##  Section C. Rating

#### Overview

+------------+---------------------------------------------------------+
| ##### In   | > The next stage in the Chapter 18 benefit claims       |
| troduction | > process is to prepare a rating decision.              |
|            |                                                         |
|            | > This section contains information on:                 |
|            |                                                         |
|            | -   the overall rating process for Chapter 18 benefits  |
|            |                                                         |
|            | -   disability rating levels assigned to spina bifida   |
|            |     claims                                              |
|            |                                                         |
|            | -   disability rating levels assigned to other covered  |
|            |     birth defect claims, and                            |
|            |                                                         |
|            | -   preparation of a Chapter 18 benefit rating decision |
|            |     with codesheet.                                     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ---------- ----------------------------------------------- ------------
  Topic      Topic Name                                      See Page

  11         Rating Process Overview for Chapter 18 Benefits 2-C-2

  12         Disability Rating Levels Assigned to Spina      2-C-8
             Bifida Claims                                   

  13         Disability Rating Levels Assigned to Other      2-C-14
             Covered Birth Defect Claims                     

  14         Preparation of a Chapter 18 Benefits Rating     2-C-19
             Decision with Codesheet                         
  ---------- ----------------------------------------------- ------------

#### 11. Rating Process Overview for Chapter 18 Benefits

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on the rating         |
| troduction | > process, including                                    |
|            |                                                         |
|            | -   roles and responsibilities in the rating process    |
|            |                                                         |
|            | -   rating process for spina bifida                     |
|            |                                                         |
|            | -   rating process for other covered birth defects, and |
|            |                                                         |
|            | -   determining a beginning date of entitlement.        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > August 14, 2006                                       |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Veterans Service Representatives (VSRs) are           |
|  a. Roles  | > responsible for initial development and review of     |
| and Respon | > claims.                                               |
| sibilities |                                                         |
+------------+---------------------------------------------------------+

Continued on next page

11\. Rating Process Overview for Chapter 18 Benefits, Continued

+------------+---------------------------------------------------------+
| ##### b. R | > The table below describes the stages in the rating    |
| ating Proc | > process for Spina Bifida claims.                      |
| ess for Sp |                                                         |
| ina Bifida |                                                         |
+------------+---------------------------------------------------------+

+-------+--------------------+-----------------------------------------+
| Stage | Who is Responsible | Description                             |
+-------+--------------------+-----------------------------------------+
| 1     | VSR                | Confirms that elements of basic         |
|       |                    | eligibility have been met.              |
|       |                    |                                         |
|       |                    | Have elements of basic eligibility been |
|       |                    | met?                                    |
|       |                    |                                         |
|       |                    | -   If yes, VSR continues to Stage 2.   |
|       |                    |                                         |
|       |                    | -   If no, VSR                          |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   prepares an administrative denial,  |
|       |                    |     and                                 |
|       |                    |                                         |
|       |                    | -   notifies claimant of denial.        |
|       |                    |                                         |
|       |                    | ***Exception***: Rating Service         |
|       |                    | Representative (RVSR) must prepare      |
|       |                    | rating decision with codesheet if the   |
|       |                    | reason for denial is                    |
|       |                    |                                         |
|       |                    | -   spina bifida occulta (Reason 02),   |
|       |                    |     or                                  |
|       |                    |                                         |
|       |                    | -   no spina bifida condition exists    |
|       |                    |     (Reason 03).                        |
+-------+--------------------+-----------------------------------------+
| 2     | VSR                | Forwards claims folder with all medical |
|       |                    | and lay evidence to RVSR for review and |
|       |                    | preparation of rating decision.         |
|       |                    |                                         |
|       |                    | ***Important***: Claims are delivered   |
|       |                    | to RVSR for rating *only* if all other  |
|       |                    | evidence concerning eligibility has     |
|       |                    | been obtained and verified.             |
+-------+--------------------+-----------------------------------------+

Continued on next page

11\. Rating Process Overview for Chapter 18 Benefits, Continued

  -----------------------------------------------------------------------
  b\. Rating Process for Spina Bifida (continued)

