Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65207

(e) Content and Manner of ISM Code

Notice. (1) ISM Code notice includes the

following:

(i) the date of issuance for the

company’s Document of Compliance

certificate that covers the vessel,

(ii) the date of issuance for the

vessel’s Safety Management Certificate,

and,

(iii) the name of the Flag

Administration, or the recognized

organization(s) representing the vessel

flag administration, that issued those

certificates.

(2) If you meet the criteria in

paragraph (d) of this section, you must

give the ISM Code notice to the Coast

Guard Captain of the Port of the port or

place of your destination in the U.S. at

least 24 hours before you enter the port

or place of destination. The ISM Code

notice may be combined and provided

with the report required by paragraph

(a) of this section.

Dated: December 5, 1997.

R.C. North,

Rear Admiral, U.S. Coast Guard, Assistant

Commandant for Marine Safety and

Environmental Protection.

[FR Doc. 97–32447 Filed 12–10–97; 8:45 am]

BILLING CODE 4910–14–P

DEPARTMENT OF VETERANS

AFFAIRS

38 CFR Part 4

RIN 2900–AE40

Schedule for Rating Disabilities; The

Cardiovascular System

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 addressing the

cardiovascular system. The effect of this

action is to update the cardiovascular

system 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.

EFFECTIVE DATE: This amendment is

effective January 12, 1998.

FOR FURTHER INFORMATION CONTACT:

Caroll McBrine, M.D., Consultant,

Regulations Staff (213A), Compensation

and Pension Service, Veterans Benefits

Administration, Department of Veterans

Affairs, 810 Vermont Avenue NW,

Washington, DC 20420, (202) 273–7230.

SUPPLEMENTARY INFORMATION: As part of

a comprehensive review of the rating

schedule, VA published, in the Federal

Register of January 19, 1993 (58 FR

4954–60), a proposal to amend 38 CFR

4.100, 4.101, 4.102, and 4.104.

Interested persons were invited to

submit written comments, suggestions,

or objections on or before March 22,

1993. We received comments from the

Disabled American Veterans, the

Veterans of Foreign Wars, the Paralyzed

Veterans of America, the American

Legion, and several VA employees.

One commenter, stating that the

primary objective of the review is to

update the medical terminology and

criteria used to evaluate disabilities

rather than to amend the percentage

evaluations, contended, without being

specific, that a substantial number of the

proposed changes go beyond the stated

purpose and expressed general

opposition to any changes that are

inconsistent with the stated objective.

The commenter also stated that the

proposed criteria retain, and in some

cases expand upon, the vague,

indefinite, and arbitrary elements

previously found in the schedule and

felt that substantial revision of the

proposed rules is required.

The purpose of the review was to

update the cardiovascular system

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. The

proposed revisions published January

19, 1993, were intended to update the

medical terminology; revise the criteria,

including the length of convalescence

evaluations, based on medical advances;

and make criteria more objective, i.e.,

less ambiguous and, thereby, assure

more consistent ratings. These proposed

changes were consistent with the stated

purposes of the revision. However, since

establishing less ambiguous criteria to

assure consistent evaluations is one of

the purposes of this revision, and a

number of commenters stated that the

proposed criteria contained language

that is too subjective to provide effective

guidance in evaluating cardiovascular

disabilities, we have further revised the

proposed evaluation criteria to

eliminate indefinite terminology and

establish more objective and

quantifiable criteria wherever possible.

These changes will be discussed in

detail under the individual codes

affected.

One commenter suggested that the

proposed criteria will discriminate

against veterans of Desert Storm and

future veterans because their conditions

will be evaluated under criteria that he

perceived as less generous than those in

the prior rating schedule.

Significant medical advances,

including new surgical and anesthetic

techniques, new medications, and

earlier diagnoses, have occurred, which

we must take into account in revising

the rating schedule. Doing so is, in fact,

one of the primary reasons for

conducting this review. Since recently

discharged veterans clearly benefit from

the application of these new techniques,

in our judgment they are not

discriminated against by having their

disabilities evaluated under criteria

which reflect the effects of these same

medical advances.

One commenter objected that the

rating schedule fails to take into

consideration the disabling effects of the

veteran’s shortened life expectancy.

To consider a factor so far removed

from ‘‘the average impairments of

earning capacity’’ as the effect of various

conditions on life expectancy would

clearly exceed the parameters

established by Congress in 38 U.S.C.

1155.

One commenter, citing a statistical

economic validation study from the

1960s, implied that statistical studies

may justify increased disability

evaluations.

The statute (38 U.S.C. 1155)

authorizing establishment of the rating

schedule directs that ‘‘[t]he Secretary

shall from time to time readjust the

schedule of ratings in accordance with

experience’’ (emphasis supplied).

Rather than requiring statistical studies

or any other specific type of data, the

statute clearly leaves the nature of the

experience which warrants an

adjustment, and by extension the

manner in which any review is

conducted, to the discretion of the

Secretary. Although during the 1970s

VA considered adjusting the rating

schedule based on the same statistical

studies cited by the commenter, that

approach proved to be unsatisfactory,

and the proposed changes based on that

study were not adopted.

One commenter agreed that

ambiguous words such as ‘‘severe’’

should be deleted, but cautioned against

making the evaluation criteria too

objective.

Providing clear and objective criteria

is the best way to assure that disabilities

will be evaluated fairly and

consistently. Judgment and flexibility

cannot be eliminated from the

evaluation process, however, because

patients do not commonly present as

textbook models of disease, and rating

agencies have the task of assessing

which evaluation level best represents

the overall disability picture. (See § 4.7.)

The previous schedule provided

convalescence evaluations for six
65208 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

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 proposed to

change the duration of convalescence

evaluations for DC 7000, DC 7005, and

DC 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 7016, DC 7110, DC 7011

(now ventricular arrhythmias), DC 7111

(aneurysm of any large artery), and DC

7123. We also proposed an indefinite

period of convalescence evaluation, but

with an examination at one year, for

cardiac transplantation (DC 7019).

One commenter stated that VA should

justify the proposed changes in periods

of convalescence evaluation by citing

medical experts or texts.

A report from Jefferson Medical

College that included a clinical review

of the cardiovascular portion of the

rating schedule and recommendations

for changes was available to us when we

undertook the revision of this body

system. In addition, we received advice

from the Veterans Health

Administration and consulted standard

medical texts such as ‘‘Cecil Textbook of

Medicine’’ (James B. Wyngaarden, M.D.

et al. eds., 19th ed. 1992), ‘‘Heart

Disease’’ (Eugene Braunwald, M.D. ed.,

4th ed. 1992), and ‘‘The Heart’’ (J. Willis

Hurst, M.D. et al. eds., 7th ed. 1990). We

published the proposed revision only

after reviewing all of these sources of

information. We have provided specific

citations supporting many of the

changes in the length of convalescence

evaluations later in this document

under the discussions of convalescence

evaluation periods that have been

changed.

One commenter stated that the

proposed periods of convalescence

evaluation do not represent the average

impairment, but only the optimal

recovery times. This commenter also

stated that the changes in the duration

of convalescence evaluations do not

take into account advanced age, poor

state of health, or the presence of

etiologically related or concomitant

disease.

The periods of convalescence

evaluation we have established reflect,

according to the sources noted above,

the average periods of recovery needed

by the average person following certain

procedures and illnesses. These periods

can be extended, when medically

warranted, under the authority of 38

CFR 4.29 and 4.30.

One commenter said that the

proposed changes in the length of

convalescence evaluations appear to

have been developed from a purely

economic perspective.

As previously discussed, revisions to

periods of convalescence evaluations

were based on medical considerations

rather than cost projections.

One of the commenters suggested that

where the length of convalescence

evaluations has been reduced to two,

three, or six months, all claims should

be referred to the Adjudication Officer

for a possible extension of the

convalescence rating under 38 CFR

4.30(b)(2).

The rating agency itself has the

authority to extend the period of

convalescence evaluations for up to

three months under the provisions of

§ 4.30; the approval of the Adjudication

Officer is required only when extending

a convalescence evaluation for a longer

period. Referring claims to the

Adjudication Officer when the medical

evidence does not warrant any

extension, or when the rating agency

can extend the evaluation for a

sufficient period on its own authority,

would cause needless delay, and we

have made no change based on this

suggestion.

Several commenters objected to

indefinite periods of convalescence

evaluation with a mandatory VA

examination at a prescribed time. In our

judgment, however, this method of

determining the length of the total

evaluation is both fairer and more

accurate than assigning a total

evaluation for a specified length of time,

since the evaluation will be based on

actual residual disability as documented

by the examination, and the veteran will

receive advance notice of any change

and have the opportunity to submit

additional evidence showing that the

change is not warranted.

One set of comments reflected the

view that applying § 3.105(e) to

indefinite periods of convalescence

evaluations will cause significant

administrative problems and, in some

instances, significantly lengthen the

period for which a convalescence

evaluation is assigned. These concerns

appear to be based on the assumption

that if medical information justifying a

certain period of convalescence

evaluation is not submitted until

months or even years after the event, the

condition must be evaluated as totally

disabling from the date entitlement is

established, through the entire

intervening period, and until such time

as an examination can be performed,

advance notice be provided, and the

effective date provisions of § 3.105(e) be

observed.

Section 3.105(e) applies only to

reductions in ‘‘compensation payments

currently being made;’’ it does not apply

in cases where a total evaluation is both

assigned and reduced retroactively. We

have established convalescence

evaluations for indefinite periods under

other portions of the rating schedule

(See DC 7528, malignant neoplasms of

the genitourinary system, in 38 CFR

4.115b and DC 7627, malignant

neoplasms of gynecological system or

breast, in 38 CFR 4.116), some having

been in effect for over two years, and

there is no evidence that they cause the

type of administrative problems that the

commenters foresee.

