8474 Federal Register / Vol. 87, No. 31 / Tuesday, February 15, 2022 / Proposed Rules 

Viewing material in docket. To view 

documents mentioned in this proposed 

rule as being available in the docket, 

find the docket as described in the 

previous paragraph, and then select 

‘‘Supporting & Related Material’’ in the 

Document Type column. Public 

comments will also be placed in our 

online docket and can be viewed by 

following instructions on the https://

www.regulations.gov Frequently Asked 

Questions web page. We review all 

comments received, but we will only 

post comments that address the topic of 

the proposed rule. We may choose not 

to post off-topic, inappropriate, or 

duplicate comments that we receive. 

Personal information. We accept 

anonymous comments. Comments we 

post to https://www.regulations.gov will 

include any personal information you 

have provided. For more about privacy 

and submissions to the docket in 

response to this document, see DHS’s 

eRulemaking System of Records notice 

(85 FR 14226, March 11, 2020). 

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 is proposing 

to amend 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: 46 U.S.C. 70034, 70051; 33 CFR 

1.05–1, 6.04–1, 6.04–6, and 160.5; 

Department of Homeland Security Delegation 

No. 00170.1, Revision No. 01.2. 

■ 2. Add § 165.T05–0040 to read as 

follows: 

§ 165.T05–0040 Security Zone, Delaware 

River, Philadelphia, PA. 

(a) Location. The following area is a 

security zone: All waters within the 

Delaware River, contiguous with the 

Pennsylvania shoreline and extending 

out into the Delaware River 

approximately 250 yards, within an area 

bounded by a line connecting the 

following points: Beginning at the 

Pennsylvania shoreline at latitude 

39°56.87′ N, longitude 075°8.36′ W, 

thence east to latitude 39°56.85′ N, 

longitude 075°8.20′ W, thence south to 

latitude 39°56.45′ N, longitude 075°8.25′ 

W, thence west to the Pennsylvania 

shoreline at latitude 39°56.47′ N, 

longitude 075°8.41′ W, thence north 

following the shoreline to the 

originating point. These coordinates are 

based on North American Datum 83 

(NAD83). 

(b) Definitions. As used in this 

section— 

Designated representative means any 

Coast Guard commissioned, warrant or 

petty officer who has been designated 

by the Captain of the Port Delaware Bay 

(COTP) to act on his or her behalf. The 

designated representative may be on an 

official patrol vessel or may be on shore 

and will communicate with vessels via 

VHF–FM radio or loudhailer. In 

addition, members of the Coast Guard 

Auxiliary may be present to inform 

vessel operators of the regulations in 

this section. 

Very important person (VIP) means 

any person for whom the United States 

Capital Police request implementation 

of a security zone in order to 

supplement protection of said person(s). 

Official patrol vessel means any Coast 

Guard, Coast Guard Auxiliary, State, or 

local law enforcement vessel assigned or 

approved by the COTP. 

(c) Regulations. (1) In accordance with 

the general regulations contained in 

subpart D of this part, entry into or 

remaining in the zone described in 

paragraph (a) of section is prohibited 

unless authorized by the COTP, Sector 

Delaware Bay, or designated 

representative. 

(2) Only vessels or people specifically 

authorized by the Captain of the Port, 

Delaware Bay, or designated 

representative, may enter or remain in 

the regulated area. Access to the zone 

will be determined by the COTP or 

designated representative on a case-bycase basis when the zone is enforced. To 

seek permission to enter, contact the 

COTP or the COTP’s representative on 

VHF–FM channel 13 or 16. Those in the 

security zone must comply with all 

lawful orders or directions given to 

them by the COTP or the COTP’s 

designated representative. No person 

may swim upon or below the surface of 

the water of this security zone unless 

authorized by the COTP or his 

designated representative. 

(3) Upon being hailed by an official 

patrol vessel or the designated 

representative, by siren, radio, flashing 

light or other means, the operator of the 

vessel shall proceed as directed. Failure 

to comply with lawful direction may 

result in expulsion from the regulated 

area, citation for failure to comply, or 

both. 

(4) Unless specifically authorized by 

on scene enforcement vessels, any 

vessel granted permission to enter or 

transit the security zones must comply 

with the instructions of the COTP or 

designated representative and operate at 

bare steerage or no-wake speed while 

transiting through the Security Zone, 

and must not loiter, stop, or anchor, and 

shall do so for the entirety of its time 

within the boundaries of the security 

zones. 

(d) Enforcement. (1) This security 

zone is effective from 11 a.m. on March 

9, 2022, through 11:59 p.m. on March 

11, 2022. 

(2) This security zone will be enforced 

with actual notice by the U.S. Coast 

Guard representatives on scene, as well 

as other methods listed in § 165.7. The 

Coast Guard will enforce the security 

zone created by this section only when 

it is necessary for the protection and 

security of the VIPs attending the 

Democratic National Caucus in the 

vicinity of Penns Landing located in 

Philadelphia, PA. The U.S. Coast Guard 

may be additionally assisted in the 

patrol and enforcement of the zone by 

Federal, State, and local agencies. 

Dated: February 9, 2022. 

Leon McClain, Jr., 

Captain, U. S. Coast Guard, Alternate Captain 

of the Port, Delaware Bay. 

[FR Doc. 2022–03132 Filed 2–14–22; 8:45 am] 

BILLING CODE 9110–04–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Parts 3 and 4 

RIN 2900–AQ72 

Schedule for Rating Disabilities—Ear, 

Nose, Throat, and Audiology 

Disabilities; Special Provisions 

Regarding Evaluation of Respiratory 

Conditions; Schedule for Rating 

Disabilities—Respiratory System 

AGENCY: Department of Veterans Affairs. 

ACTION: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) proposes to revise sections 

that address the ear, nose, throat, 

audiology, and respiratory systems. The 

purpose of these changes is to update 

medical terminology, incorporate 

medical advances that have occurred 

since the last review, and provide welldefined criteria in accordance with 

actual clinical practice. VA will also 

rename the body system currently 

designated for conditions related to 

hearing and the ear, to include the nose 

and throat. VA will also consolidate 

within the scope of otolaryngology 

several diagnostic codes (DCs) currently 

listed within the respiratory system. 

DATES: VA must receive comments on or 

before April 18, 2022. 

ADDRESSES: Comments may be 

submitted through 


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www.Regulations.gov. Comments 

received will be available at 

www.Regulations.gov for public 

viewing, inspection or copies. 

FOR FURTHER INFORMATION CONTACT: Gary 

Reynolds, M.D., Medical Officer, 

Regulations Staff (210), 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 telephone 

number.) 

SUPPLEMENTARY INFORMATION: As part of 

its ongoing revision of the Schedule for 

Rating Disabilities (VASRD, or the 

Rating Schedule), VA is proposing 

changes to the portions of the VASRD 

that address the audiology system, 

which VA last addressed in 1999 (see 64 

FR 25202), as well as the respiratory 

system, which VA last addressed in 

2006 (see 71 FR 52457). The proposed 

rule reflects advances in medical 

knowledge, recommendations from VA 

experts in audiology and respiratory 

conditions, and comments from experts 

and the public gathered during an 

October 2011 forum in New York City. 

VA proposes to incorporate more 

current respiratory and auditory 

terminology and apply current 

standards of assessing and evaluating 

impairment. Where changes to the 

scientific and/or medical nature of a 

given condition have been proposed, 

VA has cited the published, publiclyavailable sources for these changes. The 

proposed changes are not a reflection of 

any particular expert’s comments or 

recommendations but were based on 

published, peer-reviewed materials. 

Materials from the public forum are 

available for public inspection at the 

Office of Regulation Policy and 

Management (see the ADDRESSES section 

of this rulemaking), and other 

deliberative materials are cited herein. 

VA also intends to reorganize the 

Rating Schedule so its classifications of 

injuries and diseases more closely 

resemble those used in health care. This 

reorganization involves moving several 

diagnostic codes (DCs) from ‘‘The 

Respiratory System’’ to a new body 

system designated as ‘‘Ear, Nose, Throat, 

and Auditory Disabilities.’’ 

I. The Respiratory System 

A. Proposed Changes to 38 CFR 4.96 

VA proposes to revise § 4.96 to clarify, 

simplify, and eliminate redundancies in 

the special provisions regarding 

respiratory conditions. Paragraph (a) 

currently precludes simultaneous 

ratings for specific coexisting 

respiratory conditions. VA proposes to 

amend paragraph (a) by simply stating 

that VA may not combine, under 38 CFR 

4.25, Combined Ratings Table, 

coexisting respiratory conditions unless 

otherwise directed. Under this proposed 

rule, the only respiratory disability that 

VA may combine with other respiratory 

disabilities is DC 6847, sleep apnea. The 

proposed rule notes which DCs may be 

combined with DC 6847. 

VA does not propose any change to 

current paragraph (b), which discusses 

veterans who received, or were entitled 

to receive, compensation for 

tuberculosis as of August 19, 1968. 

VA proposes to remove paragraph (c), 

which deals with special monthly 

compensation (SMC) for complete 

organic aphonia. Complete organic 

aphonia, currently evaluated under DC 

6519, is among those disabilities that 

VA is proposing to move to the new 

body system, ‘‘Ear, Nose, Throat, and 

Auditory Disabilities,’’ as DC 6230, with 

a footnote discussing SMC. Therefore, 

the respiratory system no longer 

requires this paragraph. 

As a result of this deletion, VA 

intends to redesignate current paragraph 

(d) as paragraph (c). The current 

paragraph (d) provides information on 

the use of pulmonary function tests 

(PFTs) to evaluate the severity of certain 

respiratory conditions. As discussed in 

detail below, VA proposes to evaluate a 

number of respiratory conditions using 

a General Rating Formula for 

Respiratory Conditions (General Rating 

Formula), which reference various 

PFTs. As such, VA proposes to amend 

the subheading for revised § 4.96(c) to 

expand the list of all DCs that VA will 

rate using the General Rating Formula. 

Within revised paragraph (c), VA 

proposes to amend subparagraph (1). 

Currently, § 4.96(d)(1)(ii) states that 

PFTs are not necessary when an 

individual is diagnosed with pulmonary 

hypertension, cor pulmonale, or right 

ventricular hypertrophy. A new DC 

addressing the requirements for 

‘‘pulmonary hypertension’’ (discussed 

below) is being proposed herein. 

Furthermore, the proposed General 

Rating Formula for Respiratory 

Conditions includes METS as an 

evaluation criteria, which are the same 

evaluation criteria used in the General 

Rating Formula for Diseases of the 

Heart. This means cor pulmonale and 

right ventricular hypertrophy can both 

be evaluated within the respiratory 

system under its General Rating 

Formula. Therefore, the current 

subparagraph (d)(1)(ii) will no longer be 

necessary. With the absence of that 

subparagraph, VA proposes to 

redesignate current subparagraphs 

(d)(1)(iii) and (d)(1)(iv) as subparagraphs 

(c)(1)(ii) and (c)(1)(iii), respectively. 

Current subparagraph (d)(2) discusses 

the use of diffusion capacity of the lung 

for carbon monoxide by the single 

breath method (DLCO (SB)). The new 

General Rating Formula and proposed 

pulmonary hypertension code have 

sufficient alternative criteria to evaluate 

respiratory disabilities when the DLCO 

(SB) is not available. VA may still 

consider using DLCO (SB) to evaluate 

respiratory disabilities, but VA will not 

require it and the examiner need not 

state why the test would not be useful 

or valid in a particular case. 

Accordingly, VA proposes to delete 

current subparagraph (d)(2). 

VA proposes to remove current 

subparagraphs (d)(4) and (d)(5). These 

paragraphs discuss the need for postbronchodilator studies during 

examinations, except in certain 

circumstances, and the need to utilize 

post-bronchodilator results as a more 

accurate value in evaluating respiratory 

disabilities. VA proposes to remove 

these subparagraphs because whether 

pre- or post-bronchodilator studies 

accurately reflect an individual’s 

medical condition is a medical 

determination and therefore is more 

appropriately decided by a medical 

practitioner and/or examiner; this 

information should be considered as 

part of the medical record, to include 

treatment notes and/or examination. 

Therefore, there is no need to instruct 

rating personnel on the use of postbronchodilator studies. 

VA also proposes to remove current 

subparagraph (d)(7) because it is 

inaccurate. Obstructive respiratory 

disease may be present, ratable, and 

compensable even though both Forced 

Expiratory Volume in one second (FEV– 

1) and Forced Vital Capacity (FVC) are 

greater than 100 percent. See Matthew 

J. Hegewald and Robert O. Crapo, 

‘‘Pulmonary Function Testing,’’ Murray 

and Nadel’s Textbook of Respiratory 

Medicine 527–28 (5th ed. 2010). 

As a result of the above deletions, VA 

intends to redesignate current 

subparagraph (d)(3) as (c)(2), and 

redesignate current subparagraph (d)(6) 

as (c)(3), with no substantive changes. 

Finally, VA proposes to add a new 

paragraph (d), Respiratory conditions 

and comorbid cardiovascular 

conditions. A MET is defined as the 

amount of oxygen consumed by a 

person at rest. This measurement is 

used to calculate the energy cost of a 

specific activity in multiples of the 

amount of oxygen consumed by a 

person at rest. Oxygen consumption is 

possible through the integrated 

operation of two distinct body systems, 

the cardiovascular and respiratory 

systems. The respiratory system 


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captures and collects oxygen, while the 

cardiovascular system delivers the 

oxygen to muscles (including the heart 

itself) performing the work associated 

with a specific activity. See M. Jette. 

‘‘Metabolic Equivalents (METS) in 

Exercise Testing, Exercise Prescription, 

and Evaluation of Functional Capacity,’’ 

13(8) Clin. Cardiol. 555–65 (1990). 

Typically, when disability affects 

either the cardiovascular or respiratory 

systems, it is easy to apportion 

disability using METs to the affected 

system. However, when both the 

cardiovascular and respiratory systems 

are involved, it is difficult to apportion 

the contribution to the observed 

disability by each system. To avoid the 

potential rating complications posed by 

situations where coexistent 

cardiovascular and respiratory 

disabilities can be evaluated using 

METs, VA will instruct raters to 

evaluate only one body system using 

METs and evaluate the other body 

system using criteria other than METs, 

absent instructions otherwise in 

individual DCs. (The evaluation levels 

for METs will be the same in both 

cardiovascular and respiratory 

systems—that is, the METs yielding a 60 

percent evaluation level in the 

cardiovascular system will yield the 

same evaluation in the respiratory 

system.) The General Rating Formula for 

Respiratory Conditions in § 4.97 lists 

several types of test results that can be 

used to evaluate a respiratory condition. 

When METs are used to evaluate a 

respiratory disability under 

§ 4.97, they will not be used to evaluate 

a comorbid cardiovascular disability 

under § 4.104, and vice versa. Raters 

will use METs in the evaluation of the 

disability that would provide the 

veteran with the most advantageous 

combined rating. 

B. Proposed Changes to 38 CFR 4.97 

This proposed rule addresses VA’s 

outdated organization of the DCs within 

the current respiratory schedule. This 

rule also updates diagnostic naming 

conventions and evaluation criteria 

according to modern medical practice. 

1. Removal of ‘‘Diseases of the Nose and 

Throat’’ 

VA proposes to remove the heading 

‘‘Diseases of the Nose and Throat.’’ As 

discussed in more detail below, VA is 

relocating DCs 6502 through 6524, 

currently located under this heading, to 

38 CFR 4.87, as they share similarities 

in features, impairment assessment, and 

severity levels. Such similarities are 

more closely related to the disability 

criteria that VA will propose for the ear, 

nose, and throat schedule. 

2. General Rating Formula for 

Respiratory Conditions 

VA also proposes adding the General 

Rating Formula to the beginning of the 

respiratory system. The proposed 

formula incorporates much of the 

criteria currently used by several DCs 

for respiratory conditions, notably DCs 

6600, 6603, 6604, 6825 through 6833, 

and 6840 through 6845. VA designed 

the proposed General Rating Formula to 

more succinctly organize the Rating 

Schedule by referring applicable DCs to 

a single formula, rather than repeating 

the same formula after each DC to which 

it applies. The introduction of the 

General Rating Formula for Respiratory 

Conditions revises the criteria for 

multiple DCs. 

VA derived the model for the General 

Rating Formula from the table entitled 

‘‘Pulmonary Dysfunction’’ in Guides to 

the Evaluation of Permanent 

Impairment 88 (Robert D. Rondinelli et 

al. eds., 6th ed. 2008). The table defines 

four different levels of impairment 

severity based on FVC, FEV–1, DLCO 

(SB), Maximum Oxygen Consumption 

(VO2 Max), and METs. VA proposes to 

modify these levels to rate respiratory 

conditions. The General Rating Formula 

VA proposes will utilize common PFT 

findings, such as FEV–1, FVC, the ratio 

of FEV–1 to FVC (FEV–1/FVC), and 

DLCO (SB), and continue to utilize most 

of the levels found throughout current 

§ 4.97, as they differ only slightly from 

the levels found in the ‘‘Pulmonary 

Dysfunction’’ table and are generally 

more advantageous to veterans. 

One change from current § 4.97, 

however, is to require less of a reduction 

in FEV–1 to qualify for 100 percent 

disability rating (an FEV–1 of less than 

45 percent of predicted value, rather 

than the current 40 percent), which is 

advantageous to veterans. Another is to 

no longer provide a 100 percent rating 

for outpatient oxygen therapy: The need 

for oxygen is not a sufficiently accurate 

measure of the severity of a disability to 

allow for a consistent evaluation 

without regard to other more objective 

measures. 