  -----------------------------------------------------------------------

+-------+--------------------+-----------------------------------------+
| Stage | Who is Responsible | Description                             |
+-------+--------------------+-----------------------------------------+
| 3     | RVSR               | -   Prepares rating decision            |
|       |                    |     establishing entitlement, as        |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   Level I                             |
|       |                    |                                         |
|       |                    | -   Level II, or                        |
|       |                    |                                         |
|       |                    | -   Level III, and                      |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   determines a beginning date of      |
|       |                    |     entitlement, *or*                   |
|       |                    |                                         |
|       |                    | -   prepares rating decision denying    |
|       |                    |     entitlement, as                     |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   spina bifida occulta, or            |
|       |                    |                                         |
|       |                    | -   no spina bifida condition exists.   |
|       |                    |                                         |
|       |                    | ***Important***: RVSR must prepare a    |
|       |                    | rating decision with codesheet for      |
|       |                    | every case that is granted or that is   |
|       |                    | denied based on spina bifida occulta or |
|       |                    | no spina bifida condition exists.       |
|       |                    |                                         |
|       |                    | -   ***Reference***: For more           |
|       |                    |     information on the topics listed    |
|       |                    |     above, see                          |
|       |                    |                                         |
|       |                    | -   M21-1MR, Part VI, 2.C.11.a, and     |
|       |                    |                                         |
|       |                    | -   M21-1MR, Part VI, 2.C.13.           |
+-------+--------------------+-----------------------------------------+
| 4     | RVSR               | Sends rating decision with codesheet to |
|       |                    | VSR for input and notification to       |
|       |                    | claimant.                               |
+-------+--------------------+-----------------------------------------+

Continued on next page

11\. Rating Process Overview for Chapter 18 Benefits, Continued

+------------+---------------------------------------------------------+
| #####      | > The table below describes the stages in the rating    |
|  c. Rating | > process for other covered birth defect claims.        |
|  Process f |                                                         |
| or Other C |                                                         |
| overed Bir |                                                         |
| th Defects |                                                         |
+------------+---------------------------------------------------------+

+-------+--------------------+-----------------------------------------+
| Stage | Who is Responsible | Description                             |
+-------+--------------------+-----------------------------------------+
| 1     | VSR                | Confirms that elements of basic         |
|       |                    | eligibility have been met.              |
|       |                    |                                         |
|       |                    | Have elements of basic eligibility been |
|       |                    | met?                                    |
|       |                    |                                         |
|       |                    | -   If *yes*, VSR continues to Stage 2. |
|       |                    |                                         |
|       |                    | -   If *no*, VSR                        |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   prepares an administrative denial,  |
|       |                    |     and                                 |
|       |                    |                                         |
|       |                    | -   notifies claimant of denial.        |
+-------+--------------------+-----------------------------------------+
| 2     | VSR                | Forwards claims folder with all medical |
|       |                    | and lay evidence to RVSR for review and |
|       |                    | preparation of rating decision.         |
|       |                    |                                         |
|       |                    | > ***Important***: Claims are delivered |
|       |                    | > to RVSR for rating *only* if all      |
|       |                    | > other evidence concerning eligibility |
|       |                    | > has been obtained and verified.       |
+-------+--------------------+-----------------------------------------+

Continued on next page

11\. Rating Process Overview for Chapter 18 Benefits, Continued

  -----------------------------------------------------------------------
  c\. Rating Process for Other Covered Birth Defects (continued)

  -----------------------------------------------------------------------

+-------+--------------------+-----------------------------------------+
| Stage | Who is Responsible | Description                             |
+-------+--------------------+-----------------------------------------+
| 3     | RVSR               | -   Prepares rating decision            |
|       |                    |     establishing entitlement, as        |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   Level I                             |
|       |                    |                                         |
|       |                    | -   Level II                            |
|       |                    |                                         |
|       |                    | -   Level III,                          |
|       |                    |                                         |
|       |                    | -   Level IV, or                        |
|       |                    |                                         |
|       |                    | -   Level Zero if the individual has no |
|       |                    |     current disability resulting from   |
|       |                    |     covered birth defects, and          |
|       |                    |                                         |
|       |                    | ```{=html}                              |
|       |                    | <!-- -->                                |
|       |                    | ```                                     |
|       |                    | -   determines a beginning date of      |
|       |                    |     entitlement, or                     |
|       |                    |                                         |
|       |                    | -   prepares rating decision denying    |
|       |                    |     entitlement*.*                      |
|       |                    |                                         |
|       |                    |     ***Important***: RVSR must prepare  |
|       |                    |     a rating decision with codesheet    |
|       |                    |     for every case that is granted or   |
|       |                    |     that is denied after basic          |
|       |                    |     eligibility requirements of         |
|       |                    |     biological relationship and         |
|       |                    |     mother's qualifying Vietnam era     |
|       |                    |     service are met.                    |
|       |                    |                                         |
|       |                    | -   ***Reference***: For more           |
|       |                    |     information on the topics listed    |
|       |                    |     above, see                          |
|       |                    |                                         |
|       |                    | -   M21-1MR, Part VI, 2.C.12.a, and     |
|       |                    |                                         |
|       |                    | -   M21-1MR, Part VI, 2.C.13.           |
+-------+--------------------+-----------------------------------------+
| 4     | RVSR               | Sends rating decision with codesheet to |
|       |                    | VSR for input and notification to the   |
|       |                    | claimant.                               |
+-------+--------------------+-----------------------------------------+