There were three introductory

sections to the cardiovascular system in

the previous rating schedule. Section

4.100, Necessity for complete diagnosis,

named common types of heart disease

and discussed the need for accurate

diagnosis. Section 4.101, Rheumatic

heart disease, discussed the course of

rheumatic heart disease, the significance

of a diagnosis of mitral insufficiency,

possible etiologies for later developing

aortic insufficiency, and the need for

accurate diagnosis of a serviceconnected condition. Section 4.102,

Varicose veins and phlebitis, discussed

the need to determine impairment of

deep circulation due to varicosities and

included a requirement to assign a

higher evaluation when there is

phlebitis or deep impairment of

circulation. We proposed to retitle the

introductory sections: 4.100, as ‘‘Forms

of heart disorder;’’ 4.101, as

‘‘Hypertension;’’ and 4.102, as ‘‘Varicose

veins.’’ We proposed to include in

§ 4.100 a list of common forms of heart

abnormalities, a discussion of how to

evaluate service-connected valvular

heart disease or arrhythmia in the

presence of nonservice-connected

arteriosclerotic heart disease, and a

statement that the identification of

coronary artery disease (without

occlusion or thrombosis) early in service

is not a basis for service connection, but

that any sudden development of

coronary occlusion or thrombosis

during service would be serviceconnected. However, as explained

below, we have either deleted or

relocated all of the material we had

proposed to include in §§ 4.100, 4.101,
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65209

and 4.102, and we have, therefore,

removed those sections and reserved

them for future use.

One commenter suggested that we

remove all material in §§ 4.100, 4.101,

and 4.102 that refer to the issue of

service connection because it is

inappropriate to place criteria for

determining entitlement to service

connection in the rating schedule. A

second commenter suggested that the

material about the identification of

coronary artery disease early in service

not being a basis for service connection

should be removed because the

provision violates the statutory

presumption of soundness at induction

as set forth in 38 U.S.C. 1111.

The rules governing determinations of

service connection are found in the

regulations beginning at 38 CFR 3.303,

rather than in the rating schedule,

which is a guide to evaluating

disabilities. We agree that rules affecting

determinations of service connection are

inappropriate in the rating schedule,

and we have removed that portion of the

material in § 4.100 that addressed the

issue of service connection for coronary

artery disease for that reason. We have

also removed other provisions of

§§ 4.101 and 4.102 that addressed

service connection for cardiovascular

conditions, as discussed below.

We had proposed including in

§ 4.102, varicose veins, a provision from

VA’s Adjudication Procedures Manual,

M21–1, Part VI, that if varicose veins

developed during active service in one

leg, varicose veins developing in the

other leg within three years, in the

absence of an intercurrent cause, will

also be service-connected. However, in

response to this comment, we have

determined that since it addresses the

issue of service connection, it is not

appropriate in the rating schedule, and

we have removed it.

Two commenters suggested that these

introductory sections specify which

cardiovascular diseases should be

service-connected when they develop

subsequent to certain amputations.

38 CFR 3.310(b) provides that

‘‘ischemic heart disease or other

cardiovascular diseases’’ developing in

veterans who have suffered a serviceconnected amputation of one lower

extremity at or above the knee, or

service-connected amputations of both

lower extremities at or above the ankles,

shall be held to be the result of the

service-connected amputation or

amputations. Since that issue is

addressed elsewhere in VA’s

regulations, it is unnecessary to address

it here. Furthermore, as previously

discussed, it would be inappropriate to

include material about the

determination of service connection in

the rating schedule.

One commenter recommended that

we include more discussion of pertinent

clinical and nonclinical factors to be

considered in assigning evaluations

within this portion of the rating

schedule.

We have made a number of changes

along these lines that will assist in the

evaluation of cardiovascular conditions.

Most significantly, we have adopted

more objective evaluation criteria based

on specific clinical (and, in some cases,

laboratory) findings, e.g., by using the

level of METs (metabolic equivalents,

discussed in detail below) to assess the

severity of heart disease. In addition, we

have retained or added notes, as

appropriate, containing clinical

information, e.g., by adding a note

defining characteristic attacks of

Raynaud’s syndrome.

One commenter suggested that § 4.100

discuss forms of heart disorder, § 4.101

discuss hypertension, and § 4.102

discuss varicose veins.

A regulation is an agency statement of

general applicability and future effect,

which the agency intends to have the

force and effect of law, that is designed

to implement, interpret, or prescribe law

or policy, or to describe the procedure

or practice requirements of an agency

(Executive Order 12866, Regulatory

Planning and Review). Background

material, such as general medical

information that is available in standard

textbooks, or other material that neither

prescribes VA policy nor establishes

procedures a rating activity must follow,

falls outside of those parameters and is,

therefore, not appropriate in a

regulation. The material about the age of

onset, course, etc., of rheumatic fever in

former § 4.101 is general medical

information which has no bearing on

evaluating the condition, and we have

deleted this material as not appropriate

in a regulation. Upon further review, we

have deleted the list of heart

abnormalities from proposed § 4.100

because it too is general medical

information that we do not intend to

have the force and effect of law.

We proposed to retitle § 4.101

‘‘Hypertension,’’ and to revise the

content to include a prohibition against

separately evaluating hypertension that

is secondary to thyroid or renal disease;

and a requirement that, in a veteran

with service-connected hypertension,

arteriosclerotic manifestations are to be

service-connected. One commenter

suggested adding more information to

§ 4.101 about secondary hypertension,

to include specifying when secondary

hypertension can be evaluated

separately from the condition causing it.

The rule regarding evaluation of

hypertension secondary to renal disease

is included in the part of the rating

schedule addressing the genitourinary

system at § 4.115; secondary

hypertension associated with aortic

insufficiency or thyroid disease, and

isolated systolic hypertension, which

may be secondary to arteriosclerosis, are

addressed under DC 7101 (hypertensive

vascular disease). Since the issue of

service connection of secondary

hypertension is addressed in more

appropriate areas of the regulations, it

should not be addressed here, and

rather than expanding this material, we

have deleted it from § 4.101.

The material in proposed § 4.101

about conditions that are complications

of hypertension or other medical

conditions is also general medical

information available in standard texts.

As discussed above, it is not appropriate

in a regulation, and we have, therefore,

removed it. The issue of service

connection for conditions that are

proximately due to or the result of a

service-connected condition is

addressed at 38 CFR 3.310(a). It is,

therefore, unnecessary to address the

issue in § 4.101, and we have removed

that material also.

In the former schedule, § 4.102, which

was titled ‘‘Varicose veins and

phlebitis,’’ discussed the necessity of

testing for impairment of deep

circulation in varicose veins. We

proposed to retitle it ‘‘Varicose veins’’

but to retain the material about deep

circulation. Under the revised

evaluation criteria for varicose veins

adopted in this rule, however,

determining whether the deep

circulation is impaired is unnecessary

because the evaluation criteria focus on

functional impairment rather than the

location of the venous insufficiency. We

have, therefore, deleted that material

from § 4.102.

Another commenter requested that we

address in § 4.101 the advances in

medical science or objective foundation

for requiring that adjudicators attempt

to apportion cardiac signs and

symptoms that are attributable to

nonservice-connected arteriosclerotic

heart disease that is superimposed on

service-connected rheumatic heart

disease.

While it is often possible through

modern technology to determine the

separate effects of coexisting heart

diseases, such a determination requires

a medical assessment on a case-by-case

basis and cannot be determined by

regulation. We have, therefore, revised

the material to require that the rating

agency request a medical opinion when

it is necessary to determine whether
65210 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

current signs and symptoms can be

attributed to one of the coexisting

conditions. Since the material is not

relevant to the entire cardiovascular

portion of the rating schedule, we have

moved it to a note under DC 7005,

arteriosclerotic heart disease.

One commenter suggested adding a

section to explain which diagnostic

codes should not be combined in the

case of coexisting cardiovascular

diseases.

As in the case of coexisting heart

diseases, determining whether

coexisting cardiovascular diseases have

functional impairments that can be

separately evaluated must be

determined on a case-by-case basis,

depending on the particular

manifestations of each condition. We,

therefore, make no change based on this

suggestion.

One commenter recommended that

we include cor pulmonale in the

cardiovascular portion of the schedule.

Cor pulmonale is a combination of

hypertrophy and dilatation of the right

ventricle secondary to pulmonary

hypertension, which is due to disease of

the lung parenchyma or pulmonary

vascular system (Braunwald, 1581).

Since cor pulmonale is always

secondary to a lung condition, and since

it is included in the evaluation criteria

for various conditions of the respiratory

system, in our judgment it is not

appropriate to include it in the

cardiovascular portion of the rating

schedule. For the sake of clarity,

however, we have placed a note in

§ 4.104 before DC 7000 instructing

rating agencies to evaluate cor

pulmonale as part of the pulmonary

condition that causes it.

The previous rating schedule

provided a 100-percent evaluation for

rheumatic heart disease (DC 7000) ‘‘as

active disease and, with ascertainable

cardiac manifestation, for a period of six

months.’’ We proposed to retitle DC

7000 ‘‘valvular heart disease,’’ and to

provide a 100-percent evaluation for

‘‘active infections with valvular heart

damage for three months following

cessation of therapy.’’

