32592 Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 

While some owners or operators of 

vessels intending to transit the safety 

zone may be small entities, for the 

reasons stated in section V.A above, this 

rule will not have a significant 

economic impact on any vessel owner 

or operator. 

Under section 213(a) of the Small 

Business Regulatory Enforcement 

Fairness Act of 1996 (Pub. L. 104–121), 

we want to assist small entities in 

understanding this rule. If the rule 

would affect your small business, 

organization, or governmental 

jurisdiction and you have questions 

concerning its provisions or options for 

compliance, please contact the person 

listed in the FOR FURTHER INFORMATION

CONTACT section. 

Small businesses may send comments 

on the actions of Federal employees 

who enforce, or otherwise determine 

compliance with, Federal regulations to 

the Small Business and Agriculture 

Regulatory Enforcement Ombudsman 

and the Regional Small Business 

Regulatory Fairness Boards. The 

Ombudsman evaluates these actions 

annually and rates each agency’s 

responsiveness to small business. If you 

wish to comment on actions by 

employees of the Coast Guard, call 1– 

888–REG–FAIR (1–888–734–3247). The 

Coast Guard will not retaliate against 

small entities that question or complain 

about this rule or any policy or action 

of the Coast Guard. 

C. Collection of Information 

This rule will not call for a new 

collection of information under the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 3501–3520). 

D. Federalism and Indian Tribal 

Governments 

A rule has implications for federalism 

under Executive Order 13132, 

Federalism, if it has a substantial direct 

effect on the States, on the relationship 

between the national government and 

the States, or on the distribution of 

power and responsibilities among the 

various levels of government. We have 

analyzed this rule under that Order and 

have determined that it is consistent 

with the fundamental federalism 

principles and preemption requirements 

described in Executive Order 13132. 

Also, this rule does not have tribal 

implications under Executive Order 

13175, Consultation and Coordination 

with Indian Tribal Governments, 

because it does not have a substantial 

direct effect on one or more Indian 

tribes, on the relationship between the 

Federal Government and Indian tribes, 

or on the distribution of power and 

responsibilities between the Federal 

Government and Indian tribes. If you 

believe this rule has implications for 

federalism or Indian tribes, please 

contact the person listed in the FOR

FURTHER INFORMATION CONTACT section 

above. 

E. Unfunded Mandates Reform Act 

The Unfunded Mandates Reform Act 

of 1995 (2 U.S.C. 1531–1538) requires 

Federal agencies to assess the effects of 

their discretionary regulatory actions. In 

particular, the Act addresses actions 

that may result in the expenditure by a 

State, local, or tribal government, in the 

aggregate, or by the private sector of 

$100,000,000 (adjusted for inflation) or 

more in any one year. Though this rule 

will not result in such an expenditure, 

we do discuss the effects of this rule 

elsewhere in this preamble. 

F. Environment 

We have analyzed this rule under 

Department of Homeland Security 

Directive 023–01 and Commandant 

Instruction M16475.1D, which guide the 

Coast Guard in complying with the 

National Environmental Policy Act of 

1969 (42 U.S.C. 4321–4370f), and have 

determined that this action is one of a 

category of actions that do not 

individually or cumulatively have a 

significant effect on the human 

environment. This rule involves a safety 

zone surrounding the vessels and 

machinery being used by personnel to 

repair the Wilsonville Wastewater 

Treatment Plant outfall. It is 

categorically excluded from further 

review under paragraph L60(a) of 

Appendix A, Table 1 of DHS Instruction 

Manual 023–01–001–01, Rev. 01. A 

Record of Environmental Consideration 

supporting this determination is 

available in the docket where indicated 

under ADDRESSES. 

G. Protest Activities 

The Coast Guard respects the First 

Amendment rights of protesters. 

Protesters are asked to contact the 

person listed in the FOR FURTHER

INFORMATION CONTACT section to 

coordinate protest activities so that your 

message can be received without 

jeopardizing the safety or security of 

people, places or vessels. 

List of Subjects in 33 CFR Part 165 

Harbors, Marine safety, Navigation 

(water), Reporting and recordkeeping 

requirements, Security measures, 

Waterways. 

For the reasons discussed in the 

preamble, the Coast Guard amends 33 

CFR part 165 as follows: 

PART 165—REGULATED NAVIGATION 

AREAS AND LIMITED ACCESS AREAS 

■ 1. The authority citation for part 165 

continues to read as follows: 

Authority: 33 U.S.C. 1231; 50 U.S.C. 191; 

33 CFR 1.05–1, 6.04–1, 6.04–6, and 160.5; 

Department of Homeland Security Delegation 

No. 0170.1. 

■ 2. Add § 165.T13–0647 to read as 

follows: 

§ 165.T13–0647 Safety Zone; Willamette 

River, Wilsonville, OR. 

(a) Location. The following area is 

designated safety zone: All navigable 

waters of the Willamette River 

surrounding the Wilsonville Wastewater 

Treatment Plant outfall repair vessels 

and machinery located in Wilsonville, 

OR, encompassed by a line connecting 

these points: 45°17′33.1764′′ N, 

122°46′17.3886′′ W; 45°17′31.1958′′ N, 

122°46′18.1092′′ W; 45°17′32.1504′′ N, 

122°46′8.9544′′ W; and 45° 17′ 30.1956′′ 

N, 122° 46′ 8.8746′′ W. 

(b) Regulations. In accordance with 

the general regulations in part 165, 

subpart C, of this chapter, no person 

may enter or remain in the safety zone 

created in this section or bring, cause to 

be brought, or allow to remain in the 

safety zone created in this section any 

vehicle, vessel, or object unless 

authorized by the Captain of the Port or 

his designated representative. 

(c) Enforcement period. This safety 

zone is in effect from July 9, 2018, until 

August 31, 2018. It will be subject to 

enforcement this entire period unless 

the COTP, Columbia River determines it 

is no longer needed. The Coast Guard 

will inform mariners of any change to 

this period of enforcement via Broadcast 

Notice to Mariners. 

(d) Enforcement. Any Coast Guard 

commissioned, warrant, or petty officer 

may enforce the rules in this section. 

Dated: July 6, 2018. 

D.F. Berliner, 

Captain, U.S. Coast Guard, Acting Captain 

of the Port, Sector Columbia River. 

[FR Doc. 2018–14983 Filed 7–12–18; 8:45 am] 

BILLING CODE 9110–04–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 4 

RIN 2900–AP27 

Schedule for Rating Disabilities: Skin 

AGENCY: Department of Veterans Affairs. 

ACTION: Final rule. 

SUMMARY: On August 12, 2016, VA 

published in the Federal Register the 


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proposed rule for Schedule for Rating 

Disabilities: Skin. VA received multiple 

responses during the 60-day comment 

period. This final rule implements the 

Secretary’s proposed rule with limited 

revisions. 