Continued on next page

11\. Rating Process Overview for Chapter 18 Benefits, Continued

+------------+---------------------------------------------------------+
| ##         | > Use the table below to determine how the beginning    |
| ### d. Det | > date of entitlement is established.                   |
| ermining a |                                                         |
|  Beginning | > ***Important***: Spina bifida benefits cannot be      |
|  Date of E | > awarded prior to December 1, 1997, and for other      |
| ntitlement | > covered birth defects, the date is December 1, 2001.  |
+------------+---------------------------------------------------------+

+-----------------------+----------------------------------------------+
| If ...                | Then the effective date of award is the      |
|                       | later of the date ...                        |
+-----------------------+----------------------------------------------+
| the claim is          | -   VA received the claim, or                |
|                       |                                              |
| -   the original      | -   the entitlement arose.                   |
|     claim             |                                              |
|                       |     ***Exception***: On a claim for          |
| -   a reopened claim, |     increase, the effective date is the      |
|     or                |     earliest date of evidence supporting a   |
|                       |     higher disability level, if the claim is |
| -   a claim for       |     received within one year of such date;   |
|     increase          |     otherwise, the effective date is the     |
|                       |     date of receipt of the claim.            |
+-----------------------+----------------------------------------------+
| the claimant reopens  | -   the veteran or beneficiary applied for   |
| a previously denied   |     correction of military records           |
| claim based on        |                                              |
| corrected military    | -   the disallowed claim was filed, or       |
| records               |                                              |
|                       | -   one year before the reopened claim was   |
|                       |     received.                                |
+-----------------------+----------------------------------------------+
| If claim is received  | then the effective date for both spina       |
| within one year of    | bifida and other covered birth defects is    |
| date of birth         | the date of birth.                           |
+-----------------------+----------------------------------------------+

#### 12. Disability Rating Levels Assigned to Spina Bifida Claims

+------------+---------------------------------------------------------+
| ##### In   | > If the RVSR determines that the individual is         |
| troduction | > entitled to benefits based on spina bifida            |
|            | > disability, the RVSR assigns the highest disability   |
|            | > level based on severity of symptoms and degree of any |
|            | > permanent physical or mental disability.              |
|            |                                                         |
|            | > This topic contains information on                    |
|            |                                                         |
|            | -   spina bifida disability levels                      |
|            |                                                         |
|            | -   categories of neurological impairment               |
|            |                                                         |
|            | -   minimum disability level assignable                 |
|            |                                                         |
|            | -   exceptional cases, and                              |
|            |                                                         |
|            | -   scheduling periodic reassessment of disability      |
|            |     levels.                                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > November 1, 2004                                      |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > The table below describes the disability levels for   |
| Spina Bifi | > spina bifida ratings.                                 |
| da Disabil |                                                         |
| ity Levels |                                                         |
+------------+---------------------------------------------------------+

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| I      | The individual                                              |
|        |                                                             |
|        | -   walks without braces or other external support as       |
|        |     his/her primary means of mobility in the community      |
|        |                                                             |
|        | -   has no sensory or motor impairment of upper extremities |
|        |                                                             |
|        | -   has an IQ of 90 or higher, and                          |
|        |                                                             |
|        | -   is continent of urine and feces without the use of      |
|        |     medication or other means to control incontinence.      |
+--------+-------------------------------------------------------------+

Continued on next page

12\. Disability Rating Levels Assigned to Spina Bifida Claims, Continued

  -----------------------------------------------------------------------
  a\. Spina Bifida Disability Levels (continued)