Three commenters objected to the

proposed change in the length of the

convalescence evaluation for DC 7000

(valvular heart disease).

Rheumatic fever is the condition most

commonly associated with valvular

heart damage, and its acute phase rarely

lasts longer than three months

(Braunwald, 1729). The level of activity

following this period depends on the

severity of residual disease (Cecil,

1637). While in the past patients with

acute rheumatic fever were put to bed

for several months, bed rest is no longer

considered necessary unless there is

significant carditis (Hurst, 1527). In

addition, most rebounds of rheumatic

fever (that is, reappearances of clinical

or laboratory evidence of acute

rheumatic fever following cessation of

treatment) occur within two weeks after

cessation of therapy, and do not occur

more than five weeks after complete

cessation of anti-rheumatic therapy

(Braunwald, 1730). In our judgment,

three months following cessation of

therapy is a reasonable period to allow

for stabilization of valvular damage due

to infection, and we have retained the

convalescence provision as proposed,

except for minor editorial changes.

We proposed that valvular heart

disease (DC 7000) be evaluated on the

basis of the level of physical activity,

i.e., ‘‘any,’’, ‘‘ordinary,’’ or ‘‘strenuous,’’

required to produce cardiac symptoms,

such as ‘‘dyspnea,’’ ‘‘fatigue,’’ etc. We

received three comments objecting to

the proposed criteria.

One commenter suggested that

although the proposed general rating

formula for rheumatic heart disease (DC

7000), arteriosclerotic heart disease (DC

7005), and ventricular arrhythmia (DC

7011) is consistent with the

classifications of the New York Heart

Association, they are mostly for

subjective complaints, and the

commenter suggested that the current

criteria be retained except for deleting

words like ‘‘characteristic’’ and

‘‘definitely.’’ Another commenter stated

that the proposed criteria for valvular

heart disease are highly subjective and

urged that we adopt objectively

confirmable criteria at every level.

We agree that more objective criteria

would result in more consistent

evaluations. In our judgment, however,

simply removing such terms as

‘‘characteristic’’ and ‘‘definitely’’ from

the criteria in the previous schedule

would not have the intended effect. We

have, therefore, revised the criteria to

incorporate objective measurements of

the level of physical activity, expressed

in METs (metabolic equivalents), at

which cardiac symptoms develop. This

does not represent a substantive change

in the method of evaluating cardiac

disabilities that we proposed, i.e.,

basing evaluations on the level of

physical activity that causes symptoms,

but is an objective method for

measuring the level of activity that

causes symptoms.

The exercise capacity of skeletal

muscle depends on the ability of the

cardiovascular system to deliver oxygen

to the muscle, and measuring exercise

capacity can, therefore, also measure

cardiovascular function. The most

accurate measure of exercise capacity is

the maximal oxygen uptake, which is

the amount of oxygen, in liters per

minute, transported from the lungs and

used by skeletal muscle at peak effort

(Braunwald, 1382). Because

measurement of the maximal oxygen

uptake is impractical, multiples of

resting oxygen consumption (or METs)

are used to calculate the energy cost of

physical activity. 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 and standardizing the

reporting of exercise workloads when

different exercise protocols are used

(Braunwald, 162).

We have revised the evaluation

criteria for the major types of heart

disease based on: the level of physical

activity, expressed in METs, that leads

to cardiac symptoms; whether there is

heart failure; the extent of any left

ventricular dysfunction; the presence of

cardiac hypertrophy or dilatation; and

the need for continuous medication. We

had proposed that valvular heart disease

(DC 7000) be evaluated on the basis of

the level of physical activity that

produces symptoms—100 percent if

‘‘any,’’ 60 percent if ‘‘ordinary,’’ and 30

percent if ‘‘strenuous’’ activity produces

symptoms. We have revised those

criteria to assign a 100-percent

evaluation 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. We have revised

the criteria to assign a 60-percent

evaluation 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. We have revised the

criteria to assign a 30-percent evaluation

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 (Fox, S. M. III,

Naughton, J.P., Haskell, W.L.: Physical

activity and the prevention of coronary

heart disease. Ann. Clin. Res., 3:404,

1971 and Goldman, L. et al.:

Comparative reproducibility and

validity of systems for assessing

cardiovascular functional class:

Advantages of a new specific activity
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65211

scale. Circulation 64:1227, 1981). 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 (Cecil, 175 and

Harrison, 966).

Administering a treadmill exercise

test may not be feasible in some

instances, however, because of a

medical contraindication, such as

unstable angina with pain at rest,

advanced atrioventricular block, or

uncontrolled hypertension. We have,

therefore, provided objective alternative

evaluation criteria, such as cardiac

hypertrophy or dilatation, decreased left

ventricular ejection fraction, and

congestive heart failure, for use in those

cases. We have also indicated 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.

The other objective criteria that we

have added as alternatives to the METsbased criteria for valvular heart disease

are a left ventricular ejection fraction of

less than 30 percent or chronic

congestive heart failure for a 100-

percent evaluation; a left ventricular

ejection fraction of 30 to 50 percent, or

more than one episode of acute

congestive heart failure in the past year

for a 60-percent evaluation; evidence of

cardiac hypertrophy or dilatation on

electrocardiogram, echocardiogram, or

X-ray for a 30-percent evaluation, and a

requirement for continuous medication

for a 10-percent evaluation.

Since neurologic, gastrointestinal, and

other cardiovascular disorders may

result in symptoms similar to those for

valvular heart disease, we have also

added a requirement that valvular heart

disease be documented by findings on

physical examination and by

echocardiogram, Doppler

echocardiogram, or cardiac

catheterization.

Another commenter felt that the

proposed criteria for the 100-percent

level for valvular heart disease (DC

7000), arteriosclerotic heart disease (DC

7005), and ventricular arrhythmias (DC

7011)—that ‘‘any’’ physical activity

results in specified cardiac symptoms—

correlates not with total industrial

impairment but with being housebound

or helpless. Similarly, the commenter

objected that the requirement for the 60-

percent level—that ‘‘ordinary’’ physical

activity results in symptoms—actually

represents total impairment.

The proposed criteria for the 100-

percent level of these conditions were

meant to indicate a severe level of

impairment, but the language was

imprecise and perhaps suggested a

degree of impairment beyond total

impairment. Under the more objective

criteria that we are adopting here, a 100-

percent evaluation requires that a

workload of three METs or less

produces dyspnea, fatigue, angina,

dizziness, or syncope. A workload of

three METs includes such activities as

level walking, driving, and very light

calisthenics. While the development of

cardiac symptoms at this level of

activities indicates total impairment, it

does not suggest that the patient is

either housebound or helpless.

Similarly, under the more objective

criteria, a 60-percent evaluation requires

that a workload of greater than three

METs but not greater than five METs

produces cardiac symptoms. Since

activities that fall into this range include

walking two and a half miles per hour,

social dancing, and light carpentry, this

range does not represent total

impairment. In our judgment, by

adopting more objective criteria, we

have eliminated the problem that the

commenter identified.

The prior schedule assigned a 10-

percent evaluation under DC 7000

(rheumatic heart disease, now

designated as valvular heart disease),

when there was an identifiable valvular

lesion, with little dyspnea and no

cardiomegaly. We proposed to delete

the 10-percent level and to evaluate the

condition as zero percent disabling if it

does not limit physical activity.

Two commenters objected to the

proposed deletion of a 10-percent level

of evaluation for valvular heart disease.

One suggested a 10-percent evaluation

when dietary adjustments and

medication are necessary to control

symptoms or prevent emboli; the other

suggested a 10-percent evaluation for

asymptomatic valvular heart disease or

arrhythmias that require medication.

Upon further consideration, we have

added a 10-percent evaluation, which

will be assigned when 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. We have also

established an alternative criterion for a

10-percent evaluation—the need for

continuous medication—consistent with

the 10-percent evaluations assigned

under other body systems, e.g.,

gynecological and endocrine conditions,

when continuous medication is

required. We have also deleted the zeropercent level of evaluation as

unnecessary, since zero percent may be

assigned under any diagnostic code

when the criteria for a compensable

evaluation are not met (38 CFR 4.31).

DC 7000 was titled ‘‘rheumatic heart

disease’’ in the previous schedule. We

proposed to retitle it ‘‘valvular heart

disease,’’ and to specify that it included

rheumatic heart disease, syphilitic heart

disease, and sequelae involving valvular

heart damage from endocarditis,

pericarditis, or trauma. Because each of

the conditions listed under DC 7000

(except trauma) has its own diagnostic

code and criteria, we have revised the

title to ‘‘valvular heart disease

(including rheumatic heart disease)’’

and deleted the list of conditions. The

term ‘‘valvular heart disease’’

encompasses all types of valvular

disease not otherwise specified,

including those due to trauma.

We proposed to require that

endocarditis (DC 7001), pericarditis (DC

7002), and pericardial adhesions (DC

7003) be rated as valvular heart disease.

We have instead repeated the evaluation

criteria under each diagnostic code to

which they apply. We have also deleted

the three-month period of

convalescence evaluation that would

have been available for pericardial

adhesions if evaluated strictly under the

criteria for valvular heart disease (DC

7000); pericardial adhesions are a

chronic condition rather than an acute

infection, and a convalescence

evaluation is, therefore, inappropriate.

We proposed that syphilitic heart

disease (DC 7004) be evaluated under

the criteria for either valvular heart

disease or aortic aneurysm (DC 7110).

We have now provided criteria for DC

7004 that are based on the same

objective measurements of the level of

physical activity that causes symptoms.