DATES: This rule is effective on August 

13, 2018. 

FOR FURTHER INFORMATION CONTACT: Gary 

Reynolds, M.D., Regulations Staff 

(211C), Compensation Service, Veterans 

Benefits Administration, Department of 

Veterans Affairs, 810 Vermont Avenue 

NW, Washington, DC 20420, (202) 461– 

9700. (This is not a toll-free number.) 

SUPPLEMENTARY INFORMATION: 

Applicability 

In reviewing the proposed rule to 

prepare for publication of the final rule, 

VA determined that the statements 

regarding the applicability date in the 

proposed rule should be revised in 

order to avoid potential misapplication 

of this final rule. In the proposed rule, 

VA stated that the provisions of the new 

regulations would apply to all 

applications for benefits received by VA 

or that are pending before the agency of 

original jurisdiction on or after the 

effective date of the final rule. VA has 

indeed structured some regulations this 

way in the past, due to the dynamics of 

the regulation in question. See 

‘‘Schedule for Rating Disabilities— 

Mental Disorders and Definition of 

Psychosis for Certain VA Purposes,’’ 80 

FR 14308 (March 19, 2015). However, 

for this final rule, VA’s intent is that the 

claims pending prior to the effective 

date will be considered under both old 

and new rating criteria, and whatever 

criteria is more favorable to the veteran 

will be applied. For applications filed 

on or after the effective date, only the 

new criteria will be applied. 

Comments Received 

Ten different commenters (including 

two Veterans Service Organizations) 

submitted comments in response to the 

proposed rule. VA will address their 

comments within the topics below. 

Comments Warranting Revisions to the 

Proposed Rule 

VA has made five changes to the 

proposed rule based on comments 

received. First, two commenters noted 

that additional guidance regarding 

coexistent skin conditions and 

pyramiding might be helpful. VA agrees 

and has added a clarifying note at the 

start of § 4.118(b) which states: ‘‘Two or 

more skin conditions may be combined 

in accordance with § 4.25 only if 

separate areas of skin are involved. If 

two or more skin conditions involve the 

same area of skin, then only the highest 

evaluation shall be used.’’ 

Second, two commenters felt that the 

proposed language ‘‘per 12-month 

period’’ in multiple diagnostic codes 

(DCs) was unclear about which 12- 

month period would be used for 

evaluation purposes. VA concurs and 

has revised the criteria to specify that 

‘‘over the past 12-month period’’ is the 

applicable time frame for these DCs. 

Third, a commenter asserted that the 

evaluation criteria for eczema (DC 7806) 

should consider itching. Eczema (also 

known as atopic dermatitis) is often 

called ‘‘the itch that rashes.’’ The 

intense itching (without lesions at first) 

leads to the scratching, resulting in the 

characteristic lesions. See 

‘‘Dermatology’’ 210 (Jean Bolognia et al. 

eds., 3d ed. 2012). Thus, itching is part 

of the pathology in all eczema ratings, 

even though only involved areas 

(lesions, scars) are considered for 

compensation purposes. Based on this 

comment, VA has clarified that it is the 

area of lesions, not the itching, that 

forms the basis of a rating, by revising 

in this final rule each criteria level in 

the General Rating Formula for the Skin 

to include the phrase ‘‘Characteristic 

lesions involving. . . .’’ 

Fourth, a commenter expressed 

concern that a long-lasting urticarial 

attack with no breaks would qualify for 

a 10% rating, rather than a 60% rating 

under DC 7825 (Urticaria). VA 

understands this concern and has 

revised the criteria in this final rule to 

be based on the condition’s response to 

required treatment. First, VA has 

retitled the diagnostic code, ‘‘Chronic 

urticaria’’ and added a definition for 

chronic urticaria, which is ‘‘continuous 

urticaria at least twice per week, off 

treatment, for a period of six weeks or 

more.’’ A subset of patients has chronic 

urticaria that is unresponsive to first 

line treatment (antihistamines). If a 

patient is also unresponsive to second 

line treatment (e.g., epinephrine, 

corticosteroids, aminosalicylates), it is 

considered refractory chronic urticaria. 

It was, and continues to be, VA’s intent 

to have evaluation levels that clearly 

and distinctly reflect increasing 

disability. To that end, VA has revised 

the evaluation criteria to more clearly 

establish three distinct levels of 

disability: (1) Chronic urticaria 

requiring first line treatment for control, 

(2) chronic urticaria requiring second 

line treatment for control, and (3) 

chronic urticaria which is refractory to 

both first line and second line 

treatment. A non-exhaustive list of 

examples for first line, second line, and 

third line treatment is given with each 

evaluation level. This should ensure, 

commensurate with the commenter’s 

concern, that more severe and less 

controllable urticarial attacks receive 

higher ratings. 

Fifth, a commenter asked if active 

psoriatic arthritis would be entitled to a 

60% evaluation under DC 7816 

(Psoriasis) and a 100% evaluation under 

DC 5009 (Arthritis, other types), 

allowing for special monthly 

compensation at the ‘‘s’’ level, i.e., 

housebound. To clarify that separate 

ratings are permissible, VA has added 

the term ‘‘separately’’ to the note in DC 

7816. Special monthly compensation 

would be warranted under 38 CFR 

3.350(i)(1), if the psoriasis and the 

arthritis constitute ‘‘separate and 

distinct’’ disabilities ‘‘involving 

different anatomical segments or bodily 

systems.’’ 

Beyond the changes made in response 

to comments, this final rule contains 

several technical and non-substantive 

amendments to the proposed rule. 

Comments Related to Systemic and 

Topical Therapy and Johnson v. 

McDonald 

A total of six comments either 

disagreed with or questioned VA’s 

proposal for defining topical and 

systemic therapy in light of the Johnson 

v. McDonald decision of the U.S. Court 

of Appeals for Veterans Claims (CAVC) 

in 2016. That decision found that any 

use of a topically-applied corticosteroid 

constituted ‘‘systemic therapy’’ 

pursuant to diagnostic code 7806. 

However, in July 2017, the U.S. Court of 

Appeals for the Federal Circuit (Federal 

Circuit) reversed the CAVC’s 

interpretation. See Johnson v. Shulkin, 

862 F.3d 1351 (Fed. Cir. 2017). The 

Federal Circuit held that the CAVC was 

incorrect to ‘‘read DC 7806 as 

unambiguously elevating any form of 

corticosteroid treatment, including any 

degree of topical corticosteroid 

treatment, to the level of ‘systemic 

therapy.’’’ Id. at 1354. 