VA also proposes to adjust the values 

for maximum oxygen consumption, 

which has a fixed relationship to METs 

(every 3.5 ml of oxygen consumed is 

equal to 1 MET). This modification will 

ensure equity with values already used 

in other body systems using METs to 

evaluate disability (in particular, the 

cardiovascular system). Finally, VA 

proposes to continue utilizing FEV–1/ 

FVC as a PFT that can be used for rating 

purposes despite its absence from the 

‘‘Pulmonary Dysfunction’’ table. 

Note (1) to the proposed General 

Rating Formula will instruct rating 

personnel to base the impairment 

assessment on the criteria that reflects 

the greatest impairment and, therefore, 

the greatest evaluation. Note (2) will 

address combined ratings, consistent 

with proposed § 4.96(a). 

Finally, VA will add Note (3) to the 

proposed General Rating Formula, 

which will address comorbid 

respiratory and cardiovascular 

disabilities in accord with proposed 

§ 4.96(d). As noted above, raters may 

use METs to evaluate the respiratory 

disability under § 4.97 or the 

cardiovascular disability under § 4.104, 

but not both. 

It should be noted that the General 

Rating Formula does not reference cor 

pulmonale and right ventricular 

hypertrophy. Under current § 4.97, some 

evaluation criteria reference cor 

pulmonale and right ventricular 

hypertrophy without an associated 

respiratory system disability. One of 

VA’s goals with this revision is to 

ensure that all evaluation criteria within 

§ 4.97 contain at least one element of 

respiratory disability. Thus, under the 

proposed rule, any cardiovascular 

disabilities incorporated within § 4.97 

will be associated with at least one 

respiratory disability as part of any and 

all evaluation criteria. 

3. Other Changes to § 4.97 

In addition to incorporating the 

General Rating Formula, VA proposes a 

number of organizational changes to the 

respiratory system. Specifically, VA 

proposes removing the current headings 

and subheadings and reorganizing the 

VASRD Respiratory System under two 

broad headings. The first heading will 

be ‘‘Intrinsic Lung Diseases.’’ VA 

proposes to add seven subheadings 

under Intrinsic Lung Diseases: ‘‘Airway 

Disorders (Trachea, Bronchi),’’ 

‘‘Tuberculous Lung Diseases,’’ 

‘‘Vascular Lung Diseases,’’ ‘‘Lung 

Neoplasms,’’ ‘‘Bacterial Lung Diseases,’’ 

‘‘Parenchymal Lung Disease (Including 

Interstitium and Alveolar Spaces),’’ and 

‘‘Mycotic Lung Diseases.’’ The second 

heading that VA proposes is ‘‘Other 

Respiratory Conditions.’’ VA will 

include these remaining respiratory 

diagnoses in accordance with modern 

medical practice. See Peter D. Wagner et 

al., ‘‘Ventilation, Blood Flow and Gas 

Exchange,’’ Murray and Nadel’s 

Textbook of Respiratory Medicine 53–88 

(5th ed. 2010). 

To help the reader understand VA’s 

proposed changes to the individual DCs 

within the Respiratory System, VA has 

organized the following discussion by 

the seven subheadings under Intrinsic 


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Lung Diseases in the order of their 

appearance. VA will then discuss 

changes within the proposed Other 

Respiratory Conditions. 

i. Airway Disorders (Trachea, Bronchi) 

Current DCs 6600 through 6604 shall 

appear in their current order under this 

proposed rule after the subheading 

Airway Disorders (Trachea, Bronchi). 

VA proposes to modify the rating 

criteria for DCs 6600, 6601, 6603, and 

6604 to refer to the General Rating 

Formula, which assesses severity using 

current medical understanding. As 

discussed above, VA is proposing a 

General Rating Formula to simplify 

evaluations and expand the criteria 

upon which to evaluate respiratory 

conditions, to include FEV–1 and METs. 

Regarding DC 6602, bronchial asthma, 

VA proposes to maintain most of the 

current evaluation criteria but 

reorganize how the VASRD presents the 

various criteria for improved usefulness. 

This reorganization is similar to the 

proposed General Rating Formula: Each 

evaluation requires meeting at least one 

of its criteria. 

ii. Tuberculous Lung Diseases 

VA proposes removing the heading 

‘‘Diseases of the Lung and PleuraTuberculosis’’ and replacing it with 

‘‘Tuberculous Lung Diseases.’’ VA 

proposes to retain the current 

subheadings, ‘‘Ratings for Pulmonary 

Tuberculosis Entitled on August 19, 

1968,’’ ‘‘Ratings for Pulmonary 

Tuberculosis Initially Evaluated After 

August 19, 1968,’’ and their 

corresponding DCs. These changes 

organize the DCs along current medical 

practice. 

VA will not substantively alter the 

criteria for evaluating tuberculosis for 

individuals entitled on August 19, 1968, 

though it will delete a statutory 

reference that no longer exists. It also 

will not substantively change the 

current rating instructions for chronic, 

active pulmonary tuberculosis (DC 

6730). However, VA proposes to amend 

the evaluation criteria for DC 6731, 

Chronic, inactive primary pulmonary 

tuberculosis. The current criteria 

evaluate residuals ‘‘as interstitial lung 

disease, restrictive lung disease, or, 

when obstructive lung disease is the 

major residual, as chronic bronchitis 

(DC 6600).’’ The amended rule would 

refer specifically to the General Rating 

Formula and provide notes consistent 

with the language of current DC 6731. 

VA proposes this change because the 

General Rating Formula provides 

sufficient rating criteria for assessing 

residual lung function of this disorder. 

VA proposes no substantive change to 

DC 6732. 

iii. Vascular Lung Diseases 

VA proposes to replace the current 

heading, ‘‘Nontuberculous diseases,’’ 

with the subheading ‘‘Vascular Lung 

Diseases.’’ This arrangement will form 

the third subheading under ‘‘Intrinsic 

Lung Diseases.’’ VA also proposes that 

DC 6817, presently ‘‘Pulmonary 

vascular disease,’’ be renamed as 

‘‘Pulmonary thromboembolic disease.’’ 

The new name reflects current medical 

terminology for the same condition. See 

Timothy A. Morris and Peter F. Fedullo, 

‘‘Pulmonary Thromboembolism,’’ 

Murray and Nadel’s Textbook of 

Respiratory Medicine 1186 (5th ed. 

2010). 

VA proposes the following changes to 

the criteria of DC 6817: (1) Removing 

‘‘primary pulmonary hypertension’’ 

from the 100 percent evaluation criteria, 

because it will be rated under new DC 

6849, (2) removing references to cor 

pulmonale, which can be adequately 

evaluated under the proposed General 

Rating Formula, (3) recharacterizing the 

current note as Note (1), (4) adding a 

note (Note (2)) prohibiting separate 

evaluations for pulmonary 

thromboembolic disease with right 

ventricular hypertrophy and selected 

comorbid cardiovascular conditions in 

order to avoid pyramiding, and (5) 

adding a note (Note (3)) outlining when 

a rating under DC 6817 can be combined 

with other ratings under § 4.97. 

Additionally, VA proposes adding a 

new DC 6849 for ‘‘Pulmonary 

hypertension.’’ Currently, VA rates 

pulmonary hypertension analogously to 

other respiratory conditions. However, 

this common condition has its own 

features and treatments, so evaluations 

analogous to other respiratory DCs may 

be inadequate or inappropriate. As 

indicated previously, medicine assesses 

impairment by changes in right 

ventricular diameter, B-natriuretic 

levels, and mean pulmonary artery 

pressure. The rating criterion VA 

proposes for DC 6849 applies such 

measurements to this unique respiratory 

condition. VA proposes four levels of 

disability, similar to the levels of the 

proposed General Rating Formula. 

Where rating criteria METs levels 

conflict with other METs levels found 

within the cardiovascular system, the 

conflicting METs levels will conform to 

those found within the cardiovascular 

system. See Rondinelli, supra at 71–73. 

Three notes would accompany DC 

6849. The first would state that acute 

pulmonary hypertension is not a 

disability for ratings purposes. VA 

compensates disabilities that impair 

earning capacity, not temporary 

conditions that generally do not impact 

earning capacity. See 38 U.S.C. 1155; 

Davis v. Principi, 276 F.3d 1341, 1345– 

47 (Fed. Cir. 2002); see also Moore v. 

Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 

2009). The second note would prohibit 

separate evaluations for pulmonary 

hypertension and selected coexisting 

cardiovascular conditions; instead, one 

rating would be assigned either under 

DC 6849 or under the appropriate 

cardiovascular DC (38 CFR 4.104), 

whichever represents the predominant 

disability. Compensating the same 

disability under two different body 

systems would represent pyramiding, 

which is impermissible under 38 CFR 

4.14. The third note would outline 

when a rating under DC 6849 can be 

combined with other ratings under 

§ 4.97. 

iv. Lung Neoplasms 

VA next proposes to reorganize DCs 

6819, ‘‘Neoplasms, malignant, any 

specified part of respiratory system 

exclusive of skin growths,’’ and 6820, 

‘‘Neoplasms, benign, any specified part 

of respiratory system,’’ under the 

proposed subheading ‘‘Lung 

Neoplasms.’’ DCs 6819 and 6820 are 

currently listed under ‘‘Nontuberculous 

Diseases.’’ 

VA also proposes to modify the note 

for DC 6819, which currently instructs 

rating personnel to evaluate residuals 

six months after the cessation of all 

forms of active treatment. VA intends to 

refer rating personnel to the General 

Rating Formula because this evaluation 

tool provides the most appropriate 

criteria for assessing residual 

impairment from a malignant lung 

neoplasm. Potential residuals include, 

but are not limited to, removal 

(resection) of a lung (in part or in whole) 

or persistent pleural effusions. 

Similarly, VA proposes that DC 6820, 

benign neoplasms of the respiratory 

system, be rated under the General 

Rating Formula. Currently, DC 6820 

directs rating personnel to ‘‘Evaluate 

using an appropriate respiratory 

analogy.’’ The General Rating Formula 

provides a broad range of alternative 

criteria with which to assess most 

respiratory conditions. 

v. Bacterial Lung Diseases 

VA proposes renaming the heading 

‘‘Bacterial Infections of the Lung’’ to the 

subheading ‘‘Bacterial Lung Diseases.’’ 

DCs 6822 through 6824 will continue to 

appear under Bacterial Lung Diseases. 

VA does not propose any substantive 

criteria changes for the rating formula 

for these DCs. 


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vi. Parenchymal Lung Disease 

(Including Interstitium and Alveolar 

Spaces) 

VA proposes to remove the current 

subheading, ‘‘Interstitial Lung Disease,’’ 

to add instead, ‘‘Parenchymal Lung 

Disease (Including Interstitium and 

Alveolar Spaces).’’ VA also proposes to 

relocate DC 6846 (Sarcoidosis) from the 

current ‘‘Restrictive Lung Disease’’ 

subheading to the newly proposed 

‘‘Parenchymal Lung Disease (Including 

Interstitium and Alveolar Spaces)’’ 

subheading, as sarcoidosis is medicallycategorized as a parenchymal lung 

disease. This new subheading reflects 

modern medical terminology for the 

associated DCs. In addition, VA 

proposes to rate these conditions under 

the General Rating Formula. This 

change will incorporate current medical 

standards for assessing impairment. By 

applying the General Rating Formula, 

VA proposes to expand the types of PFT 

results, to include FEV–1/FVC, and 

METs, to evaluate these conditions. 

In addition, VA proposes to include a 

note for DCs 6825 through 6833 and DC 

6846. This note instructs rating 

personnel to add an additional 10 

percent to any rating during certain 

kinds of treatment, specifically, oral 

prednisone greater than 20 milligrams 

(mg) daily, or daily second-line 

immunosuppressive medication (e.g., 

non-steroidal agents; such 

immunomodulatory drugs as 

azathioprine or cyclophosphamide; antifibrotic agents such as colchicine; 

penicillamine; or biologic agents such as 

etanercept). VA proposes to add this 

additional 10 percent rating because the 

treatments themselves may result in 

adverse effects involving the bloodforming organs or the gastrointestinal 

system. See M. Selman et al., 

‘‘Idiopathic Interstitial Pneumonias,’’ 

Murray and Nadel’s Textbook of 

Respiratory Medicine 1380–81 (5th ed. 

2010). 

VA also proposes to rename DC 6825, 

‘‘Diffuse interstitial fibrosis (interstitial 

pneumonitis, fibrosing alveolitis), to 

’’Diffuse interstitial fibrosis (interstitial 

pneumonitis, fibrosing alveolitis, 

idiopathic fibrosis).’’ The proposed 

name reflects current medical 

terminology. See id. at 1370. 

vii. Mycotic Lung Diseases 

VA also proposes to rename ‘‘Mycotic 

Lung Disease’’ to ‘‘Mycotic Lung 

Diseases’’ and organize DCs 6834 

through 6839 under this subheading. No 

substantive criteria changes are 

proposed for these diseases. 

viii. Other Respiratory Conditions 

The final organizational change VA 

proposes for the respiratory system is 

assembling all remaining respiratory 

disabilities under the heading ‘‘Other 

Respiratory Conditions.’’ VA will 

arrange DCs 6840 through 6847 under 

this heading. 

In addition to moving these DCs 

under the new heading, VA proposes to 

rename DCs 6841 and 6842. 

Specifically, VA intends to rename DC 

6841, currently ‘‘Spinal cord injury with 

respiratory insufficiency,’’ as 

‘‘Respiratory insufficiency due to spinal 

cord injury.’’ As for DC 6842, 

‘‘Kyphoscoliosis, pectus excavatum, 

pectus carinatum,’’ VA proposes to 

rename it as ‘‘Pulmonary disease 

secondary to kyphoscoliosis, pectus 

excavatum, or pectus carinatum.’’ 

Renaming these DCs clarifies that the 

primary disability is related to the 

respiratory system. 

VA proposes that DCs 6840 through 

6846 be rated under the General Rating 

Formula. This proposed change 

modifies the current criteria by, most 

notably, adding FVC and METs as 

additional measures. This proposed 

change favors veterans because it allows 

additional, alternative criteria to assess 

disability that do not currently exist in 

these DCs. As previously discussed, VA 

proposes to change these criteria to 

reflect current medical standards for 

assessing the severity of impairment. 

VA also proposes to modernize the 

rating criteria for DC 6847, ‘‘Sleep 

Apnea Syndromes (Obstructive, Central, 

Mixed)’’ and retitle that DC as ‘‘Sleep 

Apnea Syndromes (Obstructive, Central, 

or Mixed)’’. The discipline of sleep 

medicine has greatly evolved since VA 

published the existing criteria. The 

American Academy of Sleep Medicine 

(AASM), founded since then, conducted 

in-depth, peer-reviewed research in 

conjunction with its partners to develop 

scientifically-refined criteria regarding 

the definition, measurement, and 

treatment of sleep apnea. Sleep apnea 

may be defined as complaints of 

unintentional sleep episodes and/or 

awakenings and/or snoring associated 

with an apnea-hypopnea index (AHI) 

equal to or greater than 5 per hour or, 

alternatively, an asymptomatic patient 

with an AHI greater than 15 per hour. 

See Richard B. Berry, Fundamentals of 

Sleep Medicine 238 (2012). Additional 

findings supporting a diagnosis of sleep 

apnea include oxygen desaturation 

greater than 4 percent and/or a 

reduction in airflow below 70 percent. 

Such measurements can evaluate the 

effectiveness of treatment intervention 

or lifestyle modifications such as weight 

loss. 

VA proposes to extensively revise the 

rating criteria for sleep apnea to 

primarily provide compensation that is 

more compatible with earning 

impairment than the current criteria. 

The current criteria evaluate based upon 

treatment rather than actual 

impairment. VA currently assigns 

higher ratings to individuals when their 

physicians prescribe more intensive 

therapies, such as continuous airway 

pressure (CPAP) machines, without 

regard to whether individuals first tried 

more conservative therapies, such as 

weight loss or oral appliances, or what 

actual impairment continues following 

use of CPAP machines. As discussed 

below, VA’s proposed criteria will focus 

on the result rather than the type of 

treatment. Hence, individuals whose 

treatments are equally effective will 

receive equal disability ratings, 

regardless of the treatments. Individuals 

for whom treatment similarly fails (or is 

only partially effective) will also receive 

similar ratings. These proposed changes 

for sleep apnea comply with 38 U.S.C. 

1155 that the VASRD ratings reflect 

average losses in earning capacity. 

Specifically, VA proposes to assign a 

0 percent evaluation when sleep apnea 

syndrome is asymptomatic, with or 

without treatment. VA would assign a 

10 percent evaluation when treatment 

yields ‘‘incomplete relief.’’ VA would 

assign ratings above 10 percent (e.g., 50 

and 100 percent) only when treatment is 

either ineffective or the veteran is 

unable to use the prescribed treatment 

due to comorbid conditions. VA would 

assign a 100 percent evaluation only if 

there is also end-organ damage. VA 

proposes to include an informational 

note that defines and gives examples of 

qualifying comorbid conditions, i.e., 

conditions that, in the opinion of a 

qualified medical provider, directly 

impede or prevent the use of, or 

implementation of, a recognized form of 

treatment intervention normally shown 

to be effective. 

VA proposes to add a new DC 6848 

for ‘‘Lung transplantation.’’ Lung 

transplantation involves a unique 

treatment that is not addressed in the 

current Rating Schedule. This procedure 

for a service connected pulmonary 

condition results in significant 

disability that is not adequately 

captured by the current rating schedule. 