We placed a note following this

diagnostic code directing that syphilitic

aortic aneurysms be evaluated under DC

7110 (aortic aneurysm), since the

criteria under DC 7110 apply to aortic

aneurysm of any etiology. Since

syphilitic heart disease has no phase of

active infection, being the late result of

a much earlier syphilitic infection, we

have omitted the criteria based on active

infection, as we did under DC 7003.

We proposed to revise the length of

convalescence evaluation following a

myocardial infarction (DC 7005 or 7006)

from six months to three months. One

commenter objected that three months

represents the optimal, rather than the
65212 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

average, recovery period following

myocardial infarction.

The interval between an

uncomplicated myocardial infarction

and return to work is 70–90 days

(Braunwald, 1390), and a return to work

evaluation can be performed within five

weeks after an uncomplicated

myocardial infarction (‘‘The Heart’’

1115 (J. Willis Hurst, M.D. et al. eds.,

7th ed. 1990)). Complete healing of the

myocardium, i.e., replacement of the

infarcted area by scar tissue, takes six to

eight weeks, and most patients will be

able to return to work by 12 weeks,

many much earlier (‘‘Harrison’s

Principles of Internal Medicine’’ 956–57

(Jean D. Wilson, M.D. et al. eds., 12th

ed. 1991)). This information clearly

establishes that most patients with

myocardial infarction recover within

three months, and, in our judgment, that

is an adequate period for a

convalescence evaluation.

Another individual said that three

months is not an adequate length of

convalescence evaluation following

myocardial infarction because it takes

six months, which according to the

commenter is the normally accepted

recovery time, for ancillary circulation

patterns to develop.

The development of collateral

circulation represents a long-range

adaptation to ischemia due to coronary

artery disease (Hurst, 944). It is,

therefore, more relevant in predicting

whether an infarction will occur or how

severe it might be, than in determining

the length of convalescence after

infarction, and we have made no change

based on this comment.

In response to requests for more

objective criteria, we have adopted

criteria for the 10-, 30-, 60-, and 100-

percent levels for arteriosclerotic heart

disease using the same METs-based

criteria we have adopted for DC 7000

(valvular heart disease). We have also

adopted similar alternative criteria

based either on chronic or multiple

episodes of congestive heart failure, left

ventricular dysfunction with decreased

ejection fraction percentages, or cardiac

hypertrophy or dilatation.

The prior rating schedule assigned 30-

percent evaluations under DCs 7005

(arteriosclerotic heart disease) and 7006

(myocardium, infarction of, due to

thrombosis or embolism) ‘‘following

typical coronary occlusion or

thrombosis,’’ or ‘‘with history of

substantiated anginal attack, ordinary

manual labor feasible,’’ but provided

neither a 10-percent level nor specific

criteria for a zero-percent evaluation.

We proposed to assign a 30-percent

evaluation for those with cardiac

symptoms appearing after strenuous

physical activity, and to establish a

zero-percent level for those with no

limitation of physical activity.

Two commenters objected to the

proposed changes. One suggested we

provide a 20-percent level under DC

7005 for some limitation of activities

and a 30-percent level for one or more

symptoms. One felt that 30 percent

should be the minimum under DC 7005

or DC 7006 because permanent

disability results.

In keeping with the objective

evaluation criteria we are adopting, it is

feasible to establish additional levels of

impairment based on an objective

measurement of the workload at which

symptoms develop. We have added a

10-percent evaluation under DC’s 7005

and 7006 for those who have cardiac

symptoms at a workload greater than 7

METs but not greater than 10 METs,

which includes such activities as

gardening and skating. The 10-percent

evaluation may also be assigned when

continuous medication is required,

which is consistent with the evaluation

of other heart conditions. As a result, if,

for different conditions, the same

workload elicits symptoms, the

conditions will be assigned the same

evaluation. A 30-percent minimum

evaluation is not warranted.

Arteriosclerotic heart disease may be

mild enough that it imposes little or no

functional impairment, and, in our

judgment, the most equitable way to

evaluate the condition is to do so

objectively according to the physical

workload that causes symptoms.

We proposed that arteriosclerotic

heart disease (DC 7005) and myocardial

infarction (DC 7006) be evaluated under

the same criteria. That was reasonable

under the subjective evaluation criteria

that were proposed, but there are some

condition-specific differences that the

criteria must reflect. We have provided

for a three-month convalescence

evaluation following a myocardial

infarction (DC 7006), a condition of

sudden onset. Arteriosclerotic heart

disease (DC 7005), on the other hand, is

a chronic condition that does not

warrant a convalescence evaluation. We

have added a requirement to DC 7005

that the veteran have ‘‘documented’’

coronary artery disease. Similarly, we

have headed DC 7006 with the

statement ‘‘with history of myocardial

infarction, documented by laboratory

tests.’’ This replaces the requirement

that the myocardial infarction be

‘‘typical’’ in order to assign the

convalescence evaluation. Since

atypical myocardial infarctions may be

just as disabling as typical ones, we

have revised the criteria for a

convalescence rating to require that an

infarction be ‘‘documented’’ rather than

‘‘typical.’’

We have deleted the instruction

proposed under DC 7005 that

cardiomyopathies (DC 7020) and

hypertensive heart disease (DC 7007) are

to be rated as arteriosclerotic heart

disease because we have provided each

of these conditions with criteria under

its own diagnostic code.

We proposed that hypertensive heart

disease (DC 7007) be evaluated under

the criteria for arteriosclerotic heart

disease, i.e., percentage evaluations

based on the level of activity that causes

symptoms, and we have revised the

criteria using the same objective

evaluation criteria as for arteriosclerotic

heart disease.

We have made minor editorial

changes under DC 7008 (hyperthyroid

heart disease).

We proposed that a 30-percent

evaluation under DC 7010

(supraventricular arrhythmias) require

paroxysmal atrial fibrillation or other

supraventricular tachycardia, with

severe frequent attacks despite therapy,

and that the 10-percent evaluation

require permanent atrial fibrillation or

infrequent or mild attacks documented

by electrocardiogram (ECG) or Holter

monitor.

Two commenters pointed out that

such phrases as ‘‘severe, frequent

attacks’’ are indefinite, and one

suggested that we replace these terms

with more objective ones.

We agree and have revised the criteria

to require more than four episodes a

year of paroxysmal atrial fibrillation or

other supraventricular tachycardia for

the 30-percent level, and permanent

atrial fibrillation or one to four episodes

a year of paroxysmal atrial fibrillation or

other supraventricular tachycardia for

the 10-percent level. Both sets of criteria

require documentation by ECG or Holter

monitor.

We proposed to evaluate sustained

ventricular arrhythmias (DC 7011)

according to whether ‘‘ordinary’’ or

‘‘strenuous’’ activity results in

palpitations or symptoms of arrhythmia.

A commenter objected to the

subjectivity of the proposed criteria for

DC 7011.

Based on this comment, we have

revised the criteria using the same

objective measurements that we are

using for arteriosclerotic heart disease.

We have, however, retained specific

provisions for a total evaluation while

an Automatic Implantable CardioverterDefibrillator (AICD) is in place. The use

of AICDs is associated with the potential

for serious complications such as

myocardial infarction, stroke,

cardiogenic shock, and complications
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65213

associated with the thoracotomy

required for its insertion (Braunwald,

750). We have revised the language

slightly to make it clear that a 100-

percent evaluation will be assigned for

as long as the AICD is in place. We have

also made other nonsubstantive changes

in the language at 100 percent for the

sake of clarity.

The previous schedule provided a

100-percent evaluation for DC 7015,

atrioventricular block, for one year

following implantation of a pacemaker

when required by a complete heart

block with attacks of syncope, and a 60-

percent evaluation for complete heart

block with Stokes-Adams attacks several

times a year despite medication or a

pacemaker. We proposed to eliminate

the 100-percent level while retaining

essentially the same criteria for the

other levels.

One commenter stated that a 100-

percent evaluation is warranted under

DC 7015 when there is a complete heart

block with syncopal attacks despite

therapy or a pacemaker. Another

commenter suggested that we replace

the requirement for ‘‘several’’ attacks a

year for the 60-percent evaluation under

DC 7015 with a definite number.

Upon further review, in response both

to these comments and to the requests

for more objective criteria, we have

revised the criteria for DC 7015 by

providing the same objective evaluation

criteria we have used for ventricular

arrhythmias (DC 7011) and many other

heart conditions, since heart block may

result in a variety of cardiac signs and

symptoms and a wide range of

disabilities. This change restores the

100-percent evaluation level. These

criteria replace evaluation criteria based

on the electrocardiographic designation

of complete or incomplete block.

Because both complete and incomplete

heart blocks can differ in severity,

basing evaluations on the degree of

heart block could lead to different

evaluations for similar symptoms. In our

judgment, the revised criteria are a

better measure of the disabling effects of

atrioventricular block than whether the

block is complete or incomplete.

The only difference in the criteria for

atrioventricular block (DC 7015) and

ventricular arrhythmias (DC 7011) is

that a 10-percent evaluation for DC 7015

will be assigned when either a

pacemaker, a common method of

treatment for this condition, or

continuous medication is required. We

have deleted the proposed zero-percent

evaluation, since under the provisions

of 38 CFR 4.31a, a zero-percent

evaluation may be assigned when the

findings are less than those needed for

a compensable level. We have also

edited the note requiring that certain

unusual cases of associated arrhythmias

are to be submitted to the Director of the

Compensation and Pension Service for

evaluation, for the sake of clarity.