Although VA’s proposal for systemic 

and topical therapy was in part a 

reaction to the CAVC’s now-reversed 

Johnson decision, its aim was also to 

provide clarity for raters adjudicating 

these claims. VA proposed to clarify 

that treatment administered through the 

skin is ‘‘topical therapy,’’ while 

treatment administered through any 

route other than the skin (orally, 

injection, suppository, intranasally) is 

‘‘systemic therapy.’’ This final rule 

adopts VA’s proposal. One theme of the 

comments was that topically-applied 

medications could be considered 

systemic therapy or could have systemic 

effects. In this regard, one commenter 

questioned why VA does not provide 


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more information as to the potential 

systemic effects of topically-applied 

corticosteroids, and another asserted 

that topically-applied medications can 

cause heightened effects in elderly 

populations. 

As noted in the supplementary 

information to the proposed rule, 

however, it creates a dramatic 

disconnect to rate a medication applied 

to the skin—affecting only the localized 

area to which it is applied—as 

‘‘systemic therapy’’ that affects the 

entire body. Rather, the prevailing 

medical understanding is that ‘‘topical’’ 

therapy ‘‘pertain[s] to a particular 

surface area . . . and affect[s] only the 

area to which it is applied,’’ while 

‘‘systemic’’ therapy ‘‘pertain[s] to or 

affect[s] the body as a whole.’’ Dorland’s 

Illustrated Medical Dictionary 1865, 

1940 (32d ed. 2012). VA’s proposal, 

adopted as a final rule here, sets clear 

guidelines in accordance with this 

understanding: creams applied to the 

skin are ‘‘topical therapy,’’ and 

treatments applied in a way (orally, 

intranasally, etc.) that the medication 

circulates throughout the entire body 

and suppresses the immune system as a 

whole are ‘‘systemic therapy.’’ 

VA also acknowledged in the 

supplementary information that some 

medications applied to the skin, if 

administered on a large enough scale, 

could have a systemic effect; but in 

those situations the veteran can obtain 

a higher rating due to the percentage of 

the body affected. For example, a 

veteran who is required to apply a 

cream on his entire body is not subject 

to a noncompensable rating; even 

though he is not taking systemic 

therapy, he would obtain a compensable 

rating under this final rule based on the 

percentage of his body affected by the 

condition. 

Overall, the aim of this rule is to 

clarify the terms used in the rating 

schedule, in order to distinguish 

between a condition that affects a large 

portion of the body or requires therapy 

affecting the entire body, and a 

condition that is localized and involves 

localized treatment. The former 

generally impairs earning capacity more 

than the latter. To the extent that 

topically-applied medications might 

affect different people (such as the 

elderly) in different ways, the rating 

schedule is based on the average 

impairment in earning capacity. 38 

U.S.C. 1155. If there is an exceptional or 

unusual effect of applying corticosteroid 

cream, a claimant can submit argument 

for an extraschedular rating. 38 CFR 

3.321(b)(1). VA can also raise the issue 

of an extraschedular rating on its own 

when the evidence of record suggests 

such consideration is appropriate. This 

is why VA cannot provide more specific 

information on the potential systemic 

effects of topically-applied 

corticosteroids: the potency of the 

medication, the amount of skin affected, 

and the strength of the condition, will 

vary from veteran to veteran. 

One comment on this topic advocated 

that VA should automatically assume 

that topical corticosteroids have 

systemic effects based on the benefit-ofthe-doubt standard. The benefit-of-thedoubt rule, however, applies to the 

adjudication of claims, not formulation 

of the rating schedule. 38 U.S.C. 

5107(b). This commenter further stated 

that certain skin conditions cannot be 

cured, but only treated, and that the 

burden of applying medication with 

little effect is not taken into 

consideration in the proposed rule. To 

the contrary, frequency in application is 

a factor in the schedule for rating 

systemic therapy, but it remains VA’s 

assessment that applying cream on the 

skin of less than 5% of the body reflects 

a condition that does not impair earning 

capacity at a compensable level. 

Two additional commenters viewed 

the proposed rule as an attempt to 

circumvent or undermine the CAVC’s 

ruling. These comments are obviated by 

the fact that the CAVC’s ruling has been 

reversed. See Johnson v. Shulkin, supra. 

But even if it had not been reversed, it 

is well established that a judicial 

interpretation of regulatory language 

does not preclude an agency from 

revising that language (for prospective 

application) pursuant to its rulemaking 

authority. See Nat’l Org. of Veterans 

Advocates Inc., v. Sec’y of Veterans 

Affairs, 260 F.3d 1365, 1373 (Fed. Cir. 

2001) (argument that CAVC holdings 

prevent revision of regulations 

‘‘seriously misunderstand[s] . . . the 

nature of the judicial function.’’). VA 

may clarify the rating schedule to 

accord with its original intent in 

promulgating these diagnostic codes. 

One of these commenters added that 

skin conditions can cause real pain and 

embarrassment and should not be 

devalued. We understand this concern, 

but the objective criteria of (1) 

percentage of body affected and (2) 

mode and frequency of therapy are 

better suited in determining average 

impairment of earning capacity than an 

individual’s level of embarrassment. 

Another commenter questioned the 

consistency of the proposed definition 

for systemic therapy with DC 6602 and 

the overall rating schedule. This rule is 

consistent with DC 6602—which 

defines ‘‘systemic’’ corticosteroids as 

‘‘oral or parenteral,’’ i.e., the 

corticosteroids that circulate throughout 

the body and affect the entire immune 

system. We are unaware, and the 

commenter does not provide further 

information, as to how the rule is 

inconsistent with other portions of the 

rating schedule. 

Finally, two commenters asserted that 

VA is emphasizing topical treatment in 

order to save money at the expense of 

quality care. This rule, however, should 

not affect how doctors treat conditions; 

rather, its aim is to clarify terms for 

raters adjudicating claims. We are not 

aware of any VA instruction that its 

doctors prescribe topical treatment to 

save money when it is not best for the 

patient. 

Comments Recommending Revisions to 

Evaluation Criteria 

A number of comments recommended 

revisions to criteria within the proposed 

rule. VA received two comments 

regarding DC 7806, Dermatitis or 

eczema. One comment has been 

addressed above and prompted a 

revision to this final rule. The other 

comment requested that VA include 

biopsy results in the evaluation criteria, 

because eczema can occur sporadically 

over the year and a doctor might only 

take account of what is observable 

during the examination. VA declines to 

make changes based upon this 

comment. The General Rating Formula 

for the Skin employs two routes to 

compensation, based on either the 

extent of skin involvement or the 

intensity of treatment. If the condition 

requires constant or near-constant 

systemic therapy, then, regardless of the 

extent of skin involvement at the time 

of examination, the veteran would be 

entitled to the highest evaluation. It is 

unclear how criteria based on biopsy 

results would be more favorable to 

veterans than this scheme. Moreover, 

obtaining a biopsy for every ratable skin 

condition is not necessarily appropriate, 

and a service-connected veteran is free 

to request an additional examination if 

a skin disorder becomes more extensive 

than what was observed during a given 

examination. VA received two 

comments concerning DC 7817, 

Erythroderma. One comment asked why 

the ‘‘treatment failure’’ language was 

incorporated into the proposed criteria 

when the term ‘‘uncontrolled’’ in the 

evaluation criteria for diabetes (DC 

7913) ‘‘was found to be problematic.’’ 