For one, recovery with pulmonary 

function testing performance usually 

takes about 12 months. Yet outcome 

studies reveal significant variation in 

return to work time. This can be 

explained when you look at the two 

main populations receiving lung 


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transplants. There is a population who 

receive the lung transplant due to 

hereditary/genetic conditions that 

would preclude military service all 

together (such as cystic fibrosis), and 

another population who receive a lung 

transplant due to acquired conditions 

(such as chronic obstructive pulmonary 

disease). VA believes the population 

with lung transplantation due to 

acquired conditions is a better 

characterization of the population of 

veterans who might receive this 

procedure and thus would be eligible 

for compensation. On this basis, VA 

intends to assign a 100 percent 

evaluation for lung transplantation 

surgery, and for one year following 

discharge from the hospital for such 

surgery. Thereafter, consistent with 

other respiratory conditions, VA will 

base the evaluation on residuals 

according to the proposed General 

Rating Formula, but with a minimum 

evaluation of 30 percent. See Lisa 

Cicutto et al., ‘‘Factors Affecting 

Attainment of Paid Employment After 

Lung Transplantation,’’ 23 J. Heart Lung 

Transplant 481–86 (2004); see also 

Dmitry Tumin et al., ‘‘Attained 

Functional Status Moderates Functional 

Outcomes of Return to Work After Lung 

Transplantation,’’ 194 Lung 437–45 

(2016). 

II. Ear, Nose, Throat, and Audiology 

Disabilities 

Otolaryngology is the field of 

medicine concerned with diseases of, 

and injury to, the ears, nose, and throat. 

Currently, the VASRD spreads these 

diseases and conditions among several 

systems. This disbursement of diseases 

and conditions amongst several body 

systems does not represent the current 

scientific and medical understanding of 

the specific anatomy, etiology, and 

disabling effect of diseases and 

conditions of the ears, nose, and throat. 

Reorganization of these diseases and 

conditions to reflect current medical 

and scientific practice improves rating 

efficiency and effectiveness by allowing 

for easy identification of the medical 

source for each rating and reducing the 

need to rely on analogous codes when 

evaluating certain disabilities. 

The system titled ‘‘Impairment of 

Auditory Acuity,’’ found at 38 CFR 

4.85–4.87, already includes conditions 

of hearing and the ear, including the 

symptom of tinnitus (ringing in the ear), 

hearing loss, vestibular disorders 

(dizziness), neoplasms (tumors), and 

infections. For the reasons discussed 

above, VA proposes to rename the body 

system ‘‘Ear, Nose, Throat, and Auditory 

Disabilities’’ and relocate 16 DCs from 

§ 4.97, the Respiratory System, to § 4.87. 

Under § 4.87, VA will redesignate DCs 

6502 through 6524 as DCs 6220 through 

6235, respectively. VA discusses in 

more detail below any changes to the 

sections and/or DCs under this new 

arrangement (e.g., §§ 4.85 through 4.87). 

A. Audiology and Hearing Loss 

1. Defining Hearing Loss Disability 

VA considered expanding the current 

definition of hearing loss, located at 38 

CFR 3.385, to include the concept of 

acoustic ‘‘notches’’ (see below). 

However, VA concluded that the current 

definition of hearing loss is sufficient 

and fair for evaluating levels of 

disability. 

Noise exposure is often associated 

with a pattern of hearing loss across 

frequencies referred to as ‘‘noise 

notches’’ or a ‘‘notch.’’ According to a 

2006 Institute of Medicine (IOM) study, 

a noise notch typically shows hearing 

that is normal or nearly normal at lower 

frequencies (less than 2000 Hertz (Hz)), 

with worse hearing thresholds typically 

occurring at frequencies in the 3000– 

6000 Hz region, with better hearing 

thresholds at 8000 Hz. IOM, Noise and 

Military Service: Implications for 

Hearing Loss and Tinnitus 38 (The 

National Academies Press, 2006). A 

notched pattern in the 3000–6000 Hz 

frequency region, together with 

supporting evidence from a detailed 

case history, can lead to the diagnosis of 

noise-induced hearing loss. However, 

this characteristic pattern in the high 

frequencies is not limited to noiseinduced hearing loss. The highfrequency hearing loss pattern from 

aging is indistinguishable from the 

cumulative effects of noise-induced 

hearing loss. See Linda M. Luxon, ‘‘The 

clinical diagnosis of noise induced 

hearing loss,’’ Biological Effects of Noise 

83–113 (Deepak Prasher and Linda 

Luxon eds. 1998); Victor Osei-Lah and 

L.H. Yeoh, ‘‘High-frequency audiometric 

notch: an outpatient clinic survey,’’ 

49(2) Int’l J. of Audiology 95–98 (2010). 

More recent publications examined 

noise notches in the veteran population 

to again define the presence or absence 

of a noise notch more objectively than 

by simply relying on the visual pattern 

of high frequency hearing loss. See, e.g., 

Richard H. Wilson and Rachel McArdle, 

‘‘Characteristics of the Audiometric 

4,000 Hz Notch (744,553 veterans) and 

3,000, 4,000 and 6,000 Hz Notches 

(539,932 veterans),’’ 50 J. of 

Rehabilitative Research and 

Development 111–32 (2013); Ross Coles 

et al., ‘‘Guidelines on the diagnosis of 

noise-induced hearing loss for 

medicolegal purposes,’’ 25(4) Clin. 

Otolaryngology 264–73 (2000). 

However, the observed pattern of 

hearing loss in these studies neither 

rebutted nor confirmed noise injuries. In 

the Wilson and McArdle study, nothing 

indicated that notched audiograms were 

characteristic of audiograms in veterans 

of any age. Similarly, Coles et al. noted 

that the presence of notches was not 

indicative of noise exposure because 

such configurations were found in 

people with no significant noise 

exposure and not in persons with 

known exposure. Given the results of 

these studies, VA concludes that 

including notches in a definition of 

hearing loss disability would not 

rationally justify compensation benefits 

to veterans. Therefore, VA proposes no 

substantive changes to the current 

definition in § 3.385. 

2. Proposed Changes to Audiology 

Although VA will not alter its 

definition of hearing loss for 

compensation purposes, it proposes 

several updates of the current 

terminology found in 38 CFR 3.385, 

4.85–4.86. VA also proposes a note to 

§ 4.85 adding a 10 percent evaluation for 

noncompensable hearing loss with 

tinnitus present, where tinnitus is 

related to the diagnosis of hearing loss. 

i. Terminology Updates 

VA proposes a number of 

nonsubstantive changes for readability 

and to update terminology according to 

current medicine. VA proposes to 

replace the terms ‘‘speech recognition’’ 

and ‘‘speech discrimination’’ with 

‘‘word recognition’’ in § 3.385 and 

throughout § 4.85. Although used 

interchangeably, the term most 

frequently used today is ‘‘word 

recognition.’’ 

VA also proposes to replace the term 

‘‘hearing impairment’’ or ‘‘impaired 

hearing’’ with ‘‘hearing loss’’ throughout 

Part 3 and Part 4, as ‘‘hearing loss’’ is 

more commonly used today. 

In addition, VA proposes to change 

the spelling of ‘‘puretone’’ throughout 

§§ 4.85 and 4.86, to include tables VI 

and VIA. According to Dorland’s 

Illustrated Medical Dictionary 179 (32d 

ed. 2012), two words form the correct 

spelling, i.e., ‘‘pure tone’’ or, as a 

compound adjective before the noun, 

‘‘pure-tone threshold.’’ 

During the October 2011 audiology 

forum, VA received a recommendation 

to clarify the units that it uses to 

measures hearing loss. Therefore, VA 

also proposes to add to 4.85, paragraph 

(a), ‘‘Hearing levels are measured in 

decibels and expressed as dB HL.’’ 

Finally, VA proposes to replace the 

term ‘‘rating veterans service 

representative’’ in § 4.86 with ‘‘rating 


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activity.’’ This terminology update 

recognizes that not all claims are 

adjudicated by a rating veterans service 

representative (RVSR); some decisions 

are rendered by a decision review 

officer (DRO) or another individual with 

the proper authority to adjudicate a 

claim for benefits. This terminology 

update does not otherwise change the 

application of the provisions in § 4.86. 

ii. Pure-Tone Air Conduction Threshold 

Currently, VA evaluates hearing loss 

using pure-tone thresholds, but no 

regulation specifies the type of 

measurement. Audiology pure-tone 

threshold uses either air or bone 

conduction testing. See Joe Walter Kutz 

Jr. et al., ‘‘Audiology Pure-Tone 

Testing,’’ Medscape Reference, http://

emedicine.medscape.com/article/ 

1822962-overview#showall (last visited 

July 24, 2018). VA proposes to clarify 

that pure-tone thresholds refer to air 

conduction thresholds throughout 

§§ 3.385, 4.85, and 4.86, to include 

tables VI and VIA. VA chose this 

particular technique because it 

measures the usual mode of hearing. On 

the other hand, bone conduction testing 

is simply a diagnostic tool and one of 

a battery of tests by which audiologists 

determine the etiology and severity of 

hearing loss. To reflect this change, VA 

proposes to replace the term ‘‘puretone 

threshold’’ with ‘‘pure-tone air 

conduction threshold’’ wherever it 

appears in §§ 4.85 and 4.86. Similarly, 

VA also proposes to replace the 

references to ‘‘auditory’’ thresholds in 

§ 3.385 with ‘‘pure-tone auditory air 

conduction’’ thresholds. 

iii. Word Recognition Testing 

Current § 4.85(c) provides that ‘‘Table 

VIA will be used when the examiner 

certifies that use of the speech 

discrimination test is not appropriate 

because of language difficulties, 

inconsistent speech discrimination 

scores, etc., or when indicated under the 

provisions of § 4.86.’’ VA proposes to 

clarify the term ‘‘language difficulties’’ 

with the addition of the phrase ‘‘e.g., 

English non-fluency.’’ Several VA 

audiology experts with whom the 

Veterans Benefits Administration 

consulted noted that the most common 

language difficulty in service members 

is that their first language is not English, 

thus invalidating the speech 

discrimination scores. Additionally, an 

increased number of service members 

have cognitive difficulties resulting 

from traumatic brain injuries. These 

injuries result in decreased speech 

discrimination scores. See, e.g., Henry 

L. Lew et al., ‘‘Audiology dysfunction in 

Traumatic Brain Injury,’’ 44(7) J. of 

Rehabilitation Research & Development 

921–28 (2007). Therefore, VA also 

proposes to add ‘‘cognitive difficulties’’ 

to the list of reasons why word 

recognition testing may be 

inappropriate. 

iv. Percentage Evaluation for Hearing 

Loss (Diagnostic Code 6100) 

VA proposes to revise the evaluation 

criteria for this DC in order to provide 

(1) a 10 percent rating for tinnitus 

associated with service-connected, 

noncompensable hearing loss, and (2) 

two notes pertaining to tinnitus. 

Tinnitus is defined as the perception of 

sound in the absence of an external 

source. In many cases, the patient 

cannot identify the onset or cause of the 

tinnitus. J.L. Stouffer and Richard S. 

Tyler, ‘‘Characterization of tinnitus by 

tinnitus patients,’’ 55(3) J. of Speech and 

Hearing Disorders, 439–53 (Aug. 1990). 

However, current medicine reflects that 

tinnitus likely results from abnormal 

neural activity at some point or points 

in the auditory pathway, which is 

incorrectly interpreted by the brain as 

an actual sound. Id. As a result, it is a 

symptom associated with an underlying 

condition, such as hearing loss, 

Meniere’s disease, traumatic brain 

injury and cerebral atherosclerosis, not 

an independent disease. Id. 

Recognition of tinnitus for evaluation 

purposes dates back to at least 1925, 

when raters were instructed to ‘‘add 15 

[percent] to loss of hearing as a 

combined rating.’’ ‘‘The Schedule for 

Rating of Disability Ratings,’’ U.S. 

Veterans’ Bureau, Table II, p.59 (1925 

ed.). Accordingly, tinnitus was rated in 

conjunction with hearing loss, rather 

than a disease in and of itself. In a final 

rule published in 1976, VA’s rating 

criteria recognized tinnitus for 

evaluation purposes when ‘‘[p]ersistent 

as a symptom of head injury, 

concussion, or acoustic trauma.’’ 41 FR 

11291, 11298 (Mar. 18, 1976). In a final 

rule published in 1999, in part 

motivated by an effort to standardize 

tinnitus evaluations beyond these three 

specific injuries, the regulation was 

changed to award a single 10 percent 

evaluation without mention of the 

underlying condition resulting in 

tinnitus. 64 FR 25202, 25206 (May 11, 

1999). While not intended by VA, this 

rulemaking created the impression that 

tinnitus is an independent condition, 

rather than a symptom associated with 

an underlying condition. VA’s intent 

with the presently proposed revision is 

to accurately restore the medicallysupported relationship between tinnitus 

and an underlying pathology, consistent 

with current medical practice. 

VA proposes to evaluate tinnitus only 

as part of its underlying pathology and 

to delete DC 6260 entirely. In other 

words, tinnitus will be compensated 

through application of DCs 6100, 6204, 

6205, 8045, 8046, or 9305, depending on 

its service-connected cause. For tinnitus 

associated with service-connected 

hearing loss in particular, the presence 

of tinnitus generally does not impact 

earning capacity beyond what is already 

contemplated at the compensable levels 

of hearing loss, though VA recognizes 

that the presence of tinnitus combined 

with noncompensable hearing loss 

could have more than a 0% impact on 

earning capacity. Thus, DC 6100 will 

provide a 10% evaluation for tinnitus 

associated with hearing loss only when 

hearing loss is noncompensable (only 

when hearing loss, on its own, does not 

warrant a 10% evaluation or higher). If 

hearing loss is compensable (warranting 

a 10% evaluation or greater), an 

additional 10% evaluation for tinnitus 

associated with the hearing loss shall 

not be assigned. 

To that end, VA will add two notes 

under DC 6100. The first note will list 

examples of which disabilities 

contemplate tinnitus as a symptom of a 

given underlying pathology. The second 

note will provide that tinnitus is only 

compensated as part of an underlying 

service-connected condition. VA notes 

that this proposal will have no impact 

on veterans currently in receipt of 

service connection for tinnitus under 

DC 6260; these evaluations are governed 

under the provisions of 38 CFR 3.951(a). 

v. DC 6100 and Extraschedular 

Consideration 

In Doucette v. Shulkin, 28 Vet. App. 

366, 373 (2017), the U.S. Court of 

Appeals for Veterans Claims noted the 

potential value if VA ‘‘provide[d] 

additional guidance on what symptoms 

the rating criteria [for hearing loss] 

contemplate.’’ Doucette involved a 

veteran who argued for extraschedular 

consideration under 38 CFR 3.321(b)(1) 

because his hearing loss resulted in 

difficulty distinguishing sounds in a 

crowded environment, locating the 

source of sounds, understanding 

conventional speech, hearing the 

television, and using the telephone. Id. 

at 371. The court held that such 

functional effects of decreased hearing 

and difficulty understanding speech in 

an everyday environment were 

contemplated by the schedular rating 

criteria, id. at 369, 371–72, though a 

dissenting judge argued that the 

‘‘criteria are inadequate to contemplate 

a veteran’s functional effects and entire 

disability picture.’’ Id. at 374 (Schoelen, 

J., dissenting). 


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In response to the court’s statement 

concerning additional guidance, we 

clarify here that DC 6100 contemplates 

all natural or expected effects of 

decreased hearing. It is expected and 

natural that a veteran with hearing loss 

like Mr. Doucette will, for example, 

experience difficulties distinguishing 

sounds or using the telephone. The 

schedule was designed to determine a 

veteran’s level of hearing loss disability 

through objective testing and match it to 

a disability rating that compensates for 

the average impairment in earning 

capacity associated with that level of 

disability. 38 U.S.C. 1155; 38 CFR 4.1, 

4.10, 4.85. To the extent a particular 

veteran’s hearing loss may seem more 

impactful than the rating provided, that 

is characteristic of a schedule that 

compensates for ‘‘the average 

impairments of earning capacity’’—it is 

not an indication that the schedule is 

inadequate. 38 U.S.C. 1155. 

When a symptom of a hearing loss 

disability properly rated under this code 

is unusual or exceptional for that 

disability, and not contemplated by the 

code, there are alternative methods to 

ensure that a veteran is adequately 

compensated. First, if the symptom of 

the hearing loss disability implicates a 

disability addressed elsewhere in the 

schedule, an evaluation may be 

appropriate under the listed diagnostic 

code which accounts for the disability. 

If the symptom implicates a disability 

that is not listed in the schedule, an 

evaluation may be appropriate by 

analogy using a closely related disease 

or injury, giving due consideration to 

the functions affected, anatomical 

localization, and symptomatology. 38 

CFR 4.20. In such a case, because 

another diagnostic code in the schedule 

addresses a disability analogous to the 

disability implicated by the symptom, 

the schedule is not inadequate to rate 

the veteran’s disability. Finally, if the 

unusual or exceptional symptom of the 

hearing loss disability does not 

implicate any other provision or code in 

the schedule (either directly or through 

analogy), the schedule may not 

contemplate the hearing loss disability 

presented; and 38 CFR 3.321(b)(1) may 

be considered. 