The previous schedule established a

minimum 30-percent evaluation for

heart valve replacement (DC 7016); we

proposed a 30-percent evaluation when

strenuous activity causes specific

cardiac symptoms, and a zero-percent

evaluation when the condition imposes

no limitation of physical activity. One

commenter suggested that we retain the

30-percent minimum evaluation, but

gave no rationale for the suggestion.

The level of residual disability

following valve replacement can also be

objectively determined based on the

level of activity that results in

symptoms in the same manner as for

valvular heart disease. We have,

therefore, revised the criteria to assign a

30-percent evaluation when a workload

of greater than 5 METs but not greater

than 7 METs results in symptoms, or

when there is evidence of cardiac

hypertrophy or dilatation. For the sake

of consistency with the evaluation

criteria for other heart conditions

evaluated based on the level of physical

activity that causes symptoms, we have

added a ten-percent evaluation when a

workload of greater than 7 METs but not

greater than 10 METs results in

symptoms. In our judgment, specific

symptoms warrant the same evaluation

whether they occur before or after valve

replacement, and we are not aware of

any special circumstances following

valve replacement that would justify a

30-percent minimum evaluation.

We have edited the language of the

note regarding the assignment of 100

percent following admission for heart

valve replacement to assure that the

provisions of § 3.105(e) will be followed

whether the reduction from the 100-

percent evaluation is based upon the

mandatory examination six months

following discharge or following a

subsequent examination.

The previous schedule called for a

total evaluation for one year following

heart valve replacement (DC 7016). We

proposed a total evaluation for an

indefinite period, with a mandatory VA

examination six months after the

surgery, with any change in evaluation

based on that or any subsequent

examination to be made under the

provisions of 38 CFR 3.105(e).

One commenter objected to the

proposed change, stating that heart

valve replacement is a high risk surgical

procedure, and many patients have

post-operative congestive heart failure

for a considerable time. Another

commenter said that the proposed

reduction in length of the convalescence

evaluation is arbitrary, that it goes

beyond the purpose of the review, and

that no justification has been provided.

We recognize that it ordinarily takes

patients longer to recover from valve

replacement than from acute valvular

infection, endocarditis, or pericarditis

and, therefore, proposed an indefinite

period of total evaluation. We believe

that six months following discharge

from the hospital is a reasonable time at

which to examine a patient to determine

whether the condition has stabilized

and the extent of residual disability. If

the results of that or any subsequent

examination warrant a reduction in

evaluation, the reduction will be

implemented under the notice and

effective date provisions of 38 CFR

3.105(e), which require a 60-day notice

before VA reduces an evaluation and an

additional 60-day notice before the

reduced evaluation takes effect. By

requiring an examination, the revised

procedure will assure that all residuals

are documented; it also ensures that the

veteran receive timely notice of any

proposed action and have an

opportunity to present evidence

showing that the proposed action

should not be taken. In our judgment,

this method will better ensure that

actual residual disabilities and

recuperation times are taken into

account because they will be

documented on examination.

We proposed to change the length of

the total evaluation following coronary

artery bypass surgery (DC 7017) from

one year to three months. One

commenter objected, stating that

unspecified medical textbooks suggest

resumption of sedentary activity over

the two-to three-month period following

surgery, with resumption of full activity

after three months. Another expressed

his belief that a reduction to three

months is unreasonably restrictive and

does not reflect the average impairment

for those in poor health or those who

have cardiomyopathies or pulmonary

and systemic organ congestion.

An article in the Journal of the

American College of Cardiology (1029

vol. 14, no. 4, Oct. 1989) entitled

‘‘Insurability and Employability of the

Patient with Ischemic Heart Disease’’

states that return to work evaluations

are appropriate seven weeks after

bypass surgery. Neither this article nor

the unidentified information cited by

the commenter justifies the need for a

convalescence evaluation longer than

three months. For the individual who

requires a longer than average period of

convalescence, a total evaluation may be

assigned for a longer period under the

provisions of §§ 4.29 and 4.30 of the
65214 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

rating schedule. We have, therefore,

retained the provision assigning a total

evaluation for three months following

surgery as proposed.

We proposed that coronary artery

bypass surgery be evaluated using the

evaluation criteria for arteriosclerotic

heart disease, which was not a change

from the previous schedule. One

commenter suggested that 30 percent be

the minimum evaluation following

bypass surgery, analogous to

arteriosclerotic heart disease (DC 7005).

We have provided objective criteria

for evaluation following coronary

bypass surgery that are the same as the

criteria we have provided for

arteriosclerotic heart disease (DC 7005).

The surgery itself does not necessarily

produce a 30-percent level of

impairment; in fact, it often alleviates

the disability from arteriosclerotic heart

disease. In our judgment, an evaluation

based on the workload at which

symptoms develop is a reasonable and

consistent way to assess the extent of

disability; a 30-percent evaluation will

be assigned if symptoms develop at the

same workload that warrants a 30-

percent evaluation for other cardiac

conditions.

One commenter suggested that we

add a convalescence evaluation

following balloon angioplasty for

coronary artery disease.

Most patients who undergo balloon

angioplasty are discharged from the

hospital 24 hours or less after surgery,

and many can return to work in a week

or less after a successful and

uncomplicated angioplasty (Hurst, 2145

and Braunwald, 1367). In our judgment,

a total evaluation for a specified period

to allow for convalescence is, therefore,

not warranted.

We proposed changing the duration of

the total evaluation following

implantation of a cardiac pacemaker

(currently Note (2) under DC 7015,

proposed as DC 7018) from one year to

two months. One commenter said that

the total evaluation should continue for

one year; another said that pacemakers

require close monitoring postoperatively

and that patients should not concern

themselves with a return to activity

sooner than medically advisable.

Pacemaker implantation is not major

surgery, nor is it associated with

debilitating or long-term residuals.

Those who undergo a cardiac

pacemaker implantation are usually

discharged from the hospital the

following day and are seen in follow-up

two weeks after surgery to check the

wound and to test the pacing system

(Hurst, 2103–4). They are subsequently

evaluated two months after

implantation, and virtually all patients

will have definitive pacemaker

programming for long-term function at

that time (Braunwald, 747). Thereafter,

there is periodic monitoring, often

conducted by telephone. In our

judgment, a two-month convalescence

evaluation is adequate for a normal

recovery from pacemaker implantation.

One commenter suggested that we

add a 100-percent evaluation under DC

7018, implantable cardiac pacemakers,

for those patients who require frequent

follow-up and adjustment after

pacemaker implant.

DC 7018 allows evaluation of a

patient’s condition following

implantation of a pacemaker under

supraventricular arrhythmias (DC 7010),

ventricular arrhythmias (DC 7011), or

atrioventricular block (DC 7015), if

appropriate. A 100-percent evaluation

may, therefore, be assigned based either

on symptoms or on the number of

episodes of arrhythmia, depending on

the diagnostic code used. These criteria

are a better indicator of residual

disability than the frequency of

adjustments or follow-up, and we have

made no change based on this

suggestion.

Another commenter felt that 30

percent should be the minimum

evaluation for DC 7018 after a

pacemaker has been implanted.

A pacemaker requires regular

checkups and monitoring, often by

telephone, but the patient may, in fact,

be asymptomatic. An evaluation of 10

percent rather than 30 percent is more

appropriate for such cases, and we have

added a minimum evaluation of 10

percent to the criteria under DC 7018.

This is comparable to the assignment of

10 percent for other cardiac conditions

when continuous medication is

required.

One commenter suggested that we

add a caveat under pacemaker

implantation (DC 7018) that

reimplantation or replacement of a

pacemaker does not warrant a 100-

percent evaluation.

The total evaluation for two months

following implantation of a pacemaker

is to provide a period of recuperation

from the surgery and any possible sideeffects, as well as to provide a period to

adjust the device itself and test the

response of the individual’s heart. These

considerations apply as well to the

replacement of a pacemaker, and, in our

judgment, limiting convalescence

evaluations to the initial implantation

only is not warranted.

We proposed to add a new diagnostic

code (DC 7019) for cardiac

transplantation allowing a total

evaluation for an indefinite period

following the transplant, with a

mandatory VA examination to be

conducted one year later. In the past,

with no provision for cardiac

transplantation in the rating schedule, a

fixed period of convalescence

evaluation for two years was assigned,

analogous to what the rating schedule

provided following renal transplant

prior to the revisions to the

genitourinary portion of the rating

schedule published January 18, 1994.

One commenter stated that the total

evaluation following cardiac

transplantation (DC 7019) should

continue for two years because the risk

of rejection and survival data show that

this is dangerous surgery.

Because more than 85 percent of oneyear survivors of a cardiac transplant

have been rehabilitated and return to

work or to school by the end of one year

after transplant (Hurst, 2253–54), in our

judgment, one year following hospital

discharge is a reasonable time to

conduct an examination in order to

assess residual disability. As with other

indefinite periods of convalescence

evaluation, any change in evaluation

based on the results of the examination

will be implemented under the notice

and effective date provisions of

§ 3.105(e), which require VA to notify

the claimant of any proposed reduction,

once the examination has been carried

out and reviewed, and allows 60 days

for the claimant to provide additional

evidence to show that a reduction

should not be carried out.

We proposed to evaluate cardiac

transplantation (DC 7019) under the

same criteria as arteriosclerotic heart

disease (DC 7005), i.e., according to the

level of activity that causes symptoms;

we have, therefore, revised the criteria

using the same objective measurements

that we have adopted for evaluating

arteriosclerotic heart disease. We

proposed a minimum 30-percent

evaluation following cardiac

transplantation as long as the veteran is

on immunosuppressive medication.

