic code (s) added: None

The pertinent portion of the final rule is as follows:

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SUMMARY: This document amends the Department of Veterans Affairs (VA)
Schedule for Rating Disabilities to state more explicitly the method of
evaluation of tinnitus under diagnostic code 6260 in the portion of the
rating schedule that addresses evaluation of disabilities of the ear.
The intended effect of this action is to codify current standard VA
practice by stating that recurrent tinnitus will be assigned only a

single 10-percent evaluation whether it is perceived in one ear, both
ears, or somewhere in the head.

SUPPLEMENTARY INFORMATION: On September 19, 2002, VA published in the
Federal Register (67 FR 59033) a proposal to amend diagnostic code 6260
in 38 CFR 4.87, in order to codify current standard VA practice
concerning the evaluation of tinnitus. It states that recurrent tinnitus
will be assigned only a single ten-percent evaluation, whether it is
perceived in one ear, both ears, or somewhere in the head.

Interested persons were invited to submit written comments on or before
November 18, 2002. We received two comments, one from the American
Legion and one from a concerned individual.

One commenter felt that limiting tinnitus to a single ten-percent
evaluation is arbitrary and inconsistent with other provisions of VA\'s
Schedule for Rating Disabilities that deal with bilateral disabilities,
such as those providing separate evaluations for each ear with hearing
impairment. The same commenter felt that the proposed rule document
offered no substantive rationale for maintaining the current assignment
of a single evaluation for tinnitus, regardless of whether it is
perceived in one or both ears.

We disagree. VA\'s Audiology and Speech Pathology Service recently wrote
a booklet titled Hearing Impairment, an Independent Study Course for
health care providers. The section on tinnitus states that the fact that
most tinnitus appears to be coming from the ear led to a belief that
tinnitus was generated in the inner ear, but this is not the case. It
further states that damage in the inner ear may be a precursor for
subjective tinnitus, but that subjective tinnitus is generated within
the central auditory pathways. Comparing tinnitus, a central nervous
condition, to hearing loss, a disability from damage to an organ of
special sense (the ear) is not a valid comparison. We have made no
change in response to this comment. Because over 200,000 veterans are
currently rated for tinnitus under diagnostic code 6260 under Diseases
of the Ear, for administrative efficiency, and because many are
accustomed to looking in that section of the rating schedule, the
current placement of tinnitus within the rating schedule will remain
unchanged.

The SUPPLEMENTARY INFORMATION section of the proposed regulatory
amendment explained that tinnitus is a single disability arising in the
brain and that it consists of the perception of sound in the absence of
an external stimulus. This definition applies whether the tinnitus is
perceived in one ear, both ears, or somewhere undefined in the head. The
commenter provided no information that would refute this medical
explanation. The degree of disability, that is, the degree to which
tinnitus impairs the veteran\'s earning capacity, is the same regardless
of how the tinnitus is perceived. To rate each ear separately for this
single disability would violate the prohibition on pyramiding, 38 CFR
4.14. Similarly, to rate each ear separately would be a violation of the
principle of 38 CFR 4.25(b) that a \`\`single disease entity\'\' is to
be given a single rating. A single evaluation for a single disability is
appropriate. We have made no change based on this comment.

A second commenter suggested that we adopt measurable time and duration
standards for the term \`\`recurrent.\'\' Because a substantive change
to define the term \`\`recurrent\'\' is beyond the scope of this
rulemaking, we have made no change based on this comment.

VA appreciates the comments submitted in response to the proposed rule.
Based on the rationale stated in the proposed rule and in this document,
the proposed rule is adopted without change.

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
amended as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

Subpart B\--Disability Ratings

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

2\. In Sec. 4.87, diagnostic code 6260 is revised to read as follows:

Sec. 4.87 Schedule of ratings\--ear.

Diseases of the Ear

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Rating

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\* \* \* \* \*

6260 Tinnitus,
recurrent\...\...\...\...\...\...\...\...\...\...\..........................................................................\...10

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Note (1): A separate evaluation for tinnitus may be combined with an
evaluation under diagnostic codes 6100, 6200, 6204, or other diagnostic
code, except when tinnitus supports an evaluation under one of those
diagnostic codes.

Note (2): Assign only a single evaluation for recurrent tinnitus,
whether the sound is perceived in one ear, both ears, or in the head.

Note (3): Do not evaluate objective tinnitus (in which the sound is
audible to other people and has a definable cause that may or may not be
pathologic) under this diagnostic code, but evaluate it as part of any
underlying condition causing it.

(Authority: 38 U.S.C. 1155).

REGULATORY AMENDMENT

4-03-2

Regulation affected: 38 CFR 4.71a

EFFECTIVE DATE OF REGULATION: September 26, 2003

Date Secretary approved regulation: June 12, 2003

Federal Register Citation: 68 FR 51454 (August 27, 2003)

The purpose of the following comment on the changes included in this
amendment of VA regulations is to inform all concerned why this change
is being made. This comment is not regulatory.

This document amends 38 CFR part 4, by revising that portion of the
Musculoskeletal System in the Schedule for Rating Disabilities that
addresses disabilities of the spine, specifically 38 CFR 4.71a and new
diagnostic codes 5235 to 5243. The intended effect of this action is to
update this portion of the rating schedule to ensure that it uses
current medical terminology and unambiguous criteria, and that it
reflects medical advances that have occurred since the last review. For
more detailed information, review the preambles to the attached final
regulatory amendment as well as the notice of proposed rulemaking, which
was published in the [Federal Register]{.underline} on September 4, 2002
(67 FR 56509).