B. Ear, Nose, and Throat Disabilities— 

Proposed Changes to § 4.87 

As noted above, VA proposes to 

relocate a number of conditions from 

§ 4.97 to § 4.87. It also intends to update 

several of the relocated codes, as well as 

DCs already included in § 4.87, to 

ensure that the medical descriptions 

reflect the most current knowledge, 

practice, and standards of care, and that 

the criteria determining the levels of 

compensation provide fair and accurate 

benchmarks for veterans. As VA intends 

to relocate a number of conditions 

affecting the nose, throat and larynx 

(voice box) to § 4.87, VA proposes to 

retitle this section from ‘‘Schedule of 

ratings—ear’’ to ‘‘Schedule of ratings— 

ear, nose, and throat.’’ 

1. Diagnostic Code 6200 

VA proposes to revise the note under 

this DC from ‘‘Evaluate hearing loss, and 

complications such as labyrinthitis, 

tinnitus, facial nerve paralysis, or bone 

loss of skull, separately.’’ to ‘‘Evaluate 

hearing loss and complications such as 

labyrinthitis, facial nerve paralysis, or 

bone loss of skull, separately.’’ This 

revision is necessary as tinnitus 

associated with hearing loss is now 

contemplated under DC 6100. 

2. Diagnostic Code 6202 

VA currently evaluates otosclerosis 

under DC 6202. To ensure greater 

consistency in decision making, VA 

proposes to rename this code to include 

residuals of stapedectomy and 

stapedotomy. Surgeons perform these 

procedures involving the middle ear to 

prevent further deterioration of hearing 

caused by otosclerosis by improving the 

movement of sound to the inner ear. 

The primary residual of stapedectomy 

and stapedotomy is continued hearing 

loss, albeit without further deterioration 

of hearing, so VA may evaluate these 

conditions similarly to otosclerosis by 

the degree of the hearing loss. See S. 

George Lesinski, ‘‘Causes of Conductive 

Hearing Loss After Stapedectomy or 

Stapedotomy: A Prospective Study of 

279 Consecutive Surgical Revisions,’’ 

23(3) Otology & Neurotology 281–88 

(May 2002). 

3. Diagnostic Code 6204 

Peripheral vestibular disorders (DC 

6204) may originate in one or both ears 

and may cause varying degrees of 

disability. B. Gurr and N. Moffat, 

‘‘Psychological consequences of vertigo 

and the effectiveness of vestibular 

rehabilitation for brain injury patients,’’ 

15 Brain Injury 387 (2001); Hannelore K. 

Neuhauser et al., ‘‘Burden of dizziness 

and vertigo in the community,’’ 168 

Archives of Internal Medicine 2118 

(2008). DC 6204 currently evaluates 

such disorders using only dizziness and 

staggering (i.e., alteration of gait). VA 

therefore proposes to amend DC 6204 to 

better reflect the full scope of these 

disorders and their effect on a veteran’s 

ability to work and engage in other 

activities that impact earning capacity. 

Specifically, VA proposes to provide 

increasingly higher ratings depending 

on the impact of a veteran’s vestibular 

disorder on activities of self-care. VA 

may evaluate self-care activities for the 

purposes of this DC using assessments 

by qualified health care providers that 

address the capacity to bathe, dress, eat, 

manage hygiene, and/or move the body 

from place to place. VA will also 

evaluate the ability to work, to include 

whether the veteran requires significant 

modification and/or accommodation to 

accomplish tasks. Additionally, VA 

intends to expand the current disability 

evaluation levels from two (10 and 30 

percent) to three (10, 30, and 100 

percent); the 100 percent evaluation will 

include veterans whose vestibular 

disorders severely impact their life and 

result in the substantial inability to 

work. 

The proposed criteria provide a 10 

percent evaluation for a documented 

vestibular disorder with symptoms 

during the last six months that require 

brief and temporary modification of 

activity but do not prevent continuation 

of normal activities such as self-care 

and/or work. VA proposes a 30 percent 

evaluation for symptoms that occur with 

sufficient frequency to require routine 

limitation in activities, which the 

individual can overcome with effort and 

some modification and/or 

accommodation. VA proposes a 100 

percent evaluation for symptoms that 

result in an inability to independently 

perform self-care and/or work activities, 

even with modification of activity or 

accommodation. Finally, VA proposes 

two notes for this DC—one defining selfcare activities and another continuing 

this DC’s current requirement of 

objective findings supporting the 

diagnosis. 

4. Diagnostic Code 6205 

Originating in the inner ear, the 

specific causes of Meniere’s syndrome 

(DC 6205) remain unclear. However, the 

effects, which may include vertigo, 

tinnitus, hearing loss, and unstable gait, 

may impact a veteran’s earning capacity. 

The current rating criteria for DC 6205 

provide for 30, 60, and 100 percent 

evaluations depending upon the 

presence of hearing loss and the 

frequency of attacks of vertigo and 

cerebellar gait. Alternatively, rating 

personnel must separately evaluate 

vertigo (as a peripheral vestibular 

disorder) and hearing loss if a higher 

combined rating for Meniere’s syndrome 

results. 

VA does not intend to significantly 

alter the current rating criteria for DC 

6205. However, it does propose to 

change evaluative criteria so they are 

consistent and clear. VA proposes to 

alter the frequency for the 100 percent 

evaluation from ‘‘more than once 


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weekly’’ to ‘‘five or more times a 

month’’ to be consistent with the 

monthly timeframes provided in the 30 

and 60 percent levels. VA also proposes 

to eliminate the current reference to 

‘‘attacks of vertigo and cerebellar gait.’’ 

Individuals with Meniere’s syndrome 

experience attacks of dizziness (or 

vertigo) that appear suddenly but may 

or may not result in gait disturbance. 

See ‘‘Meniere’s disease,’’ National 

Institute on Deafness and Other 

Communication Disorders, https://

www.nidcd.nih.gov/health/balance/ 

pages/meniere.aspx (last visited July 24, 

2018). Occasionally, however, an 

individual’s vertigo is so extreme and 

frequent that it results in disequilibrium 

or gait instability. Id. Therefore, VA 

proposes to include vertigo in all 

evaluation levels, with the only 

reference to gait being the 100 percent 

evaluation. VA proposes a 100 percent 

evaluation for hearing loss with either 

persistent disequilibrium and gait 

instability, or with vertigo occurring five 

or more times a month. Finally, VA 

proposes to reorganize the criteria 

within each evaluation for improved 

clarity and usability. Specifically, VA 

notes that each evaluation currently 

includes hearing loss. The crucial point 

is the frequency of vertigo or, for a 100- 

percent evaluation, the presence of 

persistent disequilibrium. VA proposes 

to reorganize the criteria to emphasize 

this. 

VA intends to amend the current note 

to DC 6205 and redesignate it as Note 

(3). For reasons explained in this 

preamble’s discussion of tinnitus, 

proposed Note (3) will no longer 

include any reference to a separate 

evaluation for tinnitus. 

To ensure consistent evaluations, VA 

proposes to include a new Note (1), 

which will indicate that the Meniere’s 

diagnosis must be made by a 

otolaryngologist or neurologist. Id. The 

requirement for a specialist evaluation 

is based on the complexity of the 

diagnostic work up. This work up is 

best performed by those whose focus is 

on this area of medical care, as opposed 

to a provider without focused expertise, 

to ensure the proper diagnostic 

assessment is made. In addition, VA 

proposes a new Note (2) to direct rating 

personnel to calculate the average 

vertigo frequency using a six-month 

period. This period ensures that the 

assigned evaluation represents the 

average level of impairment, taking into 

account occasional flare-ups that may 

not represent a true increase in the 

overall severity of the disease. 

5. Diagnostic Code 6260 

As previously noted under revisions 

to § 4.85, VA proposes to remove DC 

6260. 

6. Relocated Diagnostic Codes 

As previously noted, VA proposes to 

move 16 conditions from § 4.97 (the 

Respiratory System) to § 4.87 (the 

proposed ENT System). VA will 

redesignate these DCs, currently 

designated 6502 through 6524, as DCs 

6220 through 6240, respectively. VA 

proposes to change the evaluation 

criteria for a number of these relocated 

DCs. However, VA proposes no 

substantive changes to the following 

codes: DC 6502, Septum, nasal, 

deviation of (proposed DC 6220); DC 

6515, Laryngitis, tuberculous, active or 

inactive (proposed DC 6227); DC 6516, 

Laryngitis, chronic (proposed DC 6228); 

DC 6518, Laryngectomy, total (proposed 

DC 6229); DC 6519, Aphonia, complete 

organic (proposed DC 6230); and DC 

6521, Pharynx, injuries to (proposed DC 

6232). VA will update accordingly any 

references to these DCs within other 

codes. 

i. Diagnostic Code 6504 

In relocating DC 6504, loss of part of 

the nose or nasal scars, to § 4.87, VA 

proposes to redesignate it as DC 6221. 

The current criteria for DC 6504 assign 

10 or 30 percent evaluations based on 

the exposure of nasal passages, loss of 

ala (the wings of the nose), or other 

obvious disfigurement. This focus on 

loss of particular nasal parts, rather than 

on the overall quantifiable loss of nasal 

tissue and/or structure, may result in 

inconsistent evaluations for similarly 

disabling conditions. As such, VA 

proposes to assign evaluations based on 

defined loss of the nose (i.e., more or 

less than half). Additionally, because 

the use of nasal prosthetics often has a 

positive impact on an individual’s 

psychosocial functioning, VA proposes 

to incorporate the mitigating value of 

any nasal prosthetics used. VA intends 

to provide for higher ratings when the 

loss is not amenable to the use of 

prosthesis. See Satyabodh S. Guttal et 

al., ‘‘Interim Prosthetic Rehabilitation of 

a Patient Following Partial Rhinectomy: 

A Clinical Report,’’ 4(4) European J. of 

Dentistry 482, 482–83 (Oct. 2010). 

Under the proposed criteria, VA 

would assign a 0 percent evaluation for 

any loss or disfigurement of the nose for 

which a qualified medical provider does 

not require or recommend a prosthesis. 

VA would assign a 10 percent 

evaluation for any loss of the nose for 

which a qualified medical provider 

requires or recommends a prosthesis 

and the patient is capable of using it. 

VA proposes a 20 percent evaluation for 

a loss that a prosthesis cannot treat (as 

documented by a qualified provider) 

and that loss involves less than 50 

percent of the nose. Finally, VA 

proposes a 30 percent evaluation for a 

loss that a prosthesis cannot treat (as 

documented by a qualified provider) 

and that loss involves at least 50 percent 

or more of the nose. VA intends to 

retain the current note directing rating 

personnel to alternatively evaluate any 

loss or scar under DC 7800, disfiguring 

scars of the head, face, or neck. 

ii. Diagnostic Codes 6510, 6511, 6512, 

6513, and 6514 

Current DCs 6510 through 6514 all 

refer to various types of chronic 

sinusitis evaluated using the General 

Rating Formula for Sinusitis, located 

under DC 6514. VA proposes to 

redesignate these codes as DCs 6222 

through 6226, respectively, under 

§ 4.87; additionally, VA proposes to 

rename each code to reflect current 

medical terminology. VA proposes to 

rename the redesignated DC 6222 as 

‘‘Rhinosinusitis, pansinusitis.’’ VA 

proposes to rename the redesignated DC 

6223 as ‘‘Rhinosinusitis, ethmoid.’’ VA 

proposes to rename the redesignated DC 

6224 as ‘‘Rhinosinusitis, frontal.’’ VA 

proposes to rename the redesignated DC 

6225 as ‘‘Rhinosinusitis, maxillary.’’ VA 

proposes to rename the redesignated DC 

6226 as ‘‘Rhinosinusitis, sphenoid.’’ VA 

also proposes to reflect current medical 

terminology by renaming the General 

Rating Formula for Sinusitis as General 

Rating Formula for Chronic 

Rhinosinusitis and Recurrent Acute 

Rhinosinusitis. VA will place this 

renamed rating formula immediately 

before the redesignated DC 6222. 

To modernize the rating schedule in 

regard to chronic sinusitis, VA will first 

introduce current medical terminology 

and definitions. Rhinosinusitis is 

defined as symptomatic inflammation of 

the paranasal sinuses and nasal cavity. 

Modern medicine understands three 

different clinical presentations of 

inflamed nasal passages and sinuses 

(rhinosinusitis): Acute, recurrent acute, 

and chronic. Richard M. Rosenfeld et 

al., ‘‘Clinical practice guideline: Adult 

sinusitis,’’ 137(3 Supp.) OtolaryngologyHead and Neck Surgery S19, Table 10 

(2007). 

Acute rhinosinusitis (ARS) is defined 

as up to four weeks of purulent drainage 

(anterior, posterior, or both) 

accompanied by nasal obstruction, 

facial fullness, or both. Acute 

rhinosinusitis can occur as viral 

rhinosinusitis (or VRS, defined as 

rhinosinusitis caused by a virus and 


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typically lasting less than 10 days). 

Acute rhinosinusitis can also occur as 

acute bacterial rhinosinusitis (or ABRS, 

defined as a bacterial infection that 

causes symptoms of rhinosinusitis for at 

least 10 days after the onset of an upper 

respiratory infection or causes 

recurrence of symptoms within seven 

days after initial improvement). If 

rhinosinusitis symptoms last at least 

four but less than 12 weeks, it is defined 

as subacute rhinosinusitis (SAR). Id. 

Recurrent acute rhinosinusitis (RARS) 

is defined as four or more episodes of 

ABRS without signs or symptoms of 

rhinosinusitis between episodes. Id. 

Finally, chronic rhinosinusitis, or 

CRS, is defined as 12 weeks or more of 

at least two of the following— 

mucopurulent drainage (anterior, 

posterior, or both); nasal obstruction 

(congestion); facial pain-pressurefullness; or decreased sense of smell— 

in combination with inflammation as 

documented by at least one of the 

following: Purulent mucus (not clear) in 

the middle meatus or ethmoid region; 

polyps in the nasal cavity or the middle 

meatus; or radiographic imaging 

showing inflammation of the paranasal 

sinuses. Id. 

VA compensates disabilities that 

impair earning capacity, not temporary 

conditions that generally do not impact 

earning capacity. See 38 U.S.C. 1155; 

Davis, 276 F.3d at 1345–47; see also 

Moore, 555 F.3d at 1373. In that regard, 

CRS and RARS are distinguishable from 

ARS and SAR. To assist the public and 

rating activity in better understanding 

what disabilities are compensated under 

this General Rating Formula, VA 

proposes to include a note identifying 

which conditions are eligible for 

compensation and another note 

specifying which conditions are 

explicitly excluded from compensation. 

The present rating criteria evaluate 

chronic sinusitis predominantly on the 

frequency of ‘‘incapacitating episodes,’’ 

which includes prolonged antibiotic 

treatment, as well as the need for ‘‘bed 

rest’’ and ‘‘treatment by a physician.’’ 

Current standards of medical care, 

however, no longer describe 

incapacitating episodes or bed rest as 

treatment. VA therefore proposes to 

retain those elements of the existing 

criteria—namely, frequency/duration of 

antibiotic treatment—that still relate to 

current medical practice and eliminate 

reference to incapacitating episodes. VA 

also proposes to retain the 50 percent 

criteria that require unresponsiveness to 

surgery to reflect the severity of 

disability that accompanies that rating 

level. 

In light of the above, VA’s proposed 

General Rating Formula for Chronic 

Rhinosinusitis (CRS) and Recurrent 

Acute Rhinosinusitis (RARS) will retain 

the same rating levels as the current 

General Rating Formula for Sinusitis 

(i.e., 0, 10, 30, and 50 percent). The 

criteria begin with a 50 percent 

evaluation granted for CRS/RARS which 

requires 12 weeks or more of treatment 

with antibiotics and unresponsiveness 

to surgical intervention with endoscopy 

or other surgical procedure designed to 

treat CRS/RARS. A 30 percent 

evaluation will be granted for CRS/ 

RARS that requires 12 weeks or more of 

treatment with antibiotics during the 

preceding 12-month period. A 10 

percent evaluation will be granted for 

CRS/RARS which requires antibiotic 

treatment for at least four weeks but less 

than 12 weeks during the preceding 12- 

month period. Finally, a 0 percent 

evaluation will be granted when there 

has been less than four weeks treatment 

with antibiotics during the preceding 

12-month period. Rosenfeld, supra, at 

S1–31; see also Thomas A. Tami, 

‘‘Granulomatous Diseases and Chronic 

Rhinosinusitis,’’ 38 Otolaryngol. Clin. 

N. Am. 1267–78 (2005). 

Finally, DC 6514 currently contains a 

note that defines an ‘‘incapacitating 

episode’’ for purposes of assigning 

evaluations. The proposed criteria above 

render this note no longer necessary, so 

VA proposes to delete it. 

iii. Diagnostic Code 6520 

VA proposes to redesignate stenosis of 

the larynx, currently evaluated under 

DC 6520, as DC 6231. It also proposes 

to amend the rating criteria for this DC, 

which will result in evaluations based 

upon the measured degree of stenosis, 

rather than the current utilization of 

PFTs. While stenosis of the trachea may 

affect PFTs, many other diseases may 

also impact them. Advances in 

diagnostic devices, including fiber 

optics, have improved visualization of 

the larynx and its associated structures 

and allowed more accurate assessment 

of anatomy. L. Sulica, ‘‘Hoarseness,’’ 

137 Archives of Otolaryngology-Head 

and Neck Surgery 616 (2011). Hence, 

VA proposes to update its evaluative 

criteria. 

Specifically, VA proposes to evaluate 

partial obstruction of the larynx with 

less than 25 percent narrowing of the 

airways as 30 percent disabling. VA 

proposes a 50 percent evaluation for 

partial obstruction of the larynx, with 25 

percent to less than 50 percent 

narrowing of airways. Partial 

obstruction of the larynx, with 50 

percent or more narrowing of airways, 

will warrant a 70 percent evaluation. 