  -----------------------------------------------------------------------

+--------+-------------------------------------------------------------+---+
| Level  | Description                                                 |   |
+--------+-------------------------------------------------------------+---+
| II     | The individual meets *any* of the criteria listed below.    |   |
|        | He/she                                                      |   |
|        |                                                             |   |
|        | -   walks with braces or other external support as his/her  |   |
|        |     primary means of mobility in the community, or          |   |
|        |                                                             |   |
|        | -   has sensory or motor impairment of upper extremities,   |   |
|        |     but is able to                                          |   |
|        |                                                             |   |
|        | ```{=html}                                                  |   |
|        | <!-- -->                                                    |   |
|        | ```                                                         |   |
|        | -   grasp a pen                                             |   |
|        |                                                             |   |
|        | -   feed self, and                                          |   |
|        |                                                             |   |
|        | -   perform self care, or                                   |   |
|        |                                                             |   |
|        | ```{=html}                                                  |   |
|        | <!-- -->                                                    |   |
|        | ```                                                         |   |
|        | -   has an IQ of at least 70 but less than 90, or           |   |
|        |                                                             |   |
|        | -   requires medication or other means to control the       |   |
|        |     effects of urinary bladder impairment and no more than  |   |
|        |     two times per week is unable to remain dry for at least |   |
|        |     three hours at a time during waking hours, or           |   |
|        |                                                             |   |
|        | -   requires bowel management techniques or other treatment |   |
|        |     to control the effects of bowel impairment but does not |   |
|        |     have fecal leakage severe or frequent enough to require |   |
|        |     wearing absorbent materials at least four days a week,  |   |
|        |     or                                                      |   |
|        |                                                             |   |
|        | -   has colostomy that does not require wearing a bag.      |   |
|        |                                                             |   |
|        | ***Note***: The RVSR assigns a disability at Level II       |   |
|        | provided that none of the disabilities is severe enough to  |   |
|        | warrant payment at Level III.                               |   |
+--------+-------------------------------------------------------------+---+

Continued on next page

12\. Disability Rating Levels Assigned to Spina Bifida Claims, Continued

  -----------------------------------------------------------------------
  a\. Spina Bifida Disability Levels (continued)

  -----------------------------------------------------------------------

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| III    | The individual meets *any* of the criteria listed below.    |
|        | He/she                                                      |
|        |                                                             |
|        | -   uses a wheelchair as his/her primary means of mobility  |
|        |     in the community, or                                    |
|        |                                                             |
|        | -   has sensory or motor impairment of the upper            |
|        |     extremities severe enough to prevent                    |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   grasping a pen                                          |
|        |                                                             |
|        | -   feeding self, and                                       |
|        |                                                             |
|        | -   performing self care, or                                |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   has an IQ of 69 or less                                 |
|        |                                                             |
|        | -   at least three times a week is unable to remain dry for |
|        |     three hours at a time during waking hours, despite the  |
|        |     use of medication or other means to control the effects |
|        |     of urinary bladder impairment, or                       |
|        |                                                             |
|        | -   has fecal leakage severe or frequent enough to require  |
|        |     wearing of absorbent materials at least four days a     |
|        |     week, despite bowel management techniques or other      |
|        |     treatment to control the effects of impairment, or      |
|        |                                                             |
|        | -   regularly requires manual evacuation or digital         |
|        |     stimulation to empty the bowel, or                      |
|        |                                                             |
|        | -   has a colostomy that requires wearing a bag.            |
+--------+-------------------------------------------------------------+

Continued on next page

12\. Disability Rating Levels Assigned to Spina Bifida Claims, Continued

+------------+---------------------------------------------------------+
| #####      | > In determining the appropriate disability level to    |
| b. Categor | > assign, the RVSR assesses the severity of each        |
| ies of Neu | > category of neurological impairment (extremities      |
| rological  | > functioning, mental functioning, and bowel-bladder    |
| Impairment | > functioning) as                                       |
|            |                                                         |
|            | -   least severe (1)                                    |
|            |                                                         |
|            | -   intermediate severity (2), or                       |
|            |                                                         |
|            | -   most severe (3).                                    |
|            |                                                         |
|            |     > The RVSR records these category values on the     |
|            |     > codesheet.                                        |
|            |                                                         |
|            |     > ***Important***: The highest level assigned for   |
|            |     > any of the categories determines the overall      |
|            |     > level of disability.                              |
|            |                                                         |
|            |     > ***Example***: If extremities and bowel-bladder   |
|            |     > functions are not impaired (each scored 1) but IQ |
|            |     > is 80 (scored as 2), then disability Level II is  |
|            |     > assigned.                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > The RVSR assigns the highest evaluation warranted by  |
| # c. Minim | > the evidence of record. The minimum disability level  |
| um Disabil | > assignable is Level I.                                |
| ity Level  |                                                         |
| Assignable | > Assign a Level I                                      |
|            |                                                         |
|            | -   if basic entitlement is granted, but there is no or |
|            |     insufficient evidence to determine the disability   |
|            |     level, and                                          |
|            |                                                         |
|            | -   unless or until one of the following is received    |
|            |     supporting a higher level:                          |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   additional medical evidence, or                     |
|            |                                                         |
|            | -   VA examination report.                              |
|            |                                                         |
|            |     > The RVSR prepares a deferred rating under code 38 |
|            |     > while the required evidence is pending. The       |
|            |     > minimum disability Level I remains in effect even |
|            |     > if the individual fails to report to VA           |
|            |     > examination.                                      |
+------------+---------------------------------------------------------+