Because almost every patient will

permanently require

immunosuppressive therapy following

cardiac transplantation, we have simply

made 30 percent the minimum

evaluation and deleted the requirement

that the veteran be taking

immunosuppressive medication. This is

consistent with the minimum

evaluation for kidney transplant (DC

7531), which was published in the

Federal Register of January 18, 1994 (59

FR 2523).

We also proposed to evaluate

cardiomyopathy (DC 7020) under the

same criteria as arteriosclerotic heart

disease (DC 7005), i.e., according to the

level of activity that causes symptoms;
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65215

we have, therefore, revised the criteria

using the same objective measurements

that we have adopted for evaluating

arteriosclerotic heart disease.

The previous schedule had a

diagnostic code, DC 7100, for

generalized arteriosclerosis, which we

proposed to delete. One commenter

objected, stating that this condition,

which is often present in geriatric cases,

produces total industrial incapacity

with involutional changes such as

cerebral ischemia with reduced

mentation, bone and muscle atrophy,

etc.

The effects of generalized

arteriosclerosis are so widespread that,

in our judgment, a single diagnostic

code is neither appropriate nor

necessary. Many diagnostic codes, such

as DC 7005, arteriosclerotic heart

disease, DC 7114, arteriosclerosis

obliterans, and DC 9305, multi-infarct

dementia associated with cerebral

arteriosclerosis, represent potential

effects of arteriosclerosis on end organs,

and evaluating each disability resulting

from generalized arteriosclerosis under

an appropriate code will result in more

accurate assessments of the actual

disabilities caused by the condition. We

have, therefore, made no change based

on this comment.

Two commenters requested that we

define the term hypertension (DC 7101).

In response to this comment, we have

revised Note (1) under DC 7101 to state

that, for purposes of this section,

hypertension means that the diastolic

blood pressure is predominantly 90mm.

or greater, and that isolated systolic

hypertension means that the systolic

blood pressure is predominantly

160mm. or greater with a diastolic blood

pressure of less than 90mm. (Cecil, 253,

based on the 1988 report of the Joint

National Committee on Detection,

Evaluation, and Treatment of High

Blood Pressure).

Since both essential hypertension and

secondary types of hypertension, such

as isolated systolic hypertension due to

arteriosclerosis, may be evaluated under

this diagnostic code, we have revised

the title of DC 7101 from Hypertensive

vascular disease (essential arterial

hypertension) to Hypertensive vascular

disease (hypertension and isolated

systolic hypertension).

In the previous schedule, Note (1)

under DC 7101 (hypertensive vascular

disease) stated that the 40- and 60-

percent evaluations required careful

attention to diagnosis and repeated

blood pressure readings. We proposed

to revise the note to state that careful

and repeated measurements of blood

pressure readings are required prior to

the assignment of any compensable

evaluation.

Two commenters requested that we

clarify the meaning of the note.

Standard medical texts recommend

multiple blood pressure readings for the

diagnosis of hypertension, although the

number of measurements recommended

varies, with ‘‘at least three sets over at

least a three-month interval’’

(Braunwald, 818) and ‘‘at least two

measurements on two separate

examinations’’ (Harrison, 1001) among

the specific recommendations. We have

revised the note to require that

hypertension be confirmed by readings

taken two or more times on each of at

least three different days. This will

assure that the existence of

hypertension is not conceded based

solely on readings taken on a single,

perhaps unrepresentative, day.

In a note under DC 7101

(hypertensive vascular disease), the

previous schedule established a

minimum evaluation of ten percent

when medication is necessary to control

hypertension with a history of diastolic

blood pressure predominantly 100 or

more. We proposed to keep this note.

One commenter asked if 10 percent

should be assigned whenever

continuous medication is required for

any disorder; another asked if the

assignment of 10 percent for

hypertension should depend on the

amount of medication required.

In our judgment, it would not be

appropriate to assign a ten-percent

evaluation for every condition which

requires continuous treatment by

medication. Whether a ten-percent

evaluation is warranted when

continuous medication is required is

based on a case-by-case assessment of

each condition and the usual effects of

treatment. As to the second comment,

the evaluation for hypertension is based

not on the amount of medication

required to control it, but on the level

of control that can be achieved. While

there may be more side effects with

higher levels of medication or with

combined antihypertensive

medications, the disabling side effects of

medication may be separately evaluated

under the provisions of 38 CFR 3.310(a).

Since the provision concerning the

assignment of a minimum ten-percent

evaluation when there is a history of

diastolic pressure predominantly 100 or

more and continuous medication is

required represents part of the

evaluation criteria, we have included it

in the criteria for a ten-percent

evaluation, rather than in a separate

note, as proposed.

The previous schedule called for a

100-percent evaluation for aortic

aneurysm (DC 7110) when there are

markedly disabling symptoms and for

one year following surgical correction.

Because of a typographical error,

omission of a semicolon, the proposed

criteria as published implied that a total

evaluation would be assigned following

surgery only if the aneurysm had been

5 cm. or more in diameter. One

commenter pointed out this error. We

had intended to propose that veterans

be evaluated as totally disabled under

either of two circumstances: (1) If the

aneurysm is 5 cm. or greater in

diameter, or (2) for six months following

resection of an aneurysm of any size.

We have corrected the error in the final

rule.

In addition, to assure internal

consistency, we have revised the criteria

to allow a 100-percent evaluation under

DC 7110 in an additional situation:

when an aortic aneurysm 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 assigned a

minimum 20-percent evaluation

following surgical correction of aortic

aneurysm (DC 7110). We proposed to

evaluate residuals following surgical

correction on actual residual disability,

according to the organ system affected,

in lieu of assigning a minimum

evaluation. A commenter recommended

that we retain the 20-percent minimum

evaluation following surgery,

contending that after such surgery

individuals lead a tenuous and

extremely sedentary existence, often

requiring revision of the graft.

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. Because some

would warrant a higher, and some a

lower, evaluation than 20 percent, in

our judgment it is preferable to evaluate

the actual residuals rather than provide

a minimum evaluation, and we have

made no change based on this comment.

We proposed to eliminate the fixed

one-year period of convalescence

evaluation following surgical correction

of an aortic aneurysm (DC 7110) in favor

of a 100-percent evaluation for an

indefinite period from the date of

admission for surgical correction, with a

mandatory VA examination six months

following discharge, and with any

change in evaluation subject to the

notice and effective date provisions of
65216 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

§ 3.105(e). One commenter urged that

we retain the one-year convalescence

evaluation, but gave no specific reasons.

We also proposed an indefinite total

evaluation following repair of an

aneurysm of a large artery (DC 7111)

although the previous schedule had

provided no post-surgical total

evaluation. One commenter suggested

that a one-year period of convalescence

evaluation would be appropriate

following repair of an aneurysm of a

large artery because, as after aortic

aneurysm repair, these patients lead a

tenuous and sedentary existence after

surgery.

The period of total evaluation

following surgery under DCs 7110 and

7111 will continue indefinitely under

the revised schedule, and an

examination six months following the

date of admission for surgical correction

will determine whether a change in

evaluation is warranted, based on actual

residuals documented at that time.

Since any change will be implemented

under the notice and effective date

provisions of § 3.105 (e), the veteran

will have the opportunity to present

medical evidence if he or she disagrees

with the proposed change in evaluation.

These provisions assure an evaluation

that reflects the actual disability as

documented by medical examination,

and we have made no change based on

these comments.

The previous schedule assigned a 10-

percent evaluation for aneurysm of any

small artery (DC 7112); we proposed

that such an aneurysm be assigned a

zero-percent evaluation. One

commenter stated that the proposed

change is based on empirical, as

opposed to statistical, evidence and that

evaluations that have stood the test of

time should not be routinely reduced or

discontinued.

Small artery aneurysms may produce

symptoms such as headaches or visual

abnormalities due to local pressure

effects, and an aneurysm that ruptures

may result in a wide variety of

symptoms. However, small artery

aneurysms that are asymptomatic are

found in about five percent of the

population (Cecil, 2165). Because of the

wide range of possible disabling effects,

it is appropriate to rate each one on the

actual findings rather than provide a 10-

percent evaluation in all cases. In our

judgment, an asymptomatic aneurysm of

a small artery has no disabling effects

and does not warrant a compensable

evaluation.

Another commenter asked where and

how to rate cerebral aneurysms.

Aneurysms of cerebral arteries are

evaluated under DC 7112, as are all

other aneurysms of small arteries. We

have made no change in response to this

comment.

The previous schedule specified a

minimum evaluation of 60 percent for

traumatic arteriovenous aneurysm (DC

7113) when there is cardiac

involvement, and we proposed no

change. One commenter, noting that

designating a minimum evaluation

implied that a higher one could be

assigned, asked what findings would

warrant an evaluation higher than 60

percent, since 60 percent was also the

highest evaluation under DC 7113.

The most serious potential

consequence of arteriovenous aneurysm

is congestive heart failure due to high

output, which would warrant a 100-

percent evaluation. We have, therefore,

added a 100-percent evaluation, to be

assigned if there is high output heart

failure.