Finally, VA proposes to assign a 100 

percent evaluation for obstruction of the 

larynx, requiring permanent 

tracheostomy. VA will retain the current 

note allowing for an alternative 

evaluation as aphonia. VA notes that 

research indicates airway crosssectional area reduced by 50 percent or 

more impairs breathing. See Sylvia 

Verbanck et al., ‘‘Detecting upper airway 

obstruction in patients with tracheal 

stenosis,’’ 109 J. of Applied Physiology 

47 (July 2010). As such, obstruction less 

than 50 percent reflects no more than 

moderate disability (i.e., warranting a 30 

or 50 percent evaluation). 

iv. Diagnostic Code 6522 

The current DC 6522 is ‘‘Allergic or 

vasomotor rhinitis’’ and VA will rename 

it ‘‘Rhinitis, allergic or nonallergic 

(vasomotor).’’ VA proposes to 

redesignate this DC as 6240 under 

§ 4.87. VA also proposes to modify the 

rating criteria to reflect current medical 

understanding and practice. First, VA 

proposes to modify the criteria for a 10 

percent rating to require continuous 

therapy (almost always selfadministered) to control symptoms. VA 

also proposes a 30 percent rating for the 

presence of polyps, preserving the prior 

rating criteria. VA will add a note that 

directs personnel to rate under proposed 

DC 6233 (rhinosinusitis, allergic and 

nonallergic (vasomotor) related) using 

the General Rating Formula for 

Rhinosinusitis instead of proposed DC 

6240 (Rhinitis, allergic or nonallergic 

(vasomotor)) if either chronic or 

recurrent acute form of rhinosinusitis is 

present. See Rosenfeld, supra at S1–31. 

v. Diagnostic Code 6523 

Currently, DC 6523 (bacterial rhinitis) 

addresses chronic residuals related to 

bacterial infection of the sinuses. VA 

proposes to redesignate DC 6523 as 6234 

under § 4.87. Additionally, VA proposes 

to rename this DC, ‘‘Rhinosinusitis, 

infection related,’’ for clarity to ensure 

that readers understand that it includes 

rhinosinusitis caused by bacterial or 

fungal agents. 

VA proposes that infection-related 

rhinosinusitis be evaluated under the 

proposed General Rating Formula for 

CRS and RARS to, again, reflect current 

medical understanding. 

vi. Diagnostic Code 6524 

Current DC 6524 (granulomatous 

rhinitis) provides for a 100 percent 

evaluation for Wegener’s granulomatosis 

or lethal midline granuloma; VA assigns 

a 20 percent evaluation for other types 

of granulomatous infection. These 

evaluations are outdated for a number of 

reasons. Modern medical science has 

identified lethal midline granuloma 

(also referred to as lymphomatoid 


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granulomatosis or polymorphic 

reticulosis) as a peripheral T-cell 

lymphoma. Wegener’s (now referred to 

as granulomatous disease with 

polyangiitis, or GPA), Churg-Strauss 

disease (now referred to as eosinophilic 

granulomatous disease with 

polyangiitis, or EGPA), and sarcoidosis 

are all autoimmune conditions that can 

affect the sinuses and nasal passages. 

They typically require systemic 

immunosuppressive treatment for 

extended periods (one to two years, or 

more) and may recur, requiring 

resumption of immunosuppressive 

treatment. As a result, VA proposes 

several revisions to incorporate current 

medical understanding of these 

conditions. 

First, VA proposes to redesignate this 

code as DC 6235 under § 4.87. Second, 

VA proposes to rename this code 

‘‘Rhinosinusitis, autoimmune, 

granulomatous or other causes,’’ to 

update terminology. Third, VA proposes 

to ensure consistent application by 

adding a note that directs rating 

personnel to evaluate lethal midline 

granuloma under proposed DC 6238, as 

such condition is best characterized as 

a malignant neoplasm. Fourth, VA 

proposes to transfer the 100 percent 

evaluation from the current DC 6524 to 

the new DC 6235, as well as modify its 

criteria by linking it to the current use 

of systemic immunosuppressive 

therapy. Fifth, VA proposes to direct 

personnel to use the proposed General 

Rating Formula for CRS and RARS for 

any evaluation less than 100 percent 

under proposed DC 6235. This 

instruction helps ensure appropriate, 

uniform ratings for any chronic 

residuals that do not rise to the level of 

malignancy. 

7. Proposed New Diagnostic Codes 

In addition to amending current DCs 

under § 4.87 and relocating those from 

§ 4.97, VA proposes to add several new 

conditions to better evaluate veterans 

using a more complete ear, nose and 

throat schedule. 

i. Diagnostic Code 6233 

The first new DC VA proposes to add 

to § 4.87 is Rhinosinusitis, allergic and 

nonallergic (vasomotor) related (DC 

6233). This DC enables rating personnel 

to capture CRS or RARS as a 

consequence of DC 6240 (Rhinitis, 

allergic or nonallergic (vasomotor)). DC 

6240 will instruct rating personnel to 

select DC 6233 (rhinosinusitis, allergic 

or nonallergic (vasomotor) related) if 

either CRS or RARS is present. 

ii. Diagnostic Code 6236 

A new condition frequently present in 

veterans that VA proposes to add to 

§ 4.87 is vocal cord paralysis (DC 6236). 

Its primary symptom is hoarseness, so 

VA proposes to direct rating personnel 

to evaluate this condition analogous to 

chronic laryngitis (DC 6228) or aphonia 

(DC 6230). See Seth R. Schwartz et al., 

‘‘Clinical practice guideline: Hoarseness 

(dysphonia),’’ 141(Supp. 3) 

Otolaryngology-Head and Neck Surgery 

S1 (2009). 

iii. Diagnostic Codes 6237 and 6238 

Benign and malignant neoplasms of 

the nasopharynx occur with such 

sufficient frequency among veterans that 

VA proposes to add discrete codes (DCs 

6237 and 6238, respectively) for these 

conditions. VA proposes to rate benign 

neoplasms according to impairment of 

function by utilizing the most 

appropriate evaluation criteria because 

the disability due to these neoplasms 

varies. The addition of DC 6237 does 

not represent a substantive change in 

the evaluation of benign neoplasms, but 

it allows for better tracking and data 

analysis of this condition by providing 

a specific DC. 

VA proposes to evaluate malignant 

neoplasms similarly to other 

malignancies in the VASRD. 

Specifically, VA will assign an 

evaluation of 100 percent for six months 

beyond the cessation of any surgery, 

radiation treatment, antineoplastic 

chemotherapy, or other therapeutic 

procedures. Then, VA will determine 

the appropriate disability rating by 

ordering a mandatory VA examination. 

VA will apply the provisions of 

§ 3.105(e) of this chapter to any change 

in evaluation based upon that or any 

subsequent examination. Rating 

personnel will evaluate residual 

impairment of function barring 

subsequent local recurrence or 

metastasis. 

iv. Diagnostic Code 6239 

VA proposes to add a new DC for 

diseases of the salivary glands, other 

than neoplasms (DC 6239). These 

conditions generally result in 

xerostomia (dry mouth), a condition that 

may lead to secondary effects of dental 

disease, nutritional deficit, pain, 

formation of salivary duct stones, and/ 

or changes in taste. See James J. Sciubba 

and David Goldenberg., ‘‘Oral 

complications of radiotherapy,’’ 7 

Lancet Oncology 175 (2006); S.B. Jensen 

et al., ‘‘A systematic review of salivary 

gland hypofunction and xerostomia 

induced by cancer therapies: 

management strategies and economic 

impact,’’ 18 Support Care Cancer 1061 

(2010). 

VA proposes to assign a 0 percent 

evaluation for xerostomia (dry mouth) 

not accompanied by secondary 

conditions such as difficulty in 

mastication of food or painless swelling 

of the salivary glands. VA would assign 

a 10 percent evaluation for xerostomia 

with altered sensation of taste and 

difficulty with lubrication and 

mastication of food but without 

associated weight loss or increase in 

dental caries. VA would also award a 10 

percent evaluation if there was chronic 

inflammation of a salivary gland with 

pain and swelling on eating; or one or 

more salivary calculi, or gland stricture. 

Finally, VA proposes a maximum 20 

percent evaluation for xerostomia with 

altered sensation of taste and difficulty 

with lubrication and mastication of food 

that results in either weight loss or an 

increase in dental caries. Diseases of the 

salivary glands may also result in 

neurological residuals and facial 

disfigurement due to swelling, so VA 

intends to include a note directing 

rating personnel to evaluate such 

residuals under the appropriate code(s). 

Executive Orders 12866 and 13563 

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. The Office of 

Information and Regulatory Affairs has 

determined that this rule is an 

economically significant regulatory 

action under Executive Order 12866. 

The Regulatory Impact Analysis 

associated with this rulemaking can be 

found as a supporting document at 

www.regulations.gov. 

Regulatory Flexibility Act 

The Secretary hereby certifies that 

this proposed 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). The 

certification is based on the fact that no 

small entities or businesses assign 

evaluations for disability claims. 

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

the initial and final regulatory flexibility 


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analysis requirements of 5 U.S.C. 603 

and 604 do not apply. 

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 is likely to 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 given year. This proposed rule 

would have no such effect on State, 

local, and tribal governments, or on the 

private sector. 

Paperwork Reduction Act 

Although this proposed rule contains 

provisions constituting a collection of 

information under the Paperwork 

Reduction Act of 1995 (44 U.S.C. 3501– 

3521), no new or proposed revised 

collections of information are associated 

with this proposed rule. Specifically, 

the information collection requirements 

associated with this proposed rule are 

related to the filing of disability benefits 

claims (VA Form 21–526EZ) as well as 

Disability Benefits Questionnaires 

(DBQs) (Groups 3 and 4) which enable 

claimants to gather the necessary 

information from his or her treating 

physician as to the current symptoms 

and severity of a disability. The 

information collection requirements are 

approved by OMB and have been 

assigned OMB control numbers 2900– 

0747, 2900–0778, and 2900–0781. 

Assistance Listing 

The Assistance Listing numbers and 

titles for this rule are 64.104, Pension 

for Non-Service-Connected Disability 

for Veterans; 64.109, Veterans 

Compensation for Service-Connected 

Disability; and 64.110, Veterans 

Dependency and Indemnity 

Compensation for Service-Connected 

Death. 

List of Subjects 

38 CFR Part 3 

Claims, Disability benefits, Pensions, 

Veterans. 

38 CFR Part 4 

Disability benefits, Pensions, 

Veterans. 

Signing Authority 

Denis McDonough, Secretary of 

Veterans Affairs, approved this 

document on July 6, 2021, and 

authorized the undersigned to sign and 

submit the document to the Office of the 

Federal Register for publication 

electronically as an official document of 

the Department of Veterans Affairs. 

Michael P. Shores, 

Director, Office of Regulation Policy & 

Management, Office of the Secretary, 

Department of Veterans. 

For the reasons set forth in the 

preamble, VA proposes to amend 38 

CFR parts 3 and 4 as set forth below: 

PART 3—ADJUDICATION 

Subpart A—Pension, Compensation, 

and Dependency and Indemnity 

Compensation 

■ 1. The authority citation for part 3, 

subpart A, continues to read as follows: 

Authority: 38 U.S.C. 501(a), unless 

otherwise noted. 

■ 2. Amend § 3.350 by revising 

paragraphs (e)(1)(iii), (e)(1)(iv), (f)(2)(v), 

and (f)(2)(vi) to read as follows: 

§ 3.350 Special monthly compensation 

ratings. 

* * * * * 

(e) * * * 

(1) * * * 

(iii) Bilateral deafness rated at 60 

percent or more disabling (and the 

hearing loss in either one or both ears 

is service connected) in combination 

with service-connected blindness with 

bilateral visual acuity 20/200 or less. 

(iv) Service-connected total deafness 

in one ear or bilateral deafness rated at 

40 percent or more disabling (and the 

hearing loss in either one of both ears 

is service-connected) in combination 

with service-connected blindness of 

both eyes having only light perception 

or less. 

* * * * * 

(f) * * * 

(2) * * * 

(v) Blindness in both eyes having only 

light perception or less, or rated under 

paragraph (f)(2)(iii) of this section, when 

accompanied by bilateral deafness (and 

the hearing loss in either one or both 

ears is service-connected) rated at 10 or 

20 percent disabling, will afford 

entitlement to the next higher 

intermediate rate, or if the veteran is 

already entitled to an intermediate rate, 

to the next higher statutory rate under 

38 U.S.C. 1114, but in no event higher 

than the rate for (o). 

(Authority: Sec. 112, Pub. L. 98–223) 

(vi) Blindness in both eyes rated 

under 38 U.S.C. 1114 (l), (m) or (n), or 

rated under paragraphs (f)(2)(i), (ii) or 

(iii) of this section, when accompanied 

by bilateral deafness rated at no less 

than 30 percent, and the hearing loss in 

one or both ears is service-connected, 

will afford entitlement to the next 

higher statutory rate under 38 U.S.C. 

1114, or if the veteran is already entitled 

to an intermediate rate, to the next 

higher intermediate rate, but in no event 

higher than the rate for (o). 

(Authority: 38 U.S.C. 1114(p)) 

■ 3. Amend § 3.383 by revising 

paragraph (a)(3) and the Cross 

References to read as follows: 

§ 3.383 Special considerations for paired 

organs and extremities. 

(a) * * * 

(3) Hearing loss in one ear 

compensable to a degree of 10 percent 

or more as a result of service-connected 

disability and hearing loss as a result of 

nonservice-connected disability that 

meets the provisions of § 3.385 in the 

other ear. 

* * * * * 

Cross References: 

§ 3.385 Disability due to hearing loss; 

§ 4.85 Evaluation of hearing loss. 

■ 4. Amend § 3.815 by revising 

paragraph (d)(6)(viii) to read as follows: 

§ 3.815 Monetary allowance under 38 

U.S.C. chapter 18 for an individual with 

disability from covered birth defects whose 

biological mother is or was a Vietnam 

veteran; identification of covered birth 

defects. 

* * * * * 

(d) * * * 

(6) * * * 

(viii) Post-infancy deafness/hearing 

loss (onset after the age of one year); 

■ 5. Revise § 3.385 to read as follows: 

§ 3.385 Disability due to hearing loss. 

For the purposes of administering its 

laws, VA will consider hearing loss to 

be a disability when the pure-tone 

auditory air conduction threshold in 

any of the frequencies of 500, 1000, 

2000, 3000, or 4000 Hertz is 40 decibels 

or greater; or when the pure-tone 

auditory air conduction thresholds for at 

least three of the frequencies of 500, 

1,000, 2,000, 3,000, or 4,000 Hertz are 

26 decibels or greater; or when word 

recognition scores using the Maryland 

CNC Test are less than 94 percent. 

PART 4—SCHEDULE FOR RATING 

DISABILITIES 

Subpart B—Disability Ratings 

■ 6. The authority citation for part 4 

continues to read as follows: 

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

otherwise noted. 

■ 7. Revise the undesignated center 

heading before § 4.85 to read as follows: 


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Ear, Nose, Throat, and Auditory 

Disabilities 

■ 8. Amend § 4.85 by: 

■ a. Revising the section heading; 

■ b. Revising paragraphs (a) through (g); 

■ c. Revising tables VI, VIA, and VII; 

■ d. Adding entry for diagnostic code 

6100; and, 

■ e. Adding authority citation. 

The revisions and additions read as 

follows: 

§ 4.85 Evaluation of hearing loss. 

(a) An examination for hearing loss 

for VA purposes must be conducted by 

a state-licensed audiologist and must 

include a controlled word recognition 

test (Maryland CNC) and a pure-tone 

audiometry test. Examinations will be 

conducted without the use of hearing 

aids. Hearing levels are measured in 

decibels and expressed as dB HL. 

(b) Table VI, ‘‘Numeric Designation of 

Hearing Loss Based on Pure-Tone Air 

Conduction Threshold Average and 

Word Recognition,’’ is used to 

determine a Roman numeral designation 

(I through XI) for hearing loss based on 

a combination of the percent of word 

recognition (horizontal rows) and the 

pure-tone air conduction threshold 

average (vertical columns). The Roman 

numeral designation is located at the 

point where the percentage of word 

recognition and pure-tone air 

conduction threshold average intersect. 

(c) Table VIA, ‘‘Special Numeric 

Designation of Hearing Loss Based Only 

on Pure-Tone Air Conduction Threshold 

Average,’’ is used to determine a Roman 

numeral designation (I through XI) for 

hearing loss based only on the pure-tone 

air conduction threshold average. Table 

VIA will be used when the examiner 

certifies that use of the word recognition 

test is not appropriate because of 

language difficulties (e.g., English nonfluency), cognitive difficulties, 

inconsistent word recognition scores, 

etc., or when indicated under the 

provisions of § 4.86. 

(d) ‘‘Pure-tone air conduction 

threshold average,’’ as used in Tables VI 

and VIA, is the sum of the pure-tone air 

conduction thresholds at 1,000, 2,000, 

3,000, and 4,000 Hertz, divided by four. 

This average is used in all cases 

(including those in § 4.86) to determine 

the Roman numeral designation for 

hearing loss from Table VI or VIA. 

(e) Table VII, ‘‘Percentage Evaluations 

for Hearing Loss,’’ is used to determine 

the percentage evaluation by combining 

the Roman numeral designations for 

hearing loss of each ear. The horizontal 

rows represent the ear having the better 

hearing and the vertical columns the ear 

having the poorer hearing. The 

percentage evaluation is located at the 

point where the row and column 

intersect. 