Diagnostic code (s) revised: None

Diagnostic code (s) removed: 5285, 5286, 5287, 5288, 5289, 5290, 5291,
5292, and 5293

Diagnostic code (s) added: 5235, 5236, 5237, 5238, 5239, 5240, 5241,
5242, and 5243

For the reasons set out in the preamble, 38 CFR part 4, subpart B, is

amended as set forth below:

PART 4\--SCHEDULE FOR RATING DISABILITIES

Subpart B\--Disability Ratings

1\. The authority citation for part 4 continues to read as follows:

Authority: 38 U.S.C. 1155, unless otherwise noted.

2\. In Sec. 4.71a, the table \`\`The Spine\'\' is revised and is
transferred so that it precedes the table \`\`The Hip and Thigh\'; and
Plate V is added immediately following the table \`\`The Spine\'\', to
read

as follows:

Sec. 4.71a Schedule of ratings\--musculoskeletal system.

\* \* \* \* \*

The Spine

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Rating

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General Rating Formula for Diseases and Injuries of the Spine

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the
Formula

for Rating Intervertebral Disc Syndrome Based on Incapacitating
Episodes):

With or without symptoms such as pain (whther or not it radiates),

stiffness, or aching in the area of the spine affected by residuals

of injury or disease

Unfavorable ankylosis of the entire
spine\...\...\..................................................................100

Unfavorable ankylosis of the entire thoracolumbar
spine....................................................50

Unfavorable ankylosis of the entire cervical spine;

or, forward flexion of the thoracolumbar spine 30 degrees

or less; or, favorable ankylosis of the entire thoracolumbar
spine..........................................40

Forward flexion of the cervical spine 15 degrees or less; or

favorable ankylosis of the entire cervical
spine...............................................................30

Forward flexion of the thoracolumbar spine greater than 30 degres

but not greater than 60 degrees; or, forward flexion of the

cervical spine greater than 15 degrees but not greater than

30 degrees; or, the combined range of motion of the

thoracolumbar spine not greater than 120 degrees; or, the

the combined range of motion of the cervical spine not greater

greater than 170 degrees; or, muscles spasm or guarding severe

enough to result in an abnormal gait or abnormal spinal

contour such as scoliosis, reversed lordosis, or

abnormal
kyphosis\...\...\...\...\...\...\...\...\...\...\...........................................................................20

Forward flexion of the thoracolumbar spine greater than 60 degrees

but not greater than 85 degrees; or, forward flexion of the cervical

spine greater than 30 degrees but not greater than 40 degrees; or,
combined

range of motion of the thoracolumbar spine greater than 120 degrees but

not greater than 235 degrees; or, combined range of motion of the
cervical spine

greater than 170 degrees but not greater than 335 degrees; or, muscle
spasm,

guarding, or localized tenderness not resulting in abnormal gait or

abnormal spinal contour; or, vertebral body fracture with loss

of 50 percent or more of the
height...........................................................................10

Note (1): Evaluate any associated objective neurologic abnormalities,
including, but not limited to, bowel or bladder impairment, separately,
under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal
forward flexion of the cervical spine is zero to 45 degrees, extension
is zero to 45 degrees, left and right lateral flexion are zero to 45
degrees, and left and right lateral rotation are zero to 80 degrees.
Normal forward flexion of the thoracolumbar spine is zero to 90 degrees,
extension is zero to 30 degrees, left and right lateral flexion are zero
to 30 degrees, and left and right lateral rotation are zero to 30
degrees. The combined range of motion refers to the sum of the range of
forward flexion, extension, left and right lateral flexion, and left and
right rotation. The normal combined range of motion of the cervical
spine is 340 degrees and of the thoracolumbar spine is 240 degrees.The
normal ranges of motion for each component of spinal motion provided in
this note are the maximum that can be used for calculation of the
combined range of motion.

Note (3): In exceptional cases, an examiner may state that because of
age, body habitus, neurologic disease, or other factors not the result
of disease or injury of the spine, the range of motion of the spine in a
particular individual should be considered normal for that individual,
even though it does not conform to the normal range of motion stated in
Note (2). Provided that the examiner supplies an explanation,

the examiner\'s assessment that the range of motion is normal for that
individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five
degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a
condition in which the entire cervical spine, the entire thoracolumbar
spine, or the entire spine is fixed in flexion or extension, and the
ankylosis results in one or more of the following: difficulty walking
because of a limited line of vision; restricted opening of the mouth and
chewing; breathing limited to diaphragmatic respiration;
gastrointestinal symptoms due to pressure of the costal margin on the
abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or
dislocation; or neurologic symptoms due to nerve root stretching.
Fixation of a spinal segment in neutral position (zero degrees) always
represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and
cervical spine segments, except when there is unfavorable ankylosis of
both segments, which will be rated as a single disability.

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

5242 Degenerative arthritis of the spine (see also diagnostic

code 5003)

5243 Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or
postoperatively) either under the General Rating Formula for Diseases
and Injuries of the Spine or under the Formula for Rating Intervertebral
Disc Syndrome Based on Incapacitating Episodes, whichever method results
in the higher evaluation

when all disabilities are combined under Sec. 4.25.

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating
Episodes

With incapacitating episodes having a total duration of at

least 6 weeks during the past 12
months...........................................................................\...60

With incapacitating episodes having a total duration of at

least 4 weeks but less than 6 weeks during the past 12
months....................................................40

With incapacitating episodes having a total duration of at

least 2 weeks but less than 4 weeks during the past 12
months....................................................20

With incapacitating episodes having a total duration of at

least one week but less than 2 weeks during the past 12
months................................................\...10

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