Continued on next page

12\. Disability Rating Levels Assigned to Spina Bifida Claims, Continued

+------------+---------------------------------------------------------+
| ####       | > The RVSR assigns disability Level I for children      |
| # d. Disab | > under the age of one year unless a pediatric          |
| ility Leve | > neurologist or pediatric neurosurgeon certifies that, |
| l for Chil | > in his or her medical judgment, there is neurological |
| dren Under | > deficit that will prevent the child from              |
|  the Age o |                                                         |
| f One Year | -   ambulating                                          |
|            |                                                         |
|            | -   grasping a pen                                      |
|            |                                                         |
|            | -   self feeding                                        |
|            |                                                         |
|            | -   performing self care, or                            |
|            |                                                         |
|            | -   achieving urinary or fecal continence.              |
|            |                                                         |
|            |     > If such a deficit is present, the RVSR assigns    |
|            |     > disability Level III.                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > VA periodically reassesses the disability level of    |
| ### e. Sch | > beneficiary.                                          |
| eduling Pe |                                                         |
| riodic Rea | > Use the table below to determine course of action for |
| ssessments | > scheduling the periodic reassessments of the          |
|  of Disabi | > disability level.                                     |
| lity Level |                                                         |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| When the individual is ...       | Schedule a reassessment ...       |
+----------------------------------+-----------------------------------+
| under the age of one             | when the individual is one.       |
+----------------------------------+-----------------------------------+
| between one and twenty-one       | when medical evidence is received |
|                                  | indicating a change is warranted, |
|                                  | but at a minimum every five       |
|                                  | years.                            |
+----------------------------------+-----------------------------------+
| over the age of twenty-one       | *only* if evidence indicates      |
|                                  |                                   |
|                                  | -   a material change in          |
|                                  |     disability, or                |
|                                  |                                   |
|                                  | -   that the current rating may   |
|                                  |     be incorrect.                 |
+----------------------------------+-----------------------------------+

Continued on next page

12\. Disability Rating Levels Assigned to Spina Bifida Claims, Continued

+------------+---------------------------------------------------------+
| ##### f    | > The Director of Compensation and Pension Service may  |
| . Exceptio | > increase the monthly allowance in order to best       |
| nal Cases  | > represent the extent that the disabilities resulting  |
|            | > from spina bifida, or from treatment procedures for   |
|            | > spina bifida, limit the individual's ability to       |
|            | > engage in ordinary day-to-day activities.             |
|            |                                                         |
|            | > The Director may increase the monthly payment for an  |
|            | > individual who would otherwise be paid at Level I or  |
|            | > II, if there are one or more disabilities resulting   |
|            | > from spina bifida, or treatment for spina bifida,     |
|            | > such as                                               |
|            |                                                         |
|            | -   blindness                                           |
|            |                                                         |
|            | -   uncontrolled seizures, or                           |
|            |                                                         |
|            | -   renal failure.                                      |
|            |                                                         |
|            |     > In this case, the individual may receive a Level  |
|            |     > II or Level III payment, depending on whether the |
|            |     > effects of a disability are equal in severity to  |
|            |     > the effects specified under Level II or III.      |
+------------+---------------------------------------------------------+

#### 13. Disability Rating Levels Assigned to Other Covered Birth Defect Claims

+------------+---------------------------------------------------------+
| ##### In   | > In the process of examining medical evidence, the     |
| troduction | > RVSR determines a disability level for each case      |
|            | > qualifying for other covered birth defect benefits.   |
|            |                                                         |
|            | > This topic contains information on                    |
|            |                                                         |
|            | -   other covered birth defect disability levels        |
|            |                                                         |
|            | -   scheduling periodic reassessments of disability     |
|            |     level, and                                          |
|            |                                                         |
|            | -   exceptional cases.                                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > November 1, 2004                                      |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > The table below describes the disability levels for   |
| ## a. Othe | > other covered birth defect ratings.                   |
| r Covered  |                                                         |
| Birth Defe |                                                         |
| ct Disabil |                                                         |
| ity Levels |                                                         |
+------------+---------------------------------------------------------+