(f) If hearing loss is service-connected 

in only one ear, in order to determine 

the percentage evaluation from Table 

VII, the non-service-connected ear will 

be assigned a Roman Numeral 

designation for hearing loss of I, subject 

to the provisions of § 3.383 of this 

chapter. 

(g) When evaluating any claim for 

hearing loss, refer to § 3.350 of this 

chapter to determine whether the 

veteran may be entitled to special 

monthly compensation due either to 

deafness, or to deafness in combination 

with other specified disabilities. 

* * * * * 

BILLING CODE 8320–01–P 


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TABLE VI 

NUMERIC DESIGNATION OF HEARING LOSS BASED ON PURE-TONE AIR CONDUCTION 

THRESHOLD AVERAGE AND WORD RECOGNITION 

PURE-TONE AIR CONDUCTION THRESHOLD AVERAGE 

------ Percent of 

word 

recognition 0-41 42-49 50..57 58-65 66-73 74-81 82-89 90-97 98+ 

92-100 I I I II II II III III IV 

84-90 II II II III III III IV IV IV 

76-82 III III IV IV IV V V V V 

68-74 IV IV V V VI VI VII VII VII 

60-66 V V VI VI VII VII VIII VIII VIII 

52-58 VI VI VII VII VIII VIII VIII VIII IX 

44-50 VII VII VIII VIII VIII IX IX IX X 

36-42 VIII VIII VIII IX IX IX X X X 

0..34 IX X XI XI XI XI XI XI XI 
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BILLING CODE 8320–01–C 


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TABLE VIA* 

SPECIAL NUMERIC DESIGNATION OF HEARING LOSS BASED ONLY ON 

PURE-TONE AIR CONDUCTION THRESHOLD AVERAGE - PURE-TONE AIR CONDUCTION THRESHOLD AVERAGE 

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

I II III N V VI VII VIII IX X XI 

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

TABLE VII 

PERCENTAGE EVALUATION FOR HEARING LOSS (DIAGNOSTIC CODE 6100) 

Poorer Ear 

XI 100* i 

I 

X 90 80 I I 

I 

! I 

I 

IX 80 70 60 I 

l 

VIll 70 60 50 50 

! l I 

vn 60 60 50 40 40 I 

l 

VI 50 ! 50 40 40 30 I 30 ' I l I I ' ; 

i l 

r 

V 40 40 40 30 30 I 20 120 I i 

i i t 

IV 30 30 30 20 20 20 10 I 10 ; 

f I I 

l 

m 20 20 20 20 20 10 I 10 I 10 I 0 I I j 

l 

II 10 . 10 10 i 10 10 10 f 10 l 0- 0 0 ! 

I 10 10 0 0 0 0 0 0 0 0 0 

XI X IX vm vu VI V IV Ill D I 

"Review for entitlement to special monthly compensation under§ 3.350 of this chapter. 
8488 Federal Register / Vol. 87, No. 31 / Tuesday, February 15, 2022 / Proposed Rules 

Rating 

6100 Hearing Loss: 

If hearing loss is evaluated at 0 percent under Table VII and tinnitus is diagnosed as associated with underlying hearing loss 10 

Otherwise, evaluate using the Tables above. 

Note (1): The 10 percent evaluation is only applicable to tinnitus diagnosed as associated with non-compensable service-connected hearing loss. Tinnitus diagnosed as associated with another service-connected disability (i.e., Meniere’s disease, residuals of traumatic brain injury (TBI), cerebral arteriosclerosis, vascular neurocognitive disorder) must be evaluated as a 

part of that disability without a separate evaluation for tinnitus under diagnostic code 6100. 

Note (2): Tinnitus will only be compensated as part of an underlying service-connected condition. 

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

■ 9. Revise § 4.86 to read as follows: 

§ 4.86 Exceptional patterns of hearing 

loss. 

(a) When the pure-tone air conduction 

threshold at each of the four specified 

frequencies (1000, 2000, 3000, and 4000 

Hertz) is 55 dB HL or more, the rating 

activity will determine the Roman 

numeral designation for hearing loss 

from either Table VI or Table VIA, 

whichever results in the higher 

numeral. Each ear will be evaluated 

separately. 

(b) When the pure-tone air conduction 

threshold is 30 dB HL or less at 1000 

Hertz, and 70 dB HL or more at 2000 

Hertz, the rating activity will determine 

the Roman numeral designation for 

hearing loss from either Table VI or 

Table VIA, whichever results in the 

higher numeral. That numeral will then 

be elevated to the next higher Roman 

numeral. Each ear will be evaluated 

separately. 

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

■ 10. Amend § 4.87 by: 

■ a. Revising the section heading; 

■ b. Removing the heading ‘‘Diseases of 

the Ear’’; 

■ c. Revising entries for diagnostic 

codes 6200 through 6205; 

■ d. Adding entries for diagnostic codes 

6220 through 6240 in numerical order; 

and 

■ e. Removing entry for diagnostic code 

6260. 

The revisions and additions read as 

follows: 

§ 4.87 Schedule of ratings—ear, nose, and 

throat. 

Rating 

*******

6200 Chronic suppurative otitis media, mastoiditis, or cholesteatoma (or any combination): 

During suppuration, or with aural polyps 10 

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

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

Rate based on hearing loss. 

6202 Otosclerosis, stapedectomy, stapedotomy, residuals of: 

Rate based on hearing loss. 

6204 Peripheral vestibular disorders: 

Vestibular disorder in one or both ears with symptoms during the last six months of sufficient frequency and intensity to result 

in an inability to engage in work and/or self-care and an inability to perform routine activities of daily living without assistance of others, even with modification of activity or accommodation .......................................................................................... 100 

Vestibular disorder with symptoms during the last six months that occur with sufficient frequency to require routine limitation in 

activities such as those related to work and/or self-care but that enable independent activity with effort and some modification and/or accommodation .......................................................................................................................................................... 30 

Vestibular disorder with symptoms during the last six months that require brief and temporary modification of activity but do 

not prevent continuation of normal functions such as work and/or self-care ............................................................................... 10 

Note (1): Self-care activities for the purposes of this DC consist of bathing, dressing, eating, managing hygiene, handling 

basic transfers, and/or mobility; a qualified health care provider must determine that the individual has difficulties with these 

activities. 

Note (2): VA requires objective findings supporting the diagnosis of peripheral vestibular disorder before assigning a compensable evaluation under this code. VA will separately evaluate and combine hearing loss or suppuration.

6205 Meniere’s syndrome (endolymphatic hydrops): 

In all cases, with hearing loss, with or without tinnitus; and 

Either: 

Vertigo occurring five or more times a month; or 

With persistent disequilibrium and gait instability ..................................................................................................................... 100 

Vertigo occurring one to four times a month ................................................................................................................................... 60 

Vertigo less than once a month ....................................................................................................................................................... 30 

Note (1): The Meniere’s syndrome diagnosis must be made by a otolaryngologist or neurologist. 

Note (2): For evaluation purposes, calculate the average vertigo frequency using a six-month period. 

Note (3): Evaluate Meniere’s syndrome either under these criteria or by separately evaluating vertigo (as a peripheral vestibular disorder) and hearing loss, whichever method results in a higher overall evaluation. However, do not combine an evaluation for hearing loss or vertigo with an evaluation under this diagnostic code. 

*******

6220 Septum, nasal, deviation of: 

Traumatic only, 

With 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side ........................................ 10 

6221 Nose, loss of part of, or scars: 

Loss of half or more, unable to use prosthesis (as documented by a qualified medical provider) ................................................. 30 

Loss of less than half, unable to use prosthesis (as documented by a qualified medical provider) ............................................... 20 

Any loss of the nose for which a prosthesis is required or recommended by a qualified medical provider and is capable of use 10


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Rating 

Loss or disfigurement for which a prosthesis is not required or recommended by a qualified medical provider ........................... 0 

Note: Or evaluate as DC 7800 (scars, disfiguring, head, face, or neck). 

General Rating Formula for Chronic Rhinosinusitis (CRS) and Recurrent Acute Rhinosinusitis (RARS): DCs 6222–6226; 6233– 

6235 

12 or more weeks of treatment with antibiotics for CRS/RARS during the preceding 12-month period AND unresponsive to 

endoscopic or other surgery used to treat CRS/RARS ................................................................................................................ 50 

12 or more weeks of treatment with antibiotics for CRS/RARS during the preceding 12-month period ........................................ 30 

At least four weeks, but less than 12 weeks of treatment with antibiotics for CRS/RARS during the preceding 12-month period 10 

Less than four weeks of treatment with antibiotics for CRS/RARS during the preceding 12-month period ................................... 0 

Note (1): VA will only compensate chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS). CRS is defined as 

12 weeks or more of at least two of the following—(a) mucopurulent drainage (anterior, posterior, or both); (b) nasal obstruction (congestion); (c) facial pain-pressure-fullness; or (d) decreased sense of smell—in combination with inflammation 

as documented by either (a) purulent mucus (not clear) in the middle meatus or ethmoid region; (b) polyps in the nasal cavity or the middle meatus; or (c) radiographic imaging showing inflammation of the paranasal sinuses. RARS is defined as 

four or more episodes of acute bacterial rhinosinusitis (ABRS) without signs or symptoms of rhinosinusitis (inflammation of 

the paranasal sinuses and nasal cavity) between episodes. 

Note (2): VA will not compensate the following conditions: (a) Acute rhinosinusitis (ARS), which is defined as up to four weeks 

of purulent drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial fullness, or both; (b) Viral 

rhinosinusitis (VRS), which is defined as rhinosinusitis caused by a virus and typically lasting less than 10 days); (c) ABRS, 

which is defined as a bacterial infection which causes symptoms of rhinosinusitis for at least 10 days after the onset of an 

upper respiratory infection, or causes recurrence of symptoms within seven days after initial improvement); and (d): 

Subacute rhinosinusitis (SAR), which is defined as rhinosinusitis symptoms lasting at least four but less than 12 weeks. 

6222 Rhinosinusitis, pansinusitis. 

6223 Rhinosinusitis, ethmoid. 

6224 Rhinosinusitis, frontal. 

6225 Rhinosinusitis, maxillary. 

6226 Rhinosinusitis, sphenoid. 

6227 Laryngitis, tuberculous, active or inactive. Rate under §§ 4.88c or 4.89, whichever is appropriate. 

6228 Laryngitis, chronic: 

Hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy .............. 30 

Hoarseness, with inflammation of cords or mucous membranes .................................................................................................... 10 

6229 Laryngectomy, total ...................................................................................................................................................................... 1100 

Rate the residuals of partial laryngectomy as laryngitis (DC 6228), aphonia (DC 6230), or stenosis of larynx (DC 6231). 

6230 Aphonia, complete organic: 

Constant inability to communicate by speech .................................................................................................................................. 1 100 

Constant inability to speak above a whisper ................................................................................................................................... 60 

Note: Evaluate incomplete aphonia as laryngitis, chronic (DC 6228). 

6231 Larynx, stenosis of, including residuals of laryngeal trauma (unilateral or bilateral): 

Total obstruction of larynx, requiring permanent tracheostomy ....................................................................................................... 100 

Partial obstruction of larynx with 50 percent or more narrowing of airways .................................................................................... 70 

Partial obstruction of larynx with 25 percent to less than 50 percent narrowing of airways ........................................................... 50 

Partial obstruction of larynx with less than 25 percent narrowing of airways .................................................................................. 30 

Note: Or, evaluate as aphonia (DC 6230). 

6232 Pharynx, injuries to: 

Stricture or obstruction of pharynx or nasopharynx; absence of soft palate secondary to trauma, chemical burn, or 

granulomatous disease; or paralysis of soft palate with swallowing difficulty (nasal regurgitation) and speech impairment ..... 50 

6233 Rhinosinusitis, allergic or nonallergic (vasomotor) related. 

6234 Rhinosinusitis, infection related. 

6235 Rhinosinusitis, autoimmune, granulomatous or other causes: 

While receiving systemic immunosuppressive treatment, or for a period of six months after cessation of treatment ................... 100 

Otherwise evaluate using the General Rating Formula for CRS and RARS. 

Note: Evaluate lethal midline granuloma (also referred to as lymphomatoid granulomatosis or polymorphic reticulosis) under 

neoplasm, malignant (DC 6238). 

6236 Vocal cord paralysis: 

Evaluate under laryngitis, chronic (DC 6228) or aphonia, complete organic (DC 6230). 

6237 Neoplasm, nasopharyngeal, and/or sinus, benign: 100 

Rate on impairment of function. 

6238 Neoplasm, nasopharyngeal, and/or sinus, malignant .................................................................................................................. 100 

Note: A rating of 100 percent shall continue beyond the cessation of any surgery, radiation treatment, antineoplastic chemotherapy, or other prescribed therapeutic procedures. 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, evaluate on residual impairment of function. 

6239 Disease of the salivary glands and/or associated ducts, other than neoplasm: 

Xerostomia (dry mouth) with altered sensation of taste and difficulty with lubrication and mastication of food resulting in either 

weight loss (as defined in § 4.112 of this chapter) or an increase in dental caries ..................................................................... 20 

Xerostomia (dry mouth) with altered sensation of taste and difficulty with lubrication and mastication of food without weight 

loss or an increase in dental caries; chronic inflammation of salivary gland with pain and swelling on eating; or one or more 

salivary calculi or salivary gland stricture ..................................................................................................................................... 10 

Xerostomia (dry mouth) without difficulty in mastication of food or painless swelling of salivary gland ......................................... 0 

Note: Evaluate facial nerve (cranial nerve VII) impairment under diagnostic code 8207 (paralysis of seventh (facial) cranial 

nerve), and any disfigurement due to facial swelling under diagnostic code 7800 (disfigurement or scars of the head, face, 

or neck). 

6240 Rhinitis, allergic or nonallergic (vasomotor): 


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Rating 

With documented evidence of polyps .............................................................................................................................................. 30 

Requires continuous therapy (e.g., inhaled corticosteroids, oral or inhaled antihistamines) .......................................................... 10 

Note: If complicated by either chronic or recurrent acute rhinosinusitis, evaluate instead under rhinosinusitis, allergic or nonallergic (vasomotor) related (DC 6233). 

1 Review for entitlement to special monthly compensation under § 3.350 of this chapter. 

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

■ 11. Amend § 4.96 by: 

■ a. Revising paragraph (a); 

■ b. Removing paragraph (c); 

■ c. Redesignating paragraph (d) as 

paragraph (c); 

■ d. Revising newly redesignated 

paragraph (c); and 

■ e. Adding new paragraph (d). 

The revisions and additions read as 

follows: 

§ 4.96 Special provisions regarding 

evaluation of respiratory conditions. 

(a) Rating coexisting respiratory 

conditions. Unless otherwise directed in 

§ 4.97, do not combine ratings under 

that section. Assign a single rating 

under the diagnostic code that reflects 

the predominant disability, elevating it 

to the next higher evaluation when 

warranted by the severity of the overall 

disability picture. When permitted, 

combine coexisting conditions in 

accordance with § 4.25. 

* * * * * 

(c) Special provisions regarding 

Diagnostic Codes 6600 through 6604, 

6731, 6820, 6825 through 6833, 6840 

through 6846, and 6848. (1) Pulmonary 

Function Tests (PFTs) are required to 

evaluate these conditions except when 

one of the following circumstances 

exists: 

(i) When the results of a maximum 

exercise capacity test are of record and 

are 20 milliliters per kilogram per 

minute (ml/kg/min) or less. If a 

maximum exercise capacity test is not of 

record, evaluate based on alternative 

criteria. 

(ii) When there have been one or more 

episodes of acute respiratory failure. 

(iii) When outpatient oxygen therapy 

is required. 

(2) When the PFTs are not consistent 

with clinical findings, evaluate based on 

the PFTs unless the examiner states why 

they are not a valid indication of 

respiratory functional impairment in a 

particular case. 

(3) When there is a disparity between 

the results of different PFTs (FEV–1 

(Forced Expiratory Volume in one 

second), FVC (Forced Vital Capacity), 

etc.), so that the level of evaluation 

would differ depending on which test 

result is used, use the test result that the 

examiner states most accurately reflects 

the level of disability. 

(d) Respiratory conditions and 

comorbid cardiovascular conditions. 

Absent instructions otherwise in 

individual diagnostic codes, if there are 

comorbid respiratory and cardiovascular 

conditions that can be evaluated by 

METs, only the disability from one body 

system may be evaluated using METs, 

while the disability involving the other 

body system must be evaluated by 

criteria other than METs. 