VA incorporated language regarding 

‘‘treatment failure’’ here because it is 

easily measured and can be applied by 

rating officials with consistent results. 

Treatment failure is a common 

occurrence with erythroderma, and we 

see no connection to the term 

‘‘uncontrolled’’ in a diagnostic code for 


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a different condition (diabetes) that was 

revised over two decades ago. The 

second comment asked whether VA 

would use the new DC 7817 criteria for 

pending appeals. As explained above, 

VA will only apply the new criteria to 

pending appeals if it is advantageous to 

the appellant. 

One comment addressed DC 7824, 

Diseases of keratinization. The 

commenter stated that we would be 

underrating diseases of keratinization by 

moving them to the General Rating 

Formula for the Skin, where it would 

not account for systemic manifestations. 

While VA concurs that the term 

‘‘systemic manifestations’’ is not 

employed within the General Rating 

Formula for the Skin, this change does 

not adversely affect the veteran. Under 

the version of DC 7824 that is being 

revised by this final rule, a veteran 

needs both ‘‘systemic manifestations’’ 

and ‘‘systemic medication’’ for a 30% or 

60% rating if there is not generalized 

cutaneous involvement. Now, under 

this final rule, a veteran with a disease 

of keratinization can receive such a 

rating for taking ‘‘systemic therapy’’ 

even without any systemic 

manifestations. This change simplifies 

the evaluation for veterans with diseases 

of keratinization. 

Three comments requested changes to 

DC 7825, Urticaria, and DC 7826, 

Vasculitis, primary cutaneous. One 

comment has been addressed above, 

resulting in a revision to the final rule. 

Another comment asserted that the term 

‘‘documented’’ in DC 7826 should not 

require evidence of a visit to a 

physician, clinic, or hospital, because 

those already on medication may not 

seek medical attention if they are used 

to managing their condition. That 

commenter requested that VA clarify 

that lay evidence fulfills the 

‘‘documented’’ standard. 

VA understands that lay evidence 

must be considered when VA 

adjudicators evaluate a claim, and 

nothing in this final rule is meant to 

undercut that principle. On the other 

hand, virtually the entire VA ratings 

schedule requires some kind of 

documentation or objective testing in 

order to gauge the severity of a 

disability. In that vein, this final rule 

requires that vasculitic episodes be 

‘‘documented’’ for a higher rating. 

Though the rule does not state that the 

only acceptable documentation is a 

doctor’s contemporaneous confirmation, 

a veteran whose disease is not under 

control and continues to prompt 

episodes would most likely see a 

provider multiple times within a 12- 

month period. 

The third commenter found it 

problematic that the criteria would 

allow mild, frequent attacks to be rated 

higher than more severe and longer 

attacks. This commenter also stated that 

a reliance on treatment modality is 

problematic, because biologics are 

impossible for veterans with weakened 

immune systems and others are 

prescribed unevenly. 

VA’s change to DC 7825 in this final 

rule obviates this comment, as the 

urticaria criteria are no longer reliant on 

the number of attacks. VA also disagrees 

that basing evaluation criteria on 

treatment modality is problematic. Each 

line of treatment for chronic urticaria 

(first line, second line, or third line) has 

more than one treatment option 

available, so the fact that one particular 

option is poorly tolerated does not 

imply that veterans will be inaccurately 

rated. 

VA received three comments 

involving areas of affected skin, 

including requests to add forearms and 

lower legs as exposed areas. One of the 

commenters explained that, in summer 

temperatures, veterans cannot be 

expected to work with their forearms 

and lower legs covered. A second stated 

that there is no equitable definition of 

exposed skin, and doctors are 

commonly recommending more 

sunlight for psoriasis. The third 

suggested the work group identify 

which technique for measuring the area 

of involved skin would be best suited 

for evaluation purposes. 

VA will not make any revisions to the 

final rule based on the above comments, 

as VA is unaware of any occupations 

that require exposed forearms or lower 

legs, i.e., mandate such exposure as part 

of the job. Furthermore, dermatologists 

(who are the subject matter experts 

when it comes to conditions affecting 

the skin) have already decided how to 

calculate involved skin area and what 

constitutes a routinely exposed area; 

and the established medical practice in 

that field is to consider only the head, 

neck, and hands consistently and truly 

exposed, as long-sleeved shirts and fulllength pants have customarily been 

considered part of the typical clothing 

used in occupational settings. There is 

no justification, medical or otherwise, to 

change from established practice. Lastly, 

a treatment recommendation to get more 

sunlight for psoriatic skin neither 

precludes nor interferes with 

employment, and thus should have no 

bearing on the rating criteria. 

VA received two comments about 

alopecia, specifically DC 7830, Scarring 

alopecia, and DC 7831, Alopecia areata. 

One comment asserted that DC 7831 

should provide a compensable rating for 

loss of scalp hair, since it is an exposed 

area. The other comment recommended 

a higher evaluation under DC 7830 for 

women, because this condition is more 

socially debilitating for women and, as 

a result, women incur a higher financial 

responsibility to deal with the 

condition. VA is sympathetic to these 

issues and understands the social 

aspects of hair loss. Nevertheless, the 

rating schedule is based on the loss of 

wage-earning capacity and no reliable 

evidence establishes significant 

occupational impairment with loss of 

body hair, or that occupational 

impairment is greater in women than in 

men with scarring alopecia. As such, 

VA will not revise the final rule based 

on these two comments. 

As to the final comments, one 

requested a note adding consideration of 

the effect of disfigurement on the 

veteran’s mental health. VA 

acknowledges that secondary service 

connection under 38 CFR 3.310 may be 

possible for a mental health disability 

that is found to be causally related to a 

service-connected skin disability. 

However, we believe this is clear from 

38 CFR 3.310, such that a note is not 

necessary here. The second questioned 

why evaluation criteria do not comment 

on conditions caused by the failure of 

the immune system, such as 

lymphedema, which affect the skin and 

may require compression therapy. 

Although lymphedema may be 

evaluated under diagnostic codes 

pertaining to the skin if it disfigures 

and/or scars the skin, see 38 CFR 4.116, 

DC 7627–7628 (evaluating lymphedema 

‘‘under the appropriate diagnostic 

code(s) within the appropriate body 

system’’), it is ultimately a lymphatic 

condition, not a skin condition, such 

that its consideration would be outside 

the scope of both the proposed and final 

rules for the skin. 

Comments Regarding Interplay of 

Regulations 

VA received a number of comments 

seeking clarification or guidance on the 

interplay between section 4.118 and 

other regulations. 