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| I      | The individual                                              |
|        |                                                             |
|        | -   has residual physical or mental effects that only       |
|        |     *occasionally* or *intermittently* limit or prevent     |
|        |     some daily activities, or                               |
|        |                                                             |
|        | -   has disfigurement or scarring of the head, face, or     |
|        |     neck with gross distortion or gross asymmetry of any    |
|        |     facial feature (nose, chin, forehead, eyes (eyelids),   |
|        |     ears (auricles), cheeks, or lips).                      |
+--------+-------------------------------------------------------------+

Continued on next page

13\. Disability Rating Levels Assigned to Other Covered Birth Defect
Claims, Continued

  -----------------------------------------------------------------------
  a\. Other Covered Birth Defect Disability Levels (continued)

  -----------------------------------------------------------------------

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| II     | The individual has residual physical or mental effects that |
|        | frequently or constantly limit or prevent some daily        |
|        | activities, but the individual                              |
|        |                                                             |
|        | -   is able to work or attend school                        |
|        |                                                             |
|        | -   can carry out most household chores                     |
|        |                                                             |
|        | -   can travel                                              |
|        |                                                             |
|        | -   provides age-appropriate self-care, and                 |
|        |                                                             |
|        | -   displays communication, behavior, social interaction,   |
|        |     and intellectual functioning appropriate for age,       |
|        |     ***or***                                                |
|        |                                                             |
|        | -   has disfigurement or scarring of the head, face, or     |
|        |     neck with either gross distortion or gross asymmetry of |
|        |     one facial feature or one paired set of facial features |
|        |     (nose, chin, forehead, eyes (eyelids), ears (auricles), |
|        |     cheeks, or lips).                                       |
+--------+-------------------------------------------------------------+

Continued on next page

13\. Disability Rating Levels Assigned to Other Covered Birth Defect
Claims, Continued

  -----------------------------------------------------------------------
  a\. Other Covered Birth Defect Disability Levels (continued)

  -----------------------------------------------------------------------

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| III    | The individual                                              |
|        |                                                             |
|        | -   has residual physical or mental effects that limit or   |
|        |     hinder most daily activities, but individual is able to |
|        |     provide age-appropriate self-care, such as              |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   eating                                                  |
|        |                                                             |
|        | -   dressing                                                |
|        |                                                             |
|        | -   grooming, and                                           |
|        |                                                             |
|        | -   carrying out personal hygiene                           |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   may be unable, or does so intermittently and with       |
|        |     difficulty, to                                          |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   attend school                                           |
|        |                                                             |
|        | -   travel, or                                              |
|        |                                                             |
|        | -   carry out household chores                              |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   displays communication, behavior, social interaction,   |
|        |     and intellectual functioning that are not entirely      |
|        |     appropriate for age, ***or***                           |
|        |                                                             |
|        | -   has disfigurement or scarring of the head, face, or     |
|        |     neck with either gross distortion or gross asymmetry of |
|        |     two facial features or two paired sets of facial        |
|        |     features (nose, chin, forehead, eyes (eyelids), ears    |
|        |     (auricles), cheeks, or lips).                           |
+--------+-------------------------------------------------------------+

Continued on next page

13\. Disability Rating Levels Assigned to Other Covered Birth Defect
Claims, Continued

  -----------------------------------------------------------------------
  a\. Other Covered Birth Defect Disability Levels (continued)

  -----------------------------------------------------------------------

+--------+-------------------------------------------------------------+
| Level  | Description                                                 |
+--------+-------------------------------------------------------------+
| IV     | The individual                                              |
|        |                                                             |
|        | -   has residual physical or mental effects that prevent    |
|        |     age-appropriate self-care, such as                      |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   eating                                                  |
|        |                                                             |
|        | -   dressing                                                |
|        |                                                             |
|        | -   grooming, and                                           |
|        |                                                             |
|        | -   carrying out personal hygiene                           |
|        |                                                             |
|        | ```{=html}                                                  |
|        | <!-- -->                                                    |
|        | ```                                                         |
|        | -   displays communication, behavior, social interaction,   |
|        |     and intellectual functioning that are grossly           |
|        |     inappropriate for age, ***or***                         |
|        |                                                             |
|        | -   has disfigurement or scarring of the head, face, or     |
|        |     neck with either gross distortion or gross asymmetry of |
|        |     three facial features or three paired sets of facial    |
|        |     features (nose, chin, forehead, eyes (eyelids), ears    |
|        |     (auricles), cheeks, or lips).                           |
+--------+-------------------------------------------------------------+