In response to the request for more

objective criteria, we have revised the

criteria for a 60-percent evaluation

under DC 7113 to require an enlarged

heart, wide pulse pressure, and

tachycardia rather than the ambiguous

term ‘‘cardiac involvement’’ that we had

proposed. We have revised the criteria

for the 50-percent level for lower

extremity involvement or the 40-percent

level for upper extremity involvement,

which were proposed as ‘‘without

cardiac involvement with marked

vascular symptoms,’’ to require edema,

stasis dermatitis, and either ulceration

or cellulitis. We have revised the criteria

for the 30-percent level for lower

extremity involvement or the 20-percent

level for upper extremity involvement,

which were proposed as ‘‘with definite

vascular symptoms,’’ to require edema

or stasis dermatitis. These are not

substantive changes, but more specific

designations of the cardiac and vascular

signs that warrant these evaluations. We

have also revised the title of DC 7113

from ‘‘arteriovenous aneurysm,

traumatic’’ to ‘‘arteriovenous fistula,

traumatic,’’ the currently accepted term

for the condition, which is a direct

communication between an artery and a

vein.

One commenter requested that we

add a paragraph under arteriosclerosis

obliterans (DC 7114) addressing the

evaluation of aorto-femoral bypass

grafts.

To assure consistent evaluations of

the residuals of aortic and large arterial

bypass surgery, we have added a note

under DC 7114 stating that the residuals

of aortic and large arterial bypass

surgery or arterial grafts are to be rated

under that code. Since the most

common residuals of bypass surgery are

signs and symptoms of arterial

insufficiency, it is appropriate to

evaluate them under the criteria for

arteriosclerosis obliterans.

Two commenters suggested we

provide a specific period of

convalescence evaluation following

bypass surgery for aortoiliac and

femoral-popliteal artery disease.

The evaluation criteria for serious

complications that might result from

bypass surgery and, therefore, be

service-connected under the provisions

of 38 CFR 3.310(a), such as myocardial

infarction, have their own periods of

convalescence evaluation. For the

milder complications, or the

uncomplicated cases, the standard

periods of convalescence evaluation

authorized under § 4.30 of this part are

adequate, and we have made no change

based on these comments.

The criterion for the 40-percent

evaluation for arteriosclerosis obliterans

(DC 7114) in the previous schedule was

‘‘well-established cases with

intermittent claudication or recurrent

episodes of superficial phlebitis;’’ we

proposed to revise this criterion to

‘‘well-established cases of intermittent

claudication with associated physical

findings (hair loss, skin changes).’’ We

proposed for the 100-percent level:

‘‘severe, with marked physical signs

producing total incapacity’’; for the 60-

percent level: ‘‘claudication on minimal

walking (less than three miles per hour

on a level grade) with persistent

coldness of the extremity’’; and for the

20-percent level: ‘‘minimal circulatory

impairment, with paresthesias,

temperature changes and occasional

claudication.’’ One commenter noted

that the phrase ‘‘well-established cases’’

is one of the vague, indefinite, and

arbitrary elements in the schedule.

In response to both that comment and

the requests for more objective criteria,

we have revised the criteria under this

diagnostic code: To specify at each

evaluation level the distance that can be

covered before claudication occurs; and

to base evaluations on objective

physical findings, such as peripheral

pulses, trophic changes, persistent

coldness, and deep ischemic ulcers. We

have also added an objective alternative

criterion, the ankle/brachial index, at

each level, and a note explaining that

this index is obtained by dividing the

systolic blood pressure at the ankle by

the systolic blood pressure in the arm.

The ratio is normally one or greater; but

because arterial occlusive disease

obstructs the blood flow in the legs, the

ratio in patients with that condition is

less than one. A ratio of less than 0.5 is

consistent with severe ischemia

(Harrison, 1019). The ankle/brachial

index thus allows a noninvasive
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65217

objective assessment of the severity of

peripheral vascular disease.

We proposed to evaluate Raynaud’s

syndrome (DC 7117) as 100-percent, 60-

percent, 40-percent, or 20-percent

disabling, using measures such as

‘‘marked’’ circulatory changes,

‘‘multiple’’ ulcerated areas, ‘‘frequent’’

vasomotor disturbances, and

‘‘occasional’’ attacks of blanching or

flushing. One commenter suggested that

we replace subjective terms with more

objective requirements.

Simply replacing the indefinite words

would not result in truly objective

criteria. We have, therefore, defined

‘‘characteristic attacks’’ of Raynaud’s

disease for VA purposes as consisting of

sequential color changes of the digits

lasting minutes to hours, sometimes

with pain and paresthesias, and

precipitated by exposure to cold or by

emotional upsets. We have revised the

evaluation criteria based on the

frequency of characteristic attacks, the

number of digital ulcers, and whether

autoamputation in one or more digits

has occurred. While we proposed no

change in the former 20-percent level,

which required ‘‘occasional attacks of

blanching or flushing,’’ under the more

objective criteria we have provided both

a 20- and a 10-percent level, with 20-

percent requiring characteristic attacks

four to six times a week, and 10-percent

requiring characteristic attacks one to

three times a week. This will ensure

more consistent evaluations in milder

cases of Raynaud’s, where, in the former

schedule, the assignment of zero percent

or 20 percent depended on an

individual rater’s interpretation of

‘‘occasional.’’

One commenter suggested that we

include neurologic symptoms associated

with exposure to low or subfreezing

temperatures under the evaluation

criteria for DC 7117.

In response to this comment, we have

included pain and paresthesias, which

are neurologic symptoms, among the

possible manifestations of the

characteristic attacks of Raynaud’s

syndrome.

We proposed to assign 40-percent, 20-

percent, and zero-percent evaluations

for angioneurotic edema (DC 7118),

based generally on the frequency,

severity, and duration of attacks. One

commenter recommended that we add a

10-percent evaluation; another

recommended that we replace language

such as ‘‘frequent’’ and ‘‘infrequent’’

with more definite terms.

Angioneurotic edema is a condition

that is ordinarily self-limited, with

attacks subsiding in one to seven days

(Merck, 333), but at times palliative

treatment is used. There are also

unusual types that are more persistent

and resistant to therapy. We have

established more objective criteria based

on the typical duration of attacks, their

frequency, and on whether there is

laryngeal involvement. We have added

a 10-percent evaluation, to be assigned

if attacks without laryngeal involvement

occur two to four times a year. These

criteria will foster more consistent

evaluations for angioneurotic edema,

since different raters will not be

required to interpret subjective terms

such as ‘‘mild,’’ ‘‘moderate,’’ ‘‘frequent,’’

and ‘‘infrequent.’’

One commenter suggested that when

angioneurotic edema affects the larynx

even briefly, a 10-percent evaluation is

warranted.

In our judgment, angioneurotic edema

affecting the larynx does warrant

separate consideration in the evaluation

criteria because laryngeal edema

commonly causes respiratory distress

due to airway obstruction and requires

emergency treatment. This situation 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.

A second commenter objected that the

proposed changes to DC 7118 were

based on empirical, as opposed to

statistical, information.

As noted under the response to

comments about DC 7122, 38 U.S.C.

1155 gives the Secretary the authority to

revise the rating schedule periodically

in accordance with experience. The

revisions of these criteria are based on

the usual effects of the disease, which

is consistent with the basis of revisions

throughout the current comprehensive

revision of the rating schedule. They are

medically, rather than statistically,

based, and no statistical studies were

done in conjunction with the revision.

Under the previous schedule, there

were a variety of methods 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, with no direction for

evaluation if one extremity were more

severely affected than the other. The

criteria for intermittent claudication (DC

7116) applied to a single extremity;

determining the evaluation for multiple

extremities required application of a

complex set of rules (contained in a note

following DC 7117) that sometimes

produced an evaluation for involvement

of multiple extremities no higher than

that for involvement of a single

extremity. We proposed no substantive

change in either the methods of

evaluating these conditions or in the

percentage levels.

One commenter questioned why the

percentage evaluations and the method

of determining the evaluation when

more than one extremity is affected

differ for arterial and venous diseases.

He suggested that we use 20-, 40,-and

60-percent levels for both peripheral

arterial diseases (DCs 7114 through

7117), and venous diseases (DCs 7120

and 7121) instead of the variety of levels

proposed, and that we adopt a uniform

and simple method of determining

evaluations when more than one

extremity is involved, such as adding

ten percent for each additional

extremity involved.

We proposed evaluations levels of 20,

40, 60, and 100 percent for DCs 7114,

7115, and 7117, and we have kept those

levels in this rule, with the addition of

a 10-percent level for DC 7117. (We

removed DC 7116, ‘‘intermittent

claudication,’’ which was in the

previous schedule, because it was a

symptom of disease rather than a

disease.) In response to the comment,

we have further revised DCs 7120

(varicose veins) and 7121 (post-phlebitic

syndrome of any etiology) to provide

percentage evaluation levels of 10, 20,

40, 60, and 100 percent. In addition, we

have revised the method of evaluating

DCs 7114 (arteriosclerosis obliterans),

7115 (thromboangiitis obliterans), and

7120 (varicose veins) so that the criteria

apply to a single extremity, as the

criteria for DC 7121 do. If the paired

extremity is also affected, the evaluation

for each extremity will be separately

determined and combined using the

combined ratings table (see 38 CFR 4.25)

and the bilateral factor (see 38 CFR 4.26)

when applicable. Section 4.26 also

provides instructions on applying the

bilateral factor when there is

involvement of upper and lower

extremities. While we have made the

percentage levels similar, the signs,

symptoms, and effects of venous and

arterial diseases differ greatly and,

therefore, require different evaluation

criteria.

In order to adopt the more consistent

method of separately evaluating each

extremity affected by vascular disease

and to assure that venous conditions

with similar findings receive consistent

evaluations, further revisions of the

evaluation criteria for varicose veins
65218 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

(DC 7120) and post-phlebitic syndrome

of any etiology (DC 7121) were required.