Three comments implicated the 

relationship between part 3 regulations 

and section 4.118. One comment 

regarding multiple ratings for psoriatic 

arthritis has been addressed above, 

resulting in a revision in this final rule. 

Another comment asked if VA would 

service connect disabilities to other 

body systems resulting from the 

treatment of skin conditions. Generally, 

yes, VA may grant secondary service 

connection as long as the standards 

found in 38 CFR 3.310 are met. 


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A third comment questioned the 

consistency between the definition of 

chronic in 38 CFR 3.380 (diseases of 

allergic etiology) and the definition in 

DCs 7825 and 7826. No inconsistencies 

exist, as 38 CFR 3.380 addresses service 

connection, while DCs 7825 and 7826 

address evaluation, and none of these 

provisions address the term ‘‘chronic.’’ 

This commenter continued by stating: 

‘‘Confusion regarding ‘service 

connection’ and evaluation criteria 

applies to the ‘continuous use’ and 

‘disabling effects of medication’ to 

suggest that VA will concede secondary 

service connection [38 CFR 3.310] in 

cases with facts similar to those 

described (or are these functional 

impairments simply acute and 

transitory or will this be pyramiding?).’’ 

VA finds this portion of the comment 

unclear and is unable to respond. 

The remaining comments covered the 

relationship between section 4.118 and 

other part 4 regulations. One commenter 

assumed that combined ratings would 

result from DCs 7801 and 7802. To the 

contrary, the General Rating Formula for 

the Skin instructs the rater to use the 

relevant criteria or rate under DCs 7800, 

7801, 7802, 7804, or 7805. Hence, the 

guidance precludes combining of 

disability criteria in this regard. Another 

comment asked about the difference 

between the six zones of the body in 38 

CFR 4.118 and the five anatomic zones 

of 38 CFR 4.55(b). VA intends that the 

six zones in this final rule are specific 

for the skin and not intended to reflect 

a global standard to be applied for all 

body systems. Yet another comment 

asked about the difference between 

‘‘anogenital region’’ (noted in DC 7829) 

and ‘‘pruritus ani’’ (DC 7337), and 

whether these ratings may be combined. 

‘‘Anogenital region’’ is an anatomic area 

that may be affected by chloracne (DC 

7829), whereas ‘‘pruritus ani’’ is an 

itching near the rectum. VA may 

separately evaluate these conditions and 

combine them in accordance with 38 

CFR 4.25. 

Still another assertion involving DC 

7829 and other part 4 regulations was 

that ‘‘[i]ntertriginous areas and 

limitation of function are problematic. 

The axilla of the arm and the range of 

motion of the shoulder are similar to the 

facts in [Cullen v. Shinseki, 24 Vet. App. 

74 (2010)].’’ We discern no problem in 

the language of DC 7829 or conflict with 

Cullen. VA may separately evaluate 

disability related to acne (skin) and a 

disability affecting the shoulder 

(musculoskeletal). One last question 

presented by this commenter asked if 

the reference to ‘‘skin folds of the 

breasts’’ in DC 7829 could be used to 

justify a 20 percent evaluation by 

analogy under DC 7628, benign 

neoplasms. Because DC 7628 permits 

rating benign neoplasms as a skin 

condition, such a rating by analogy may 

be possible. 

Comments Recommending Additional 

Diagnostic Codes 

VA received four comments 

recommending additional diagnostic 

codes: One comment recommending 

additional codes generally to reduce 

analogous coding, and three other 

comments recommending codes for 

lymphedema (and/or skin conditions 

caused by immune system failure), 

pressure ulcers, actinic keratoses, and 

rosacea. VA finds these additions 

unnecessary. As noted above, VA may 

evaluate lymphedema which disfigures 

and/or scars the skin under DCs 7801, 

7802, 7804, or 7805. Furthermore, 

pressure ulcers normally are not 

considered a skin condition warranting 

compensation. Actinic keratoses and 

rosacea are not occupationally 

significant. VA is willing to consider 

adding diagnostic codes for skin 

conditions that are occupationally 

significant. 

Comment Outside the Scope of the 

Proposed Rule 

VA received a comment asking why 

the Food and Drug Administration 

could not find another manufacturer for 

EpiPen®. The EpiPen question is well 

outside the scope of this rule, so VA 

will not respond to it. 

Comment Regarding Public Access 

The last issue raised by a commenter 

dealt with public access to the materials 

developed by the Skin Disorders Work 

Group after a public forum in New York 

City in January 2012 but before the 

drafting of the proposed rule. 

Specifically, the commenter requested 

that the information developed and 

shared by the work group should be 

publicly available. 

In the SUPPLEMENTARY INFORMATION to 

the proposed rule, VA included 

information about the Skin Disorders 

Work Group. See 81 FR 53353, 53353 

(Aug. 12, 2016). As noted, the stated 

goals of the work group included 

improving and updating VA Schedule 

for Rating Disabilities (VASRD) criteria, 

and inviting public participation; this 

process included presentations on areas 

of expertise and interaction with the 

public at a public forum in January 

2012. (A transcript of this public forum 

and all related materials are on file and 

available for public inspection in the 

Office of Regulation and Policy 

Management. Contact information for 

that office is noted in the ADDRESSES

section of the proposed rule. See 81 FR 

at 53358.) The work group served as an 

initial call to various subject matter 

experts and Veterans Service 

Organizations to provide a preliminary 

review of the VASRD from both internal 

and external stakeholders. 

VA emphasizes that this review of the 

VASRD was not an opportunity for work 

group members to participate in the 

deliberative rulemaking process; the 

work group discussed the general topic 

of the VASRD body system and 

provided feedback on the areas that 

were subject to advances since the last 

major revision of the body system. To 

this end, where changes to the scientific 

and/or medical nature of a given 

condition were made in the proposed 

rule, VA cited the published, publiclyavailable source for these changes. Not 

only did this provide the public with 

access to the source for a given 

proposed change, it also confirmed that 

VA relied upon peer-reviewed scientific 

and medical information to support a 

given change. While similar information 

may have been presented by a work 

group member, VA relied upon the 

published document(s) as the primary 

source for a change and included such 

sources in the administrative record for 

this rulemaking. VA did not propose 

scientific and/or medical changes to the 

VASRD in the absence of publicly 

available, peer-reviewed sources. 

Accordingly, references in the 

proposed rule to the work group serve 

as an explanatory background and 

introduction to the VASRD rewrite 

project; the changes made by this 

rulemaking are not a reflection of the 

work group or any work group member. 

All changes based on scientific and/or 

medical information are a reflection of 

cited, published materials which are 

available to the public. VA has made 

deliberative materials available (via 

citation in the rulemaking) and is 

providing access to materials from the 

public forum available for public 

inspection at the Office of Regulation 

Policy and Management. 