■ 12. In § 4.97 amend the table by: 

■ a. Removing the heading ‘‘DISEASES 

OF THE NOSE AND THROAT’’; 

■ b. Removing entries for diagnostic 

codes 6502 through 6524; 

■ c. Adding introductory text; 

■ d. Adding entry for ‘‘General Rating 

Formula for Respiratory Conditions’’; 

■ e. Removing the heading ‘‘DISEASE 

OF THE TRACHEA AND BRONCHI’’ 

and adding in its place ‘‘INTRINSIC 

LUNG DISEASES’’; 

■ f. Adding the subheading ‘‘Airway 

Disorders (Trachea, Bronchi)’’ under 

‘‘INTRINSIC LUNG DISEASES’’; 

■ g. Revising entries for diagnostic 

codes 6600 through 6604; 

■ h. Removing the heading ‘‘DISEASES 

OF THE LUNGS AND PLEURA— 

TUBERCULOSIS’’ and adding in its 

place ‘‘Tuberculous Lung Diseases’’; 

■ i. Revising entries for diagnostic codes 

6704, 6724, 6730, and 6731; 

■ j. Removing the heading 

‘‘NONTUBERCULOUS DISEASES’’ and 

adding in its place ‘‘Vascular Lung 

Diseases’’; 

■ k. Revising entry for diagnostic code 

6817; 

■ l. Adding entry for diagnostic code 

6849 under diagnostic code 6817; 

■ m. Adding the subheading ‘‘Lung 

Neoplasms’’ above diagnostic code 

6819; 

■ n. Revising entries for diagnostic 

codes 6819 and 6820; 

■ o. Removing the subheading 

‘‘Bacterial Infections of the Lung’’ and 

adding in its place ‘‘Bacterial Lung 

Diseases’’; 

■ p. Adding entry for ‘‘General Rating 

Formula for Bacterial Lung Diseases’’ 

above diagnostic code 6822; 

■ q. Republishing entry for diagnostic 

code 6822; 

■ r. Removing the subheading 

‘‘Interstitial Lung Disease’’ and adding 

in its place ‘‘Parenchymal Lung Disease 

(Including Interstitium and Alveolar 

Spaces)’’; 

■ s. Adding note above diagnostic code 

6825; 

■ t. Revising entry for diagnostic code 

6825; 

■ u. Republishing entry for diagnostic 

code 6833; 

■ v. Adding entry for diagnostic code 

6846 under diagnostic code 6833; 

■ w. Removing entry for ‘‘General 

Rating Formula for Interstitial Lung 

Disease (diagnostic codes 6825 through 

6833)’’; 

■ x. Removing the subheading ‘‘Mycotic 

Lung Disease’’ and adding in its place 

‘‘Mycotic Lung Diseases’’; 

■ y. Adding entry for ‘‘General Rating 

Formula for Mycotic Lung Disease’’ 

above diagnostic code 6834; 

■ z. Republishing entry for diagnostic 

code 6834; 

■ aa. Removing entry for ‘‘General 

Rating Formula for Mycotic Lung 

Disease (diagnostic codes 6834 through 

6839)’’; 

■ bb. Removing the subheading 

‘‘Restrictive Lung Disease’’ and adding 

in its place ‘‘OTHER RESPIRATORY 

CONDITIONS’’; 

■ cc. Revising entries for diagnostic 

codes 6841 and 6842; 

■ dd. Removing entry for ‘‘General 

Rating Formula for Lung Diseases 

(diagnostic codes 6840 through 6845)’’; 

■ ee. Removing entry for diagnostic 

code 6846 under diagnostic code 6845; 

■ ff. Revising entry for diagnostic code 

6847; and 

■ gg. Adding entry for diagnostic code 

6848. 

The revisions and additions read as 

follows: 

§ 4.97 Schedule of Ratings—Respiratory 

System. 


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Rating 

Unless otherwise directed, evaluate diseases of the Respiratory System under the General Rating Formula for Respiratory Conditions. 

General Rating Formula for Respiratory Conditions: 

At least one of the following ............................................................................................................................................................. 100 

Forced Vital Capacity (FVC) less than 50 percent of predicted value; or 

Forced Expiratory Volume in one second (FEV–1) less than 45 percent of predicted value; or 

Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO(SB)) less than 40 percent predicted; or 

The ratio of FEV–1 to FVC (FEV–1/FVC) less than 40 percent; or 

Maximum Oxygen Consumption measured in milliliters per kilogram per minute (mL/Kg/min) (VO2 Max) less than 10.5; or 

Workload of 3 Metabolic Equivalents (METs) or less. 

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

FVC of 50 to 64 percent predicted; or 

FEV–1 of 45 to 55 percent predicted; or 

DLCO(SB) of 40 to 55 percent predicted; or 

FEV–1/FVC of 40 to 55 percent; or 

VO2 Max of 10.5 to 17.5; or 

Workload of 3.1–5.0 METs. 

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

FVC of 65 to 74 percent predicted; or 

FEV–1 of 56 to 70 percent predicted; or 

DLCO(SB) of 56 to 65 percent predicted; or 

FEV–1/FVC of 56 to 70 percent; or 

VO2 Max of 17.6 to 24.5; or 

Workload of 5.1–7.0 METs. 

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

FVC of 75 to 80 percent predicted; or 

FEV–1 of 71 to 80 percent predicted; or 

DLCO(SB) of 66 to 80 percent predicted; or 

FEV–1/FVC of 71 to 80 percent. 

Note (1): Base the rating on the criteria that reflects the greatest impairment and, therefore, the greatest disability percentage, 

unless otherwise directed by the examiner (see § 4.96(c)(3)). 

Note (2): Do not combine a rating assigned from this formula with other ratings under § 4.97, except for sleep apnea syndromes (DC 6847). 

Note (3): Per § 4.96(d), when METs are used to evaluate a respiratory disability under § 4.97, do not use METs to evaluate a 

comorbid cardiovascular disability under § 4.104, and vice versa. 

INTRINSIC LUNG DISEASES 

Airway Disorders (Trachea, Bronchi) 

6600 Bronchitis, chronic. 

6601 Bronchiectasis. 

6602 Asthma, bronchial: 

At least one of the following ............................................................................................................................................................. 100 

FEV–1 less than 45 percent predicted; or 

FEV–1/FVC less than 40 percent; or 

More than one attack per week with episodes of respiratory failure; or 

Requires daily use of systemic (oral or parenteral) high-dose corticosteroids or immuno-suppressive medications. 

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

FEV–1 of 45 to 55 percent predicted; or 

FEV–1/FVC of 40 to 55 percent; or 

At least monthly visits to a physician for required care of exacerbations; or 

Intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. 

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

FEV–1 of 56 to 70 percent predicted; or 

FEV–1/FVC of 56 to 70 percent; or 

Daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication. 

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

FEV–1 of 71 to 80 percent predicted; or 

FEV–1/FVC of 71 to 80 percent; or 

less than daily inhalational or oral bronchodilator therapy. 

Note (1): In the absence of clinical findings of asthma at the time of examination, a verified history of asthmatic attacks must 

be of record. 

Note (2): Do not combine a rating assigned under this diagnostic code with other ratings under § 4.97, except for sleep apnea 

syndromes (DC 6847). 

6603 Emphysema, pulmonary. 

6604 Chronic obstructive pulmonary disease. 

Tuberculous Lung Diseases 

Ratings for Pulmonary Tuberculosis Entitled on August 19, 1968 


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Rating 

*******

6704 Tuberculosis, pulmonary, chronic, active, advancement unspecified .......................................................................................... 100 

General Rating Formula for Inactive Pulmonary Tuberculosis: 

For two years after date of inactivity, following active tuberculosis, which was clinically identified during service or subsequently ................................................................................................................................................................................... 100 

Thereafter for four years, or in any event, to six years after date of inactivity ........................................................................ 50 

Thereafter, for 5 years, or to 11 years after date of inactivity .................................................................................................. 30 

Following far advanced lesions diagnosed at any time while the disease process was active, minimum .............................. 30 

Following moderately advanced lesions, provided there is continued disability, emphysema, dyspnea on exertion, impairment of health, etc ................................................................................................................................................................. 20 

Otherwise .................................................................................................................................................................................. 0 

Note (1): The 100 percent rating under codes 6701 through 6724 is not subject to a requirement of precedent hospital treatment. It will be reduced to 50 percent for failure to submit to examination or to follow prescribed treatment upon report to 

that effect from the medical authorities. When a veteran is placed on the 100 percent rating for inactive tuberculosis, the 

medical authorities will be appropriately notified of the fact, and of the necessity to notify the Veterans Service Center in the 

event of failure to submit to examination or to follow treatment. 

Note (2): The graduated 50 percent and 30 percent ratings and the permanent 30 percent and 20 percent ratings for inactive 

pulmonary tuberculosis are not to be combined with ratings for other respiratory disabilities. Following thoracoplasty, the 

rating will be for removal of ribs combined with the rating for collapsed lung. Resection of the ribs incident to thoracoplasty

will be evaluated as removal. 

*******

6724 Tuberculosis, pulmonary, chronic, inactive, advancement unspecified. 

*******

6730 Tuberculosis, pulmonary, chronic, active ..................................................................................................................................... 100 

Note: Active pulmonary tuberculosis will be considered permanently and totally disabling for non-service-connected pension 

purposes in the following circumstances: 

(a) Associated with active tuberculosis involving other than the respiratory system. 

(b) With severe associated symptoms or with extensive cavity formation. 

(c) Reactivated cases, generally. 

(d) With advancement of lesions on successive examinations or while under treatment. 

(e) Without retrogression of lesions or other evidence of material improvement at the end of 6 months hospitalization or 

without change of diagnosis from ‘‘active’’ at the end of 12 months hospitalization. Material improvement means lessening or absence of clinical symptoms, and X-ray findings of a stationary or retrogressive lesion. 

6731 Tuberculosis, primary, chronic, inactive: 

Depending on the specific findings, evaluate respiratory residuals using General Rating Formula for Respiratory Conditions. 

Note (1): Evaluate thoracoplasty as removal of ribs under DC 5297. 

Note (2): Request a mandatory examination immediately following notification that active tuberculosis evaluated under DC 

6730 has become inactive. Implement any change in evaluation under the provisions of § 3.105(e). 

*******

Vascular Lung Diseases 

6817 Pulmonary thromboembolic disease: 

Chronic pulmonary thromboembolism with evidence of either pulmonary hypertension or right ventricular hypertrophy .............. 100 

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

Chronic pulmonary thromboembolism requiring anticoagulant therapy; or 

Following inferior vena cava surgery without evidence of pulmonary hypertension or right ventricular dysfunction. 

Symptomatic, following resolution of acute pulmonary embolism ................................................................................................... 30 

Asymptomatic, following resolution of pulmonary thromboembolism .............................................................................................. 0 

Note (1): Evaluate other residuals following pulmonary embolism under the most appropriate diagnostic code, such as chronic 

bronchitis (DC 6600) or chronic pleural effusion or fibrosis (DC 6844), but do not combine that evaluation with any of the 

above evaluations. 

Note (2): Do not assign separate evaluations for pulmonary thromboembolic disease with right ventricular hypertrophy and a 

comorbid cardiovascular condition listed under § 4.104, diagnostic codes (DCs) 7000–7020. Assign a single rating under 

this diagnostic code or under DCs 7000–7020, whichever reflects the predominant disability. 

Note (3): Do not combine a rating assigned under this diagnostic code with other ratings under § 4.97, except for sleep apnea 

syndromes (DC 6847). 

6849 Pulmonary hypertension: 

Echocardiogram with severe right ventricular (RV) enlargement (greater than 4 cm), and at least one of the following: 

Maximum Oxygen Consumption measured in milliliters per kilogram per minute (mL/Kg/min) (VO2 Max) less than 15; or 

Workload of 3 Metabolic Equivalents (METs) or less ............................................................................................................... 100 

Echocardiogram with severe RV enlargement (greater than 4 cm), and at least one of the following: 

Brain natriuretic peptide (BNP) greater than 500; 

VO2 Max of 15 to 20; or 

Workload of 3.1 to 5.0 METs .................................................................................................................................................... 60 

Echocardiogram with moderate RV enlargement (3 to 4 cm), and at least one of the following: 

BNP of 100 to 500; or 

Workload of 5.1 to 7.0 METs .................................................................................................................................................... 30 

One of the following: 

BNP less than 100; or 

VO2 Max greater than 20 ......................................................................................................................................................... 0 


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Rating 

Note (1): Acute pulmonary hypertension is not a disability for rating purposes. 

Note (2): Do not assign separate evaluations for pulmonary hypertension and a comorbid cardiovascular condition listed 

under § 4.104, diagnostic codes (DCs) 7000–7020. Assign a single rating under this diagnostic code or under DCs 7000– 

7020, whichever reflects the predominant disability. 

Note (3): Do not combine a rating assigned under this diagnostic code with other ratings under § 4.97, except for sleep apnea 

syndromes (DC 6847). 

Lung Neoplasms 

6819 Neoplasms, malignant, any specified part of respiratory system exclusive of skin growths ...................................................... 100 

Note: A rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy, or 

other prescribed 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, 

evaluate on residuals by using the General Rating Formula for Respiratory Conditions. 

6820 Neoplasms, benign, any specified part of respiratory system. 

Bacterial Lung Diseases 

General Rating Formula for Bacterial Lung Diseases: 

Active infection with systemic symptoms such as fever, night sweats, weight loss, or hemoptysis ............................................... 100 

Depending on the specific findings, evaluate the most severe residual analogously. 

Note: Do not combine a rating assigned under this formula with other ratings under § 4.97, except for sleep apnea syndromes 

(DC 6847). 

6822 Actinomycosis. 

* * * * * * * 

Parenchymal Lung Disease (Including Interstitium and Alveolar Spaces) 

Note (1): Evaluate using the General Rating Formula for Respiratory Conditions. 

Note (2): For DCs 6825 through 6833 and DC 6846, add 10 percent to any rating if a physician prescribes either of the following: 

Oral prednisone greater than 20mg daily or daily second-line (i.e., non-steroidal) immunosuppressive medication. 

6825 Diffuse interstitial fibrosis (interstitial pneumonitis, fibrosing alveolitis, or idiopathic fibrosis). 

* * * * * * * 

6833 Asbestosis. 

6846 Sarcoidosis. 

Mycotic Lung Diseases 

General Rating Formula for Mycotic Lung Diseases: 

Chronic pulmonary mycosis with persistent fever, weight loss, night sweats, or massive hemoptysis .......................................... 100 

Chronic pulmonary mycosis requiring suppressive therapy with no more than minimal symptoms such as occasional minor 

hemoptysis or productive cough ................................................................................................................................................... 50 

Chronic pulmonary mycosis with minimal symptoms such as occasional minor hemoptysis or productive cough ........................ 30 

Healed and inactive mycotic lesions, asymptomatic ........................................................................................................................ 0 

Note (1): Coccidioidomycosis has an incubation period up to 21 days, and the disseminated phase is ordinarily manifest within 6 months of the primary phase. However, there are instances of dissemination delayed for years after the initial infection, 

which may have been unrecognized. Accordingly, when considering service connection, in the absence of record or other 

evidence of the disease in service, service in southwestern United States, where the disease is endemic, and absence of 

prolonged residence in this locality before or after service will be the deciding factor. 

Note (2): Do not combine a rating assigned under this formula with other ratings under § 4.97, except for sleep apnea syndromes (DC 6847). 

6834 Histoplasmosis of lung. 

OTHER RESPIRATORY CONDITIONS 

*******

6841 Respiratory insufficiency due to spinal cord injury. 

6842 Pulmonary disease secondary to kyphoscoliosis, pectus excavatum, or pectus carinatum. 

*******

6847 Sleep apnea syndromes (obstructive, central, or mixed): 

Treatment ineffective (as determined by sleep study) or unable to use treatment due to comorbid conditions; and with endorgan damage ............................................................................................................................................................................... 100 

Treatment ineffective (as determined by sleep study) or unable to use treatment due to comorbid conditions; and without endorgan damage ............................................................................................................................................................................... 50 

Incomplete relief (as determined by sleep study) with treatment .................................................................................................... 10 

Asymptomatic with or without treatment .......................................................................................................................................... 0 

Note: Qualifying comorbidities are conditions that, in the opinion of a qualified medical provider, directly impede or prevent the 

habitual use of a recognized form of treatment shown by sleep study to be effective in the affected veteran’s case (e.g., 

contact dermatitis where the mask or interface touches the face or nares, Parkinson’s disease, missing limbs, facial disfigurement, or skull fracture). 


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Rating 

6848 Lung transplantation: 

Following transplant surgery ............................................................................................................................................................ 100 

Thereafter, evaluate residuals under the General Rating Formula for Respiratory Conditions, minimum rating ........................... 30 

Note (1): A rating of 100 percent shall be assigned as of the date of hospital admission for lung transplant. 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. 

Note (2): Do not combine a rating assigned under this diagnostic code with other ratings under § 4.97, except for sleep apnea 

syndromes (DC 6847). 

■ 13. Amend § 4.104 by: 

■ a. Removing Note (1); 

■ b. Redesignating Note (2) as Note (1); 

and 

■ c. Redesignating Note (3) as Note (2). 

The revisions read as follows: 

§ 4.104 Schedule of ratings— 

cardiovascular system. 

* * * * * 

Rating 

Note (1): 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 breathlessness, 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, a medical examiner may estimate the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms. 

Note (2): For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. 

* * * * * * * 

■ 14. Amend appendix A to part 4 by: 

■ a. Adding entry for § 4.85; 

■ b. Revising entries for §§ 4.87 and 

4.87a; 

■ c. Revising entries for diagnostic 

codes 6502 through 6516, 6518 through 

6604, 6731, and 6817, 6819, 6820, and 

6822 through 6847; and 

■ d. Adding entries for diagnostic codes 

6848 and 6849 in numerical order. 

The revisions and additions read as 

follows: 

APPENDIX A TO PART 4–TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946 

Sec. Diagnostic 

code No. 

*******

4.85 ............. 6100 Criterion [effective date of final rule]. 

4.87 ............. .................... Tables VI and VII replaced by new Tables VI, VIA, and VII December 18, 1987. 

6200 Revised and redesignated § 4.87 June 10, 1999; criterion [effective date of final rule]. 

6201 Revised and redesignated § 4.87 June 10, 1999; criterion [effective date of final rule]. 

6202 Revised and redesignated § 4.87 June 10, 1999; title [effective date of final rule]. 

6204 Revised and redesignated § 4.87 June 10, 1999; criterion [effective date of final rule]. 

6205 Revised and redesignated § 4.87 June 10, 1999; criterion [effective date of final rule]. 

6207–6211 Revised and redesignated § 4.87 June 10, 1999. 