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

(Merck, 590), and we have 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 have, therefore, removed

references to the deep circulation from

the evaluation criteria. We have

replaced these criteria 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).

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 (Cecil,

363–7). Therefore, the possible

manifestations and disabling effects of

varicose veins and postphlebitic

syndrome are very similar, and we have

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, and

the same method of evaluation for

multiple extremity involvement as that

used in arterial vascular disease of the

extremities.

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.

One commenter suggested that we

clarify how to assign bilateral

evaluations for frozen feet (DC 7122)

and varicose veins (DC 7120) when one

extremity is more severely affected than

the other.

The changes described above that we

have made in the evaluation criteria,

evaluation percentages, and method of

determining an evaluation for multiple

extremity involvement will allow

accurate and consistent evaluations

when more than one extremity is

affected by varicose veins, but to

different degrees. We have made similar

changes in the method of evaluating

cold injury, DC 7122, in order to assure

accurate and consistent evaluations

when there is multiple extremity

involvement, and this is further

discussed below.

We proposed no change in the

previous evaluation criteria for frozen

feet (DC 7122). One commenter

suggested that we expand the criteria to

include cold injuries to the hands, face,

and ears; another suggested that higher

ratings may be warranted for loss of use

of multiple fingers or one or both hands.

We have revised the title of DC 7122

from ‘‘frozen feet, residuals of’’ to ‘‘cold

injury, residuals of’’ to indicate that it

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; we

have, however, 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

have also deleted the bilateral

evaluations contained in the prior

schedule in favor of evaluating each

affected part separately and combining

them for the overall evaluation for cold

injury, a change which is similar to

changes we have made in the method of

evaluating peripheral arterial and

venous diseases of the extremities. 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),

added following DC 7122).

The proposed note following DC 7122

directed that higher ratings could be

assigned, if warranted, because of loss of

toes, by reference to amputation ratings.

We have edited this Note (1) for clarity

and added a statement about the

evaluation of complications such as

peripheral neuropathy or squamous cell

carcinoma of the skin at the site of a

scar.

One commenter requested that we

include neurologic symptoms associated

with exposure to low or subfreezing

temperatures in the evaluation criteria

for DC 7122, cold injuries.

In response to this suggestion, we

have added numbness or locally

impaired sensation, which are

neurologic symptoms, to the evaluation

criteria.

One individual suggested that cold

injuries of the hands are generally more

disabling than those of the lower

extremities.

The severity of cold injuries to

various parts of the body depends on

such factors as the extent and duration

of exposure, more than on the particular

part affected. We have provided

evaluation criteria that, applied with the

notes regarding amputations and

complications, are flexible enough to

cover a broad range of severity and

allow evaluation of any extent of tissue

damage from cold injury to any body

part, so we have not adopted any

changes based on this comment.

The current schedule provides six

months of convalescence evaluation for

soft tissue sarcoma of vascular origin

(DC 7123). We proposed that a total

evaluation be assigned indefinitely,

with a mandatory VA examination to be

conducted six months following the

completion of therapy. One commenter

recommended that we allow one year of

convalescence evaluation.

We believe that an examination six

months following the cessation of

treatment affords sufficient time for

convalescence and stabilization of

residuals, particularly since the rule

requires only an examination, not a

reduction, at that time. In our judgment,

this method of determining the length of

the total evaluation is both fairer and

more accurate than assigning a total

evaluation for a specified length of time,

since the evaluation will be based on

actual residual disability as documented

by the examination, and the veteran will

receive advance notice of any change

and have the opportunity to submit

additional evidence showing that the

change is not warranted.

Two commenters requested that VA

provide a zero-percent evaluation for all

diagnostic codes.

On October 6, 1993, VA revised its

regulation addressing the issue zeropercent evaluations (38 CFR 4.31) to

authorize assignment of a zero-percent

evaluation for any disability in the

rating schedule when minimum

requirements for a compensable

evaluation are not met. In general, that

regulatory provision precludes the need

for zero-percent evaluation criteria.

On further review, we have revised

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

may follow thrombophlebitis. This is

not a substantive change.
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65219

For the sake of clarity, we have made

nonsubstantive changes in the notes

under ventricular arrhythmias (DC

7011), heart valve replacement (DC

7016), cardiac transplantation (DC

7019), aortic aneurysm (DC 7110),

aneurysm, any large artery (DC 7111),

and soft tissue sarcoma (DC 7123).

VA appreciates the comments

submitted in response to the proposed

rule, which is now adopted with the

amendments noted above.

The 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 (RFA), 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 amendment has been

reviewed by the Office of Management

and Budget under the provisions of

Executive Order 12866, Regulatory

Planning and Review, dated September

30, 1993.

The Catalog of Federal Domestic Assistance

program numbers are 64.104 and 64.109.

List of Subjects in 38 CFR Part 4

Disability benefits, Individuals with

disabilities, Pensions, Veterans.

Approved: August 7, 1997.

Hershel W. Gober,

Acting Secretary of Veterans Affairs.

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]

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.

Diseases of the Heart

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
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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 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: 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 nonarteriosclerotic 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 be 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
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65221

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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 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 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:
65222 Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations

Rating

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

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 of 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.
Federal Register / Vol. 62, No. 238 / Thursday, December 11, 1997 / Rules and Regulations 65223

Rating

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.
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Rating

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)

[FR Doc. 97–32413 Filed 12–10–97; 8:45 am]

BILLING CODE 8320–01–P

ENVIRONMENTAL PROTECTION

AGENCY

40 CFR Part 52

[FRL–5931–8]

Technical Amendments to Air Quality

Implementation Plan for Connecticut;

Correction

AGENCY: Environmental Protection

Agency (EPA).

ACTION: Direct final rule; correction.

SUMMARY: The Environmental Protection

Agency published in the Federal

Register of Monday, October 6, 1997, a

direct final rule concerning the approval

of regulations which define reasonably

available control technology for sources

of nitrogen oxides in Connecticut.

Inadvertently, the wrong city address

was attributed to two facilities affected

by the regulations. Also in that

document, the table of EPA approved

regulations was mislabelled.

DATES: Effective on December 11, 1997.

FOR FURTHER INFORMATION CONTACT:

Steven A. Rapp at (617) 565–2773, or Email at

Rapp.Steve@EPAMAIL.EPA.GOV.

SUPPLEMENTARY INFORMATION: The EPA

published a direct final rule in the

October 6, 1997 Federal Register (62 FR

52016) adding § 52.370(c)(72) and

§ 52.385 but inadvertently included the

wrong city address for two facilities

listed under § 52.370(c)(72)(i) and

mislabelled the table of EPA approved

regulations under § 52.385. This

correction changes the address for the

two entries as well as the label of the

table.

In FR Doc. 97–26434 published on

October 6, 1997, (62 FR 52016) make the

following corrections:

§ 52.370 [Corrected]

1. On page 52020, in the third column

in § 52.370(c)(72)(i)(B), in the fourth

line, ‘‘New Haven * * *’’ should read

‘‘Bridgeport * * *’’,

2. On page 52021, in the third column

in § 52.370(c)(72)(i)(K), in the sixth line,

‘‘New Haven’’ should read

‘‘Bridgeport’’,

§ 52.385 [Corrected]

3. On pages 52022 through 52029, the

heading for the table ‘‘Table 52.384—

EPA-Approved Regulations’’ should

read ‘‘Table 52.385—EPA-Approved

Regulations’’, and

4. On page 52027, the table in

§ 52.385, under Connecticut state

citation 22a-174–22, Control of nitrogen

oxide emissions, the subentries that

begin with the dates ‘‘5/18/95’’ and ‘‘2/

14/96’’ are corrected to read as follows:

* * * * *

TABLE 52.385—EPA-APPROVED REGULATIONS

Connecticut State Citation Title/subject

Dates

Federal Register Citation Section 52.370 Comments/description Date adopted

by State

Date approved

by EPA

* * * * * * *

* * * .............................. * * * ............... 5/18/95 ........... 10/6/97 ........... * * * ............... (c) 72 .............. Case-specific trading order for

United Illuminating’s Station

#3, in Bridgeport.

* * * * * * *

* * * .............................. * * * ............... 2/14/96 ........... 10/6/97 ........... * * * ............... (c) 72 .............. Case-specific trading order for

United Illuminating’s Station

#4, in Bridgeport.

* * * * * * *

Under Executive Order 12866 (58 FR

51735, October 4, 1993), this action is

not a ‘‘significant regulatory action’’

and, is therefore not subject to review by

the Office of Management and Budget.

In addition, this action does not impose

any enforceable duty or contain any

unfunded mandate as described in the

Unfunded Mandates Reform Act of 1995

(Pub. L. 104–4), or require prior

consultation with State officials as

specified by Executive Order 12875 (58

FR 58093, October 28, 1993), or involve

special consideration of environmental

justice related issues as required by

Executive Order 12898 (59 FR 7629,

February 16, 1994).

Because this action is not subject to

notice-and-comment requirements

under the Administrative Procedure Act

or any other statute, it is not subject to

the provisions of the Regulatory

Flexibility Act (5 U.S.C. 601 et seq.).

Under 5 U.S.C. 801(a)(1)(A) as added

by the Small Business Regulatory

Enforcement Fairness Act of 1996, EPA

submitted a report containing this rule

and other required information to the

U.S. Senate, the U.S. House of

Representatives and the Comptroller

General of the General Accounting

Office prior to publication of this rule in

today’s Federal Register. This rule is

not a ‘‘major rule’’ as defined by 5

U.S.C. 804(2).