Effective Date of Final Rule 

Veterans Benefits Administration 

personnel utilize the Veterans Benefits 

Management System for Rating (VBMS– 

R) to process disability compensation 

claims that involve disability 

evaluations made under the VASRD. In 

order to ensure that there is no delay in 

processing veterans’ claims, VA must 

coordinate the effective date of this final 

rule with corresponding VBMS–R 

system updates. As such, this final rule 

will apply effective August 13, 2018, the 

date VBMS–R system updates related to 

this final rule will be complete. 


sradovich on DSK3GMQ082PROD with RULES
Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 32597 

Executive Orders 12866, 13563, and 

13771 

Executive Orders 12866 and 13563 

direct agencies to assess the costs and 

benefits of available regulatory 

alternatives and, when regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, and other advantages; 

distributive impacts; and equity). 

Executive Order 13563 (Improving 

Regulation and Regulatory Review) 

emphasizes the importance of 

quantifying both costs and benefits, 

reducing costs, harmonizing rules, and 

promoting flexibility. Executive Order 

12866 (Regulatory Planning and 

Review) defines a ‘‘significant 

regulatory action,’’ which requires 

review by the Office of Management and 

Budget (OMB), as ‘‘any regulatory action 

that is likely to result in a rule that may: 

(1) Have an annual effect on the 

economy of $100 million or more or 

adversely affect in a material way the 

economy, a sector of the economy, 

productivity, competition, jobs, the 

environment, public health or safety, or 

State, local, or tribal governments or 

communities; (2) Create a serious 

inconsistency or otherwise interfere 

with an action taken or planned by 

another agency; (3) Materially alter the 

budgetary impact of entitlements, 

grants, user fees, or loan programs or the 

rights and obligations of recipients 

thereof; or (4) Raise novel legal or policy 

issues arising out of legal mandates, the 

President’s priorities, or the principles 

set forth in this Executive Order.’’ 

The economic, interagency, 

budgetary, legal, and policy 

implications of this regulatory action 

have been examined and it has been 

determined not to be a significant 

regulatory action under Executive Order 

12866. VA’s impact analysis can be 

found as a supporting document at 

http://www.regulations.gov, usually 

within 48 hours after the rulemaking 

document is published. Additionally, a 

copy of the rulemaking and its impact 

analysis are available on VA’s website at 

http://www.va.gov/orpm by following 

the link for ‘‘VA Regulations Published 

from FY 2004 through Fiscal Year to 

Date.’’ This rule is not an Executive 

Order 13771 regulatory action because 

this rule is not significant under 

Executive Order 12866. 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this final rule will not have a significant 

economic impact on a substantial 

number of small entities as they are 

defined in the Regulatory Flexibility Act 

(5 U.S.C. 601–612). This rule would 

directly affect only individuals and 

would not directly affect small entities. 

Therefore, pursuant to 5 U.S.C. 605(b), 

this rulemaking is exempt from the 

initial and final regulatory flexibility 

analysis requirements of sections 603 

and 604. 

Unfunded Mandates 

The Unfunded Mandates Reform Act 

of 1995 requires, at 2 U.S.C. 1532, that 

agencies prepare an assessment of 

anticipated costs and benefits before 

issuing any rule that may result in the 

expenditure by State, local, and tribal 

governments, in the aggregate, or by the 

private sector, of $100 million or more 

(adjusted annually for inflation) in any 

one year. This final rule will have no 

such effect on State, local, and tribal 

governments, or on the private sector. 

Paperwork Reduction Act 

This final rule contains provisions 

constituting a collection of information 

under the Paperwork Reduction Act of 

1995 (44 U.S.C. 3501–3521). 

Specifically, this final rule is associated 

with information collections related to 

the application for disability benefits 

(VA Form 21–526EZ), as well as 

Disability Benefits Questionnaires 

(DBQs), which enable a claimant to 

gather the necessary information from 

his or her treating physician as to the 

current symptoms and severity of a 

disability (VA Forms 21–0960F–1, 

Scars/Disfigurement DBQ, and 21– 

0960F–2, Skin Diseases DBQ). These 

information collections are currently 

approved by the Office of Management 

and Budget (OMB) and have been 

assigned OMB control numbers 2900– 

0749 (for the application) and 2900– 

0776 (for the DBQs). VA has reviewed 

the impact of this final rule on these 

information collections and determined 

that the incremental information 

collection burden for the first year of 

this rule is $8,828.20. 

Catalog of Federal Domestic Assistance 

The Catalog of Federal Domestic 

Assistance number and title for the 

program affected by this document is 

64.109, Veterans Compensation for 

Service-Connected Disability. 

Signing Authority 

The Secretary of Veterans Affairs, or 

designee, approved this document and 

authorized the undersigned to submit it 

to the Office of the Federal Register for 

electronic publication as an official 

document of the Department of Veterans 

Affairs. Jacquelyn Hayes-Byrd, Acting 

Chief of Staff, Department of Veterans 

Affairs, approved this document on June 

28, 2018, for publication. 

List of Subjects in 38 CFR Part 4 

Disability benefits, Pensions, 

Veterans. 

Dated: June 28, 2018. 

Jeffrey M. Martin, 

Impact Analyst, Office of Regulation Policy 

& Management, Office of the Secretary, 

Department of Veterans Affairs. 

For the reasons set out in the 

preamble, the Department of Veterans 

Affairs amends 38 CFR part 4, subpart 

B, as follows: 

PART 4—SCHEDULE FOR RATING 

DISABILITIES 

Subpart B—Disability Ratings 

■ 1. The authority citation for part 4 

continues to read as follows: 

Authority: 38 U.S.C. 1155, unless 

otherwise noted. 

■ 2. Amend § 4.118 as follows: 

■ a. Remove the introductory text; 

■ b. Add paragraphs (a) and (b) before 

the table; 

■ c. Revise the entries for diagnostic 

codes 7801, 7802, and 7805; 

■ d. Add an entry for ‘‘GENERAL 

RATING FORMULA FOR THE SKIN 

FOR DCs 7806, 7809, 7813–7816, 7820– 

7822, AND 7824’’, to appear after the 

entry for diagnostic code 7805; and 

■ e. Revise the entries for diagnostic 

codes 7806, 7809, 7813, 7815–7817, 

7820–7822, and 7824–7829. 

The revisions and additions read as 

follows: 

§ 4.118 Schedule of ratings–skin. 

(a) For the purposes of this section, 

systemic therapy is treatment that is 

administered through any route (orally, 

injection, suppository, intranasally) 

other than the skin, and topical therapy 

is treatment that is administered 

through the skin. 

(b) Two or more skin conditions may 

be combined in accordance with § 4.25 

only if separate areas of skin are 

involved. If two or more skin conditions 

involve the same area of skin, then only 

the highest evaluation shall be used. 