6220–6240 Added [effective date of final rule]. 

6260 Revised and redesignated § 4.87 June 10, 1999; Removed [effective date of final rule]. 

4.87a ........... 6275–6276 Moved from § 4.87b June 10, 1999. 

* * * * * * * 

4.97 ............. 6502–6514 Criterion October 7, 1996; Revised and moved to § 4.87 [effective date of final rule]. 

6515 Criterion March 11, 1969; Revised and moved to § 4.87 [effective date of final rule]. 

6516 Criterion October 7, 1996; Revised and moved to § 4.87 [effective date of final rule]. 

6517 Removed October 7, 1996. 

6518–6520 Criterion October 7, 1996; Revised and moved to § 4.87 [effective date of final rule]. 

6521–6524 Added October 7, 1996; Revised and moved to § 4.87 [effective date of final rule]. 

6600 Evaluation September 9, 1975; criterion October 7, 1996; criterion [effective date of final rule]. 

6601 Criterion October 7, 1996; criterion [effective date of final rule]. 

6602 Criterion September 9, 1975; criterion October 7, 1996; criterion [effective date of final rule]. 

6603 Added September 9, 1975; criterion October 7, 1996; criterion [effective date of final rule]. 

6604 Added October 7, 1996; criterion [effective date of final rule]. 

* * * * * * * 

6731 Evaluation September 22, 1978; criterion October 7, 1996; criterion [effective date of final rule]. 

*******

6817 Evaluation October 7, 1996; title, criterion [effective date of final rule]. 


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APPENDIX A TO PART 4–TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946—Continued 

Sec. Diagnostic 

code No. 

*******

6819 Criterion March 10, 1976; criterion October 7, 1996; criterion [effective date of final rule]. 

6820 Criterion [effective date of final rule]. 

6821 August 23, 1948; Removed October 7, 1996. 

6822–6824 Added October 7, 1996; criterion [effective date of final rule]. 

6825 Added October 7, 1996; title, criterion [effective date of final rule]. 

6826–6840 Added October 7, 1996; criterion [effective date of final rule]. 

6841–6842 Added October 7, 1996; title, criterion [effective date of final rule]. 

6843–6847 Added October 7, 1996; criterion [effective date of final rule]. 

6848 Added [effective date of final rule]. 

6849 Added [effective date of final rule]. 

*******

■ 15. Amend appendix B to part 4 by: 

■ a. Removing the heading ‘‘THE EAR’’ 

and adding in its place ‘‘EAR, NOSE, 

and THROAT’’; 

■ b. Adding entry for diagnostic code 

6100; 

■ c. Revising diagnostic code 6202; 

■ d. Adding diagnostic codes 6220 

through 6240; 

■ e. Removing diagnostic code 6260; 

■ f. Removing the subheading ‘‘Nose 

and Throat’’; 

■ g. Removing diagnostic codes 6502 

through 6524; 

■ h. Removing the subheading ‘‘Trachea 

and Bronchi’’ and adding in its place 

‘‘Airway Disorders (Trachea, Bronchi)’’; 

■ i. Removing the subheading ‘‘Lungs 

and Pleura Tuberculosis’’ and adding in 

its place ‘‘Tuberculosis Lung Disease’’; 

■ j. Removing the subheading 

‘‘Nontuberculous Diseases’’ and adding 

in its place ‘‘Vascular Lung Disease’’; 

■ k. Revising diagnostic code 6817; 

■ l. Adding entry for diagnostic code 

6849 under diagnostic code 6817; 

■ m. Adding the subheading ‘‘Lung 

Neoplasms’’ above diagnostic code 

6819; 

■ n. Republishing diagnostic code 6819; 

■ o. Removing the subheading 

‘‘Bacterial Infections of the Lung’’ and 

adding in its place ‘‘Bacterial Lung 

Diseases’’; 

■ p. Removing the subheading 

‘‘Interstitial Lung Disease’’ and adding 

in its place ‘‘Parenchymal Lung Disease 

(Including Interstitium and Alveolar 

Spaces)’’; 

■ q. Revising diagnostic codes 6825, 

6829, and 6830; 

■ r. Removing the subheading ‘‘Mycotic 

Lung Disease’’ and adding in its place 

‘‘Mycotic Lung Diseases’’; 

■ s. Removing the subheading 

‘‘Restrictive Lung Disease’’ and adding 

in its place ‘‘Other Respiratory 

Conditions’’; 

■ t. Revising diagnostic codes 6841 and 

6842; and 

■ u. Adding diagnostic code 6848. 

The revisions and additions read as 

follows: 

APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES

Diagnostic 

code No. 

*******

EAR, NOSE, and THROAT 

6100 ........... Hearing loss. 

* * * * * * * 

6202 ........... Otosclerosis, stapedectomy, stapedotomy, residuals of. 

* * * * * * * 

6220 ........... Septum, nasal, deviation of. 

6221 ........... Nose, loss of part of, or scars. 

6222 ........... Rhinosinusitis, pansinusitis, chronic; infectious. 

6223 ........... Rhinosinusitis, ethmoid, chronic; infectious. 

6224 ........... Rhinosinusitis, frontal, chronic; infectious. 

6225 ........... Rhinosinusitis, maxillary, chronic; infectious. 

6226 ........... Rhinosinusitis, sphenoid, chronic; infectious. 

6227 ........... Laryngitis, tuberculous, active or inactive. 

6228 ........... Laryngitis, chronic. 

6229 ........... Laryngectomy, total. 

6230 ........... Aphonia, complete organic. 

6231 ........... Larynx, stenosis of, including residuals of laryngeal trauma (unilateral or bilateral). 

6232 ........... Pharynx, injuries to. 

6233 ........... Rhinosinusitis, allergic or nonallergic (vasomotor) related. 

6234 ........... Rhinosinusitis, infection related. 

6235 ........... Rhinosinusitis, autoimmune, granulomatous, or other causes. 

6236 ........... Vocal cord paralysis. 


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APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES—Continued 

Diagnostic 

code No. 

6237 ........... Neoplasm, nasopharyngeal and/or sinus, benign. 

6238 ........... Neoplasm, nasopharyngeal, and/or sinus, malignant. 

6239 ........... Salivary gland and/or associated ducts disease other than neoplasm. 

6240 ........... Rhinitis, allergic or nonallergic (vasomotor). 

* * * * * * * 

THE RESPIRATORY SYSTEM 

Airway Disorders (Trachea, Bronchi) 

*******

Tuberculous Lung Diseases 

*******

Vascular Lung Diseases 

6817 ........... Pulmonary thromboembolic disease. 

6849 ........... Pulmonary hypertension. 

Lung Neoplasms 

6819 ........... Neoplasms, malignant. 

* * * * * * * 

Bacterial Lung Diseases 

*******

Parenchymal Lung Disease (Including Interstitium and Alveolar Spaces) 

6825 ........... Diffuse interstitial fibrosis. 

* * * * * * * 

6829 ........... Drug-induced pulmonary pneumonitis and fibrosis. 

6830 ........... Radiation-induced pulmonary pneumonitis and fibrosis. 

* * * * * * * 

Mycotic Lung Diseases 

*******

Other Respiratory Conditions 

*******

6841 ........... Respiratory insufficiency due to spinal cord injury. 

6842 ........... Pulmonary disease secondary to kyphoscoliosis, pectus excavatum, pectus carinatum. 

*******

6848 ........... Lung transplantation. 

*******

■ 16. Amend appendix C to part 4 by: 

■ a. Revising entries for ‘‘Aphonia, 

organic’’ and ‘‘Injury: Pharynx’’; 

■ b. Removing entry for ‘‘Injury: 

Sacroiliac: Spinal cord’’ and 

‘‘Kyphoscoliosis, pectus excavatum/ 

carinatum’’; 

■ c. Adding entry for ‘‘Hearing loss’’; 

■ d. Revising entries for 

‘‘Laryngectomy’’, ‘‘Laryngitis:’’, 

‘‘Larynx, stenosis of’’, and ‘‘Loss of: 

Nose, part of, or scars’’; 

■ e. Adding entries for ‘‘Lung, 

transplantation of’’, ‘‘Neoplasms: 

Benign: Nasopharyngeal’’, and 

‘‘Neoplasms: Malignant: 

Nasopharyngeal’’; 

■ f. Revising entry for ‘‘Otosclerosis’’; 

■ g. Adding entries for ‘‘Pulmonary: 

Disease secondary to kyphoscoliosis, 

pectus excavatum, pectus carinatum’’ 

and ‘‘Pulmonary: Hypertension’’; 


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■ h. Removing entry for ‘‘Pulmonary: 

Vascular disease’’ and adding in its 

place ‘‘Pulmonary: Thromboembolic 

disease’’; 

■ i. Adding entry for ‘‘Respiratory 

insufficiency due to spinal cord injury’’; 

■ j. Revising entry for ‘‘Rhinitis’’; 

■ k. Adding entries for 

‘‘Rhinosinusitis’’, ‘‘Salivary gland and/ 

or associated ducts disease other than 

neoplasm’’, and ‘‘Septum, nasal, 

deviation of’’; 

■ l. Removing entry for ‘‘Sinusitis’’; 

■ m. Revising entry for ‘‘Sleep Apnea 

Syndrome’’; 

■ n. Removing entry for ‘‘Tinnitus, 

recurrent’’; and 

■ o. Adding entry for ‘‘Vocal cord 

paralysis’’. 

The revisions and additions read as 

follows: 

APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES

Diagnostic 

code No. 

*******

Aphonia, organic ...................................................................................................................................................................................... 6230 

* * * * * * * 

Pharynx .................................................................................................................................................................................................... 6232 

* * * * * * * 

Hearing loss ............................................................................................................................................................................................. 6100 

* * * * * * * 

Laryngectomy .......................................................................................................................................................................................... 6229 

Laryngitis, chronic .................................................................................................................................................................................... 6228 

Laryngitis, tuberculosis ............................................................................................................................................................................ 6227 

Larynx, stenosis of ................................................................................................................................................................................... 6231 

* * * * * * * 

Loss of: 

* * * * * * * 

Nose, part of, or scars ...................................................................................................................................................................... 6221 

* * * * * * * 

Lung, transplantation of ........................................................................................................................................................................... 6848 

* * * * * * * 

Neoplasms: 

Benign: 

* * * * * * * 

Nasopharyngeal ........................................................................................................................................................................ 6237 

*******

Malignant: 

Nasopharyngeal ........................................................................................................................................................................ 6328 

*******

Otosclerosis, stapedectomy, stapedotomy .............................................................................................................................................. 6202 

* * * * * * * 

Pulmonary: ....................

Disease secondary to kyphoscoliosis, pectus excavatum, pectus carinatum ................................................................................. 6842 

Hypertension ..................................................................................................................................................................................... 6849 

Thromboembolic disease ................................................................................................................................................................. 6817 

* * * * * * * 

Respiratory insufficiency due to spinal cord injury .................................................................................................................................. 6841 

* * * * * * * 

Rhinitis, allergic or nonallergic (vasomotor) ............................................................................................................................................ 6240 

Rhinosinusitis: 

Allergic or nonallergic (vasomotor) related ...................................................................................................................................... 6223 

Autoimmune, granulomatous or other causes ................................................................................................................................. 6235 

Ethmoid ............................................................................................................................................................................................. 6233 

Frontal ............................................................................................................................................................................................... 6224 

Infection related ................................................................................................................................................................................ 6234 

Maxillary ............................................................................................................................................................................................ 6225 

Pansinusitis ....................................................................................................................................................................................... 6222 

Sphenoid ........................................................................................................................................................................................... 6226 

*******

Salivary gland and/or associated ducts disease other than neoplasm ................................................................................................... 6239 


lotter on DSK11XQN23PROD with PROPOSALS1
8498 Federal Register / Vol. 87, No. 31 / Tuesday, February 15, 2022 / Proposed Rules 

APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES—Continued 

Diagnostic 

code No. 

*******

Septum, nasal, deviation of ..................................................................................................................................................................... 6220 

* * * * * * * 

Sleep apnea syndromes .......................................................................................................................................................................... 6847 

* * * * * * * 

Vocal cord paralysis ................................................................................................................................................................................ 6236 

* * * * * * * 

[FR Doc. 2022–02049 Filed 2–14–22; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 4 

RIN 2900–AQ82 

Schedule for Rating Disabilities: 

Mental Disorders 

AGENCY: Department of Veterans Affairs. 

ACTION: Proposed rule. 

SUMMARY: The Department of Veterans 

Affairs (VA) proposes to amend the 

portion of the rating schedule dealing 

with mental disorders, including 

revising the General Rating Formula for 

Mental Disorders and combining 

currently separate General Rating 

Formula for Mental Disorders with the 

General Rating Formula for Eating 

Disorders in the VA Schedule for Rating 

Disabilities (VASRD or rating schedule). 

The proposed rule reflects changes 

made by the American Psychiatric 

Association’s Diagnostic and Statistical 

Manual of Mental Disorders 5 (DSM–5), 

advances in medical knowledge, and 

recommendations from VA’s Mental 

Disorders Work Group. 

DATES: VA must receive comments on or 

before April 18, 2022. 

ADDRESSES: Comments may be 

submitted through 

www.Regulations.gov. Comments 

received will be available at 

www.Regulations.gov for public 

viewing, inspection or copies. 

FOR FURTHER INFORMATION CONTACT: 

Ioulia Vvedenskaya, M.D., M.B.A., 

Medical Officer, Regulations Staff, 

(210A), Compensation Service, Veterans 

Benefits Administration, Department of 

Veterans Affairs, 810 Vermont Avenue 

NW, Washington, DC 20420, 

211PolicyStaff.Vbavaco@va.gov, (202) 

461–9700. (This is not a toll-free 

telephone number.) 

SUPPLEMENTARY INFORMATION: 

I. The Need for Updated Rating Criteria 

As part of its ongoing revision of the 

VASRD, VA proposes changes to the 

rating schedule for mental disorders, 

including the General Rating Formula 

for Mental Disorders codified at 38 CFR 

4.130. The proposed changes would 

update evaluation criteria based on the 

DSM–5, medical advances since the last 

substantive revision of the rating 

schedule for mental disorders in 1996, 

and current understanding of functional 

impairment associated with, or resulting 

from, mental disorders. These changes 

also reflect comments received from 

subject matter experts in the Veterans 

Benefits Administration (VBA), 

Veterans Health Administration (VHA), 

Board of Veterans’ Appeals (BVA), 

Department of Defense (DoD), and 

Veterans Service Organizations (VSOs). 

Overall, VA did not rely on one 

particular input for these proposed 

changes, but the multitude of published, 

publicly available, and peer-reviewed, 

scientific and medical sources cited 

below. 

In 2006, the Veterans’ Disability 

Benefits Commission (VDBC) asked the 

Institute of Medicine (IOM) (now named 

the National Academy of Medicine) to 

study and recommend improvements 

for the VASRD. The IOM recommended 

updating the medical content of the 

rating schedule, by placing greater 

emphasis on a disabled veteran’s ability 

to function in the work setting, rather 

than focusing on symptoms alone. 

Institute of Medicine, ‘‘A 21st Century 

System for Evaluating Veterans for 

Disability Benefits’’ 113–14 (Michael 

McGeary et al. eds., 2007). 

In March 2015, VA published a final 

rule (RIN 2900–AO96) that updated the 

nomenclature for mental disorders and 

removed outdated references to the 

fourth editions of DSM (DSM–IV and 

DSM–IV–TR), replacing them with 

references to the latest fifth edition 

(DSM–5). While this rule updated the 

nomenclature to conform to the DSM– 

5, VA did not update the rating criteria 

used to evaluate mental disorders. 

VA now proposes, however, to update 

the rating criteria for mental disorders 

in accord with IOM’s recommendation 

and the latest medical science. VA’s 

updates are based on the framework 

associated with the International 

Classification of Functioning, Disability, 

and Health (ICF) and its companion 

assessment instrument, the World 

Health Organization (WHO) Disability 

Assessment Schedule 2.0 (WHODAS 

2.0), as well as the International 

Classification of Diseases (ICD), and 

concepts and methodology from the 

DSM–5. 

The WHODAS 2.0 is a validated 

instrument that assesses health and 

disability across all diseases, including 

mental, neurological, and addictive 

disorders. O. Garin et al., ‘‘Validation of 

the ‘World Health Organization 

Disability Assessment Schedule, 

WHODAS–2’ in patients with chronic 

diseases,’’ 8 Health and Quality of Life 

Outcomes 51 (2010). It assesses the 

ability to perform tasks in six functional 

domains by measuring the impact of a 

disability across various life functions 

and assigning a score for each domain. 

‘‘WHO Disability Assessment Schedule 

2.0 (WHODAS 2.0),’’ World Health 

Organization, https://www.who.int/ 

classifications/icf/whodasii/en/ (last 

visited Nov. 19, 2019) (hereinafter 

‘‘WHODAS 2.0’’). 

The ICD is a standard tool for the 

diagnosis of disabilities for the purposes 

of epidemiology, health management, 

and clinical practice. By employing a 

standardized numerical labeling system, 

the ICD allows disease to be classified, 

monitored, and analyzed for statistical 

purposes. ‘‘Classifications,’’ World 

Health Organization, https://

www.who.int/classifications/en/ (last 

visited Nov. 19, 2019). 

Finally, the DSM–5 is a standardized 

classification of mental disorders for 

mental health professionals in the 


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