Continued on next page

13\. Disability Rating Levels Assigned to Other Covered Birth Defect
Claims, Continued

+------------+---------------------------------------------------------+
| ##         | > VA will reassess a determination whenever it receives |
| ### b. Sch | > evidence indicating that a change is warranted.       |
| eduling Pe |                                                         |
| riodic Rea |                                                         |
| ssessments |                                                         |
|  of Disabi |                                                         |
| lity Level |                                                         |
+------------+---------------------------------------------------------+

#### 14. Preparation of a Chapter 18 Benefits Rating Decision with Codesheet

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on preparing a rating |
| troduction | > decision, including                                   |
|            |                                                         |
|            | -   rating format, and                                  |
|            |                                                         |
|            | -   entries on codesheet.                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > August 14, 2006                                       |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Rating decisions for Chapter 18 benefits conform to   |
| ### a. Rat | > the general format of other rating decisions, with    |
| ing Format | > sections for                                          |
|            |                                                         |
|            | -   issue                                               |
|            |                                                         |
|            | -   evidence                                            |
|            |                                                         |
|            | -   decisions                                           |
|            |                                                         |
|            | -   facts and analysis, and                             |
|            |                                                         |
|            | -   coded conclusion.                                   |
+------------+---------------------------------------------------------+

Continued on next page

14\. Preparation of a Chapter 18 Benefits Rating Decision with
Codesheet, Continued

+------------+---------------------------------------------------------+
| ###        | > Whether granted or denied, all rating decisions       |
| ## b. Entr | > require certain entries on the codesheet.             |
| ies on Cod | >                                                       |
| esheet for | > Use the table below to determine how to annotate the  |
|  Spina Bif | > codesheet.                                            |
| ida Claims |                                                         |
+------------+---------------------------------------------------------+

+-----------------+----------------------------+-----------------------+
| If benefits are | Then state the coded       | Example               |
| ...             | conclusion as ...          |                       |
+-----------------+----------------------------+-----------------------+
| granted         | "Spina bifida benefits"    | Spina bifida benefits |
|                 | followed by                | Level II (extrm 1,    |
|                 |                            | control 1, intel 2)   |
|                 | -   disability level (I,   | from 10-01-01         |
|                 |     II, or III)            |                       |
|                 |                            |                       |
|                 | -   a parenthetical        |                       |
|                 |     evaluation for each of |                       |
|                 |     the three categories   |                       |
|                 |     of neurological        |                       |
|                 |     impairment (1, 2, or   |                       |
|                 |     3), and                |                       |
|                 |                            |                       |
|                 | -   the effective date.    |                       |
|                 |                            |                       |
|                 | ***Notes***:               |                       |
|                 |                            |                       |
|                 | -   When a minimum         |                       |
|                 |     evaluation is assigned |                       |
|                 |     because of             |                       |
|                 |     insufficient medical   |                       |
|                 |     evidence, the coded    |                       |
|                 |     conclusion is as       |                       |
|                 |     follows: Level I       |                       |
|                 |     (minimum) from         |                       |
|                 |     10-01-01.              |                       |
|                 |                            |                       |
|                 | -   If additional          |                       |
|                 |     development is         |                       |
|                 |     conducted for medical  |                       |
|                 |     evidence, reflect the  |                       |
|                 |     deferred rating as a   |                       |
|                 |     code 38 on the         |                       |
|                 |     codesheet.             |                       |
+-----------------+----------------------------+-----------------------+

Continued on next page

14\. Preparation of a Chapter 18 Benefits Rating Decision with
Codesheet, Continued

  -----------------------------------------------------------------------
  b\. Entries on Codesheet for Spina Bifida Claims (continued)

  -----------------------------------------------------------------------

+-----------------+----------------------------+-----------------------+
| If benefits are | Then state the coded       | Example               |
| ...             | conclusion as ...          |                       |
+-----------------+----------------------------+-----------------------+
| denied          | "Spina bifida benefits     | Spina bifida benefits |
|                 | denied" followed on the    | denied                |
|                 | next line by               |                       |
|                 |                            | 02-Diagnosis of spina |
|                 | -   "02-Diagnosis of spina | bifida occulta        |
|                 |     bifida occulta," or    |                       |
|                 |                            |                       |
|                 | -   "03- No spina bifida   |                       |
|                 |     condition."            |                       |
+-----------------+----------------------------+-----------------------+