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32598 Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 

Rating 

*******

7801 Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue 

damage: 

Area or areas of 144 square inches (929 sq. cm.) or greater ............................................................................................................. 40 

Area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) ....................................... 30 

Area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) ........................................... 20 

Area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) ............................................... 10 

Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, 

and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk.

Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code.

7802 Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue 

damage: 

Area or areas of 144 square inches (929 sq. cm.) or greater ............................................................................................................. 10 

Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, 

and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk.

Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code.

*******

7805 Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804: 

Evaluate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800–04 under an appropriate diagnostic code.

General Rating Formula For The Skin For DCs 7806, 7809, 7813–7816, 7820–7822, and 7824: 

At least one of the following ................................................................................................................................................................. 60 

Characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or 

Constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, 

photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the 

past 12-month period ........................................................................................................................................................................ 60 

At least one of the following ................................................................................................................................................................. 30 

Characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or 

Systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or 

other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month 

period.

At least one of the following ................................................................................................................................................................. 10 

Characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or 

At least 5 percent, but less than 20 percent, of exposed areas affected; or 

Intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, 

PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period.

No more than topical therapy required over the past 12-month period and at least one of the following .......................................... 0 

Characteristic lesions involving less than 5 percent of the entire body affected; or 

Characteristic lesions involving less than 5 percent of exposed areas affected.

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 

predominant disability. This rating instruction does not apply to DC 7824.

7806 Dermatitis or eczema. 

Evaluate under the General Rating Formula for the Skin.

* * * * * * * 

7809 Discoid lupus erythematosus. 

Evaluate under the General Rating Formula for the Skin.

Note: Do not combine with ratings under DC 6350.

* * * * * * * 

7813 Dermatophytosis (ringworm: Of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of 

nails, tinea unguium (onychomycosis); of inguinal area (jock itch), tinea cruris; tinea versicolor). 

Evaluate under the General Rating Formula for the Skin.

7815 Bullous disorders (including pemphigus vulgaris, pemphigus foliaceous, bullous pemphigoid, dermatitis herpetiformis, 

epidermolysis bullosa acquisita, benign chronic familial pemphigus (Hailey-Hailey), and porphyria cutanea tarda). 

Evaluate under the General Rating Formula for the Skin.

Note: Rate complications and residuals of mucosal involvement (ocular, oral, gastrointestinal, respiratory, or genitourinary) separately under the appropriate diagnostic code.

7816 Psoriasis. 

Evaluate under the General Rating Formula for the Skin.

Note: Rate complications such as psoriatic arthritis and other clinical manifestations (e.g., oral mucosa, nails) separately under 

the appropriate diagnostic code.

7817 Erythroderma: 

Generalized involvement of the skin with systemic manifestations (such as fever, weight loss, or hypoproteinemia) AND one of 

the following ...................................................................................................................................................................................... 100 


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Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 32599 

Rating 

Constant or near-constant systemic therapy such as therapeutic doses of corticosteroids, other immunosuppressive drugs, 

retinoids, PUVA (psoralen with long-wave ultraviolet-A light), UVB (ultraviolet-B light) treatments, biologics, or electron beam 

therapy required over the past 12 month period; or 

No current treatment due to a documented history of treatment failure with 2 or more treatment regimens ..................................... 100 

Generalized involvement of the skin without systemic manifestations and one of the following.

Constant or near-constant systemic therapy such as therapeutic doses of corticosteroids, other immunosuppressive drugs, 

retinoids, PUVA, UVB treatments, biologics, or electron beam therapy required over the past 12-month period; or ....................

No current treatment due to a documented history of treatment failure with 1 treatment regimen .................................................... 60 

Any extent of involvement of the skin, and any of the following therapies required for a total duration of 6 weeks or more, but

not constantly, over the past 12-month period: systemic therapy such as therapeutic doses of corticosteroids, other immunosuppressive drugs, retinoids, PUVA, UVB treatments, biologics, or electron beam therapy .......................................................... 30 

Any extent of involvement of the skin, and any of the following therapies required for a total duration of less than 6 weeks over 

the past 12-month period: systemic therapy such as therapeutic doses of corticosteroids, other immunosuppressive drugs, 

retinoids, PUVA, UVB treatments, biologics, or electron beam therapy .......................................................................................... 10 

Any extent of involvement of the skin, and no more than topical therapy required over the past 12-month period .......................... 0 

Note: Treatment failure is defined as either disease progression, or less than a 25 percent reduction in the extent and severity 

of disease after four weeks of prescribed therapy, as documented by medical records.

* * * * * * * 

7820 Infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic diseases). 

Evaluate under the General Rating Formula for the Skin.

7821 Cutaneous manifestations of collagen-vascular diseases not listed elsewhere (including scleroderma, calcinosis cutis, 

subacute cutaneous lupus erythematosus, and dermatomyositis). 

Evaluate under the General Rating Formula for the Skin.

* * * * * * * 

7822 Papulosquamous disorders not listed elsewhere (including lichen planus, large or small plaque parapsoriasis, pityriasis 

lichenoides et varioliformis acuta (PLEVA), lymphomatoid papulosus, mycosis fungoides, and pityriasis rubra pilaris (PRP)). 

Evaluate under the General Rating Formula for the Skin.

* * * * * * * 

7824 Diseases of keratinization (including icthyoses, Darier’s disease, and palmoplantar keratoderma). 

Evaluate under the General Rating Formula for the Skin.

7825 Chronic urticaria: 

For the purposes of this diagnostic code, chronic urticaria is defined as continuous urticaria at least twice per week, off treatment, for a period of six weeks or more.

Chronic refractory urticaria that requires third line treatment for control (e.g., plasmapheresis, immunotherapy, 

immunosuppressives) due to ineffectiveness with first and second line treatments ....................................................................... 60 

Chronic urticaria that requires second line treatment (e.g., corticosteroids, sympathomimetics, leukotriene inhibitors, neutrophil 

inhibitors, thyroid hormone) for control ............................................................................................................................................. 30 

Chronic urticaria that requires first line treatment (antihistamines) for control .................................................................................... 10 

7826 Vasculitis, primary cutaneous: 

Persistent documented vasculitis episodes refractory to continuous immunosuppressive therapy .................................................... 60 

All of the following ................................................................................................................................................................................ 30 

Recurrent documented vasculitic episodes occurring four or more times over the past 12-month period; and 

Requiring intermittent systemic immunosuppressive therapy for control ............................................................................................. 30 

At least one of the following ................................................................................................................................................................. 10 

Recurrent documented vasculitic episodes occurring one to three times over the past 12-month period, and requiring intermittent

systemic immunosuppressive therapy for control; or 

Without recurrent documented vasculitic episodes but requiring continuous systemic medication for control.

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 

predominant disability.