+-----------------------------------------------------------------------+
| > ***Note***: Rating and codesheets are not prepared for claims that  |
| > have been denied for the following reasons:                         |
|                                                                       |
| -   the individual was conceived before specific Korean or Vietnam    |
|     service                                                           |
|                                                                       |
| -   the individual failed to furnish requested evidence               |
|                                                                       |
| -   the parent(s) were not Vietnam veteran(s) or veterans with        |
|     specific Korean service                                           |
|                                                                       |
| -   the individual is not a natural child of the veteran.             |
|                                                                       |
| > ***References***: For more information on                           |
|                                                                       |
| -   Vietnam service requirements, see M21-1MR, Part VI, 2.B.5         |
|                                                                       |
| -   the specific Korean service requirements, see M21-1MR, Part VI,   |
|     2.B.6, and                                                        |
|                                                                       |
| -   administrative decisions see M21-1MR, Part III, Subpart v, 1.     |
+-----------------------------------------------------------------------+

Continued on next page

14\. Preparation of a Chapter 18 Benefits Rating Decision with
Codesheet, Continued

+------------+---------------------------------------------------------+
| ##### c    | > Whether granted or denied, all rating decisions       |
| . Entries  | > require certain entries on the codesheet. Follow the  |
| on Codeshe | > instructions below to determine how to annotate the   |
| et for Oth | > codesheet.                                            |
| er Covered |                                                         |
|  Birth Def |                                                         |
| ect Claims |                                                         |
+------------+---------------------------------------------------------+

+---------+------------------------------------------------------------+
| **Gr    | State: Chapter 18 benefits are granted for \[insert name   |
| anted** | of defect\] at level \[insert level 0, 1, 2, 3 or 4\]      |
|         | effective \[insert date\].                                 |
|         |                                                            |
|         | If benefits are granted at level 0, state: No current      |
|         | disability exists, entitlement for treatment purposes and  |
|         | vocational training only.                                  |
|         |                                                            |
|         | Example 1) Chapter 18 benefits are granted for cleft lip   |
|         | at level I effective 12-01-2001.                           |
|         |                                                            |
|         | Example 2) Chapter 18 benefits are granted for Poland      |
|         | syndrome at level II effective 01-01-2002.                 |
+---------+------------------------------------------------------------+
| **De    | State: Chapter 18 benefits are denied for \[insert name of |
| nials** | claimed condition\]. Then, list the reason:                |
|         |                                                            |
|         | -   No qualifying birth defect exists                      |
|         |                                                            |
|         | -   Disability due to familial disorder                    |
|         |                                                            |
|         | -   Disability resulted from birth-related injury          |
|         |                                                            |
|         | -   Disability is the result of a fetal or neo-natal       |
|         |     infirmity with well-established causes                 |
|         |                                                            |
|         | -   Disability not a permanent physical or mental          |
|         |     disability                                             |
|         |                                                            |
|         | -   Disability due to congenital malignant neoplasm        |
|         |                                                            |
|         | -   Disability due to chromosomal disorder, and            |
|         |                                                            |
|         | -   Disability due to developmental disorder.              |
+---------+------------------------------------------------------------+

Continued on next page

14\. Preparation of a Chapter 18 Benefits Rating Decision with
Codesheet, Continued

+------------+---------------------------------------------------------+
| c\.        | > ***Note***: Rating and codesheets are not prepared    |
| Entries on | > for claims that have been denied for the following    |
| Codesheet  | > reasons:                                              |
| for Other  |                                                         |
| Covered    | -   the individual was conceived before the             |
| Birth      |     veteran-parent first served in the Republic of      |
| Defect     |     Vietnam during the Vietnam era M21-1MR, Part VI,    |
| Claims     |     2.B.5                                               |
| (          |                                                         |
| continued) | -   the individual failed to furnish requested evidence |
|            |                                                         |
|            | -   the biological mother was not a Vietnam veteran     |
|            |                                                         |
|            | -   veteran parent is not female                        |
|            |                                                         |
|            | -   child deceased prior to 12-01-2001, and             |
|            |                                                         |
|            | > the individual is not a natural child of the veteran. |
+------------+---------------------------------------------------------+