7827 Erythema multiforme; Toxic epidermal necrolysis: 

Recurrent mucosal, palmar, or plantar involvement impairing mastication, use of hands, or ambulation occurring four or more 

times over the past 12-month period despite ongoing immunosuppressive therapy ....................................................................... 60 

All of the following ................................................................................................................................................................................ 30 

Recurrent mucosal, palmar, or plantar involvement not impairing mastication, use of hands, or ambulation, occurring four or 

more times over the past 12-month period; and requiring intermittent systemic therapy.

At least one of the following ................................................................................................................................................................. 10 

One to three episodes of mucosal, palmar, or plantar involvement not impairing mastication, use of hands, or ambulation, occurring over the past 12-month period AND requiring intermittent systemic therapy; or 

Without recurrent episodes, but requiring continuous systemic medication for control.

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 

predominant disability.

Note: For the purposes of this DC only, systemic therapy may consist of one or more of the following treatment agents: 

immunosuppressives, antihistamines, or sympathomimetics.

7828 Acne: 

Deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck ................................... 30 

Deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or deep acne other 

than on the face and neck ................................................................................................................................................................ 10 

Superficial acne (comedones, papules, pustules) of any extent ................................................................................................................ 0 

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 

predominant disability.

7829 Chloracne: 


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32600 Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 

Rating 

Deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck ................................... 30 

Deep acne (deep inflamed nodules and pus-filled cysts) affecting the intertriginous areas (the axilla of the arm, the anogenital 

region, skin folds of the breasts, or between digits) ........................................................................................................................ 20 

Deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck; or deep acne affecting non-intertriginous areas of the body (other than the face and neck) ................................................................................... 10 

Superficial acne (comedones, papules, pustules) of any extent ......................................................................................................... 0 

Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 

predominant disability.

* * * * * * * 

■ 3. Amend appendix A to part 4 in the 

table under Sec. 4.118 by revising the 

entries for diagnostic codes 7801, 7802, 

7805, 7806, 7809, 7813, 7815 through 

7817, and 7820–7833 to read as follows: 

Appendix A to Part 4—Table of 

Amendments and Effective Dates Since 

1946 

Section Diagnostic 

Code No. 

*******

4.118 ........ 7800 Evaluation August 30, 2002; criterion October 23, 2008. 

7801 Criterion July 6, 1950; criterion August 30, 2002; criterion October 23, 2008; title, note 1, note 2 August 13, 2018. 

7802 Criterion September 22, 1978; criterion August 30, 2002; criterion October 23, 2008; title, note 1, note 2 August 

13, 2018. 

*******

7805 Criterion October 23, 2008; title August 13, 2018. 

General Rating Formula for DCs 7806, 7809, 7813–7816, 7820–7822, and 7824 added August 13, 2018. 

7806 Criterion September 9, 1975; evaluation August 30, 2002; criterion August 13, 2018. 

*******

7809 Criterion August 30, 2002; title, criterion August 13, 2018. 

*******

7813 Criterion August 30, 2002; title, criterion August 13, 2018. 

*******

7815 Evaluation August 30, 2002; criterion, note August 13, 2018. 

7816 Evaluation August 30, 2002; criterion, note August 13, 2018. 

7817 Evaluation August 30, 2002; title, criterion, note August 13, 2018. 

*******

7820 Added August 30, 2002; criterion August 13, 2018. 

7821 Added August 30, 2002; title, criterion August 13, 2018. 

7822 Added August 30, 2002; title, criterion August 13, 2018. 

7823 Added August 30, 2002; criterion August 13, 2018. 

7824 Added August 30, 2002; criterion August 13, 2018. 

7825 Added August 30, 2002; title, criterion August 13, 2018. 

7826 Added August 30, 2002; criterion August 13, 2018. 

7827 Added August 30, 2002; criterion August 13, 2018. 

7828 Added August 30, 2002; criterion August 13, 2018. 

7829 Added August 30, 2002; criterion August 13, 2018. 

7830 Added August 30, 2002; criterion August 13, 2018. 

7831 Added August 30, 2002; criterion August 13, 2018. 

7832 Added August 30, 2002; criterion August 13, 2018. 

7833 Added August 30, 2002; criterion August 13, 2018. 

*******

■ 4. Amend appendix B to part 4 under 

the heading ‘‘THE SKIN’’ by revising the 

entries for diagnostic codes 7801, 7802, 7805, 7809, 7813, 7817, 7821, 7822, and 

7825 to read as follows: 

Appendix B to Part 4—Numerical Index 

of Disabilities 


sradovich on DSK3GMQ082PROD with RULES
Federal Register / Vol. 83, No. 135 / Friday, July 13, 2018 / Rules and Regulations 32601 

Diagnostic 

Code No. 

*******

THE SKIN 

*******

7801 ......... Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are associated with underlying soft tissue damage. 

7802 ......... Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are not associated with underlying soft tissue damage. 

* * * * * * * 

7805 ......... Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804. 

* * * * * * * 

7809 ......... Discoid lupus erythematosus. 

* * * * * * * 

7813 ......... Dermatophytosis. 

* * * * * * * 

7817 ......... Erythroderma. 

* * * * * * * 

7821 ......... Cutaneous manifestations of collagen-vascular diseases not listed elsewhere. 

7822 ......... Papulosquamous disorders not listed elsewhere. 

* * * * * * * 

7825 ......... Chronic urticaria. 

* * * * * * * 

■ 5. Amend appendix C to part 4 as 

follows: 

■ a. Revise the entry for ‘‘Cutaneous 

manifestations of collagen-vascular 

diseases’’ (diagnostic code 7821); 

■ b. Add in alphabetical order an entry 

for ‘‘Erythroderma’’; 

■ c. Remove the entry for ‘‘Exfoliative 

dermatitis’’; 

■ d. Revise the entry for ‘‘Scars’’; and 

■ e. Revise the entry for ‘‘Urticaria’’ 

(diagnostic code 7825). 

The revisions and addition read as 

follows: 

Appendix C to Part 4—Alphabetical 

Index of Disabilities 

Diagnostic 

Code No. 

*******

Cutaneous manifestations of collagen-vascular diseases not listed elsewhere ................................................................................. 7821 

* * * * * * * 

Erythroderma ....................................................................................................................................................................................... 7817 

*******

Scars: 

Burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of 

the head, face, or neck ............................................................................................................................................................. 7800 

Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are associated with underlying soft tissue 

damage ..................................................................................................................................................................................... 7801 

Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck that are not associated with underlying soft tissue damage .............................................................................................................................................................................. 7802 

Retina ........................................................................................................................................................................................... 6011 

Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804 ................................... 7805 

Unstable or painful ....................................................................................................................................................................... 7804 

*******

Urticaria, chronic. .......................................................................................................................................................................... 7825 

*******

[FR Doc. 2018–14957 Filed 7–12–18; 8:45 am] 

BILLING CODE 8320–01–P 


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