Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 54089 

■ e. Revising the entry for ‘‘Prostate 

gland’’ (diagnostic code 7527); 

■ f. Under the heading ‘‘Renal,’’ adding 

in alphabetical order an entry for 

‘‘Disease caused by viral infection such 

as HIV, Hepatitis B, and Hepatitis C’’ 

(diagnostic code 7544); 

■ g. Under the heading ‘‘Renal,’’ 

removing the entry for ‘‘Involvement in 

systemic diseases’’ (diagnostic code 

7541), and adding an entry for 

‘‘Involvement in diabetes mellitus type 

I or II’’ in its place; 

■ h. Removing the entry for 

‘‘Ureterolithiasis’’ (diagnostic code 

7510); 

■ i. Removing the entry for ‘‘Epididymoorchitis’’ (diagnostic code 7525); 

■ j. Adding in alphabetical order an 

entry for ‘‘Prostatitis, urethritis, 

epididymitis, orchitis (unilateral or 

bilateral), chronic only’’ (diagnostic 

code 7525); and 

■ k. Adding in alphabetical order an 

entry for ‘‘Varicocele/Hydrocele’’ 

(diagnostic code 7543). 

The additions and revisions read as 

follows: 

Appendix C to Part 4—Alphabetical 

Index of Disabilities 

Diagnostic 

code No. 

*******

Bladder: 

Calculus in .................................................................................................................................................................................... 7515 

Diverticulum of .............................................................................................................................................................................. 7545 

Fistula in ....................................................................................................................................................................................... 7516 

Injury of ......................................................................................................................................................................................... 7517 

Neurogenic ................................................................................................................................................................................... 7542 

*******

Interstitial nephritis, including gouty nephropathy, disorders of calcium metabolism ......................................................................... 7537 

*******

Nephrolithiasis/Ureterolithiasis/Nephrocalcinosis ................................................................................................................................ 7508 

*******

Penis: 

Erectile dysfunction ...................................................................................................................................................................... 7522 

Removal of glans .......................................................................................................................................................................... 7521 

Removal of half or more ............................................................................................................................................................... 7520 

*******

Prostate gland injuries, infections, hypertrophy, postoperative residuals, bladder outlet obstruction ................................................ 7527 

Prostatitis, urethritis, epididymitis, orchitis (unilateral or bilateral), chronic only ................................................................................. 7525 

*******

Renal: 

Amyloid disease ........................................................................................................................................................................... 7539 

Disease, chronic ........................................................................................................................................................................... 7530 

Disease caused by viral infection such as HIV, Hepatitis B, and Hepatitis C ............................................................................. 7544 

Involvement in diabetes mellitus type I or II ................................................................................................................................. 7541 

Tubular disorders .......................................................................................................................................................................... 7532 

*******

Varicocele/Hydrocele ........................................................................................................................................................................... 7543 

*******

[FR Doc. 2021–19997 Filed 9–29–21; 8:45 am] 

BILLING CODE 8320–01–P 

DEPARTMENT OF VETERANS 

AFFAIRS 

38 CFR Part 4 

RIN 2900–AQ67 

Schedule for Rating Disabilities: The 

Cardiovascular System 

AGENCY: Department of Veterans Affairs. 

ACTION: Final rule. 

SUMMARY: This document amends the 

Department of Veterans Affairs (VA) 

Schedule for Rating Disabilities 

(‘‘VASRD’’ or ‘‘rating schedule’’) by 

revising the portion of the rating 

schedule that addresses the 

cardiovascular system. The purpose of 

this revision is to ensure that this 

portion of the rating schedule uses 

current medical terminology and 

provides detailed and updated criteria 

for the evaluation of cardiovascular 

disabilities by incorporating medical 

advances that have occurred since the 

last review. 

DATES: This rule is effective November 

14, 2021. 

FOR FURTHER INFORMATION CONTACT: Gary 

Reynolds, M.D., Regulations Staff 

(211D), Compensation Service, Veterans 

Benefits Administration, Department of 

Veterans Affairs, 810 Vermont Avenue 

NW, Washington, DC 20420, (202) 461– 

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

SUPPLEMENTARY INFORMATION: VA 

published a proposed rule in the 

Federal Register at 84 FR 37594 on 

August 1, 2019, to amend the 

regulations involving the cardiovascular 

system. VA provided a 60-day public 

comment period and invited interested 

persons to submit written comments, 

suggestions, or objections on or before 

September 30, 2019. VA received 

comments from National Organization 

of Veterans’ Advocates (NOVA), 

Military Disability Made Easy (two 

comments), Veterans of Foreign Wars 

(VFW), National Veterans Legal Services 


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Program (NVLSP), and four individuals. 

VA has made limited changes based on 

these comments, as discussed below. 

Section-by-Section Discussion of Part 4 

of Title 38 of the CFR 

General Discussion: 

One commenter requested 

clarification for the meaning of ‘‘month’’ 

and asked that the number of days that 

a ‘‘month’’ represents be provided. VA 

clarifies that the term ‘‘month’’ is used 

to describe the procession from one 

month to the next on the Gregorian 

calendar. It does not denote a specific 

number of days since the number of 

days in a month vary throughout the 

year. However, for the purpose of 

understanding how long a temporary 

evaluation will be effective based on 

‘‘months,’’ VA clarifies that temporary 

evaluations remain effective until the 

last day of the month in which the 

temporary evaluation ends. As an 

example, under Diagnostic Code 7000, 

VA will assign a 100-percent evaluation 

during active infection with valvular 

heart disease and for three months 

following the cessation of treatment for 

the active infection. If treatment ceased 

on January 5, 2020, the temporary 

evaluation would end after three 

months (on approximately April 5, 

2020) and would remain effective until 

the end of the current month, April 30, 

2020. 

§ 4.100, Application of the evaluation 

criteria for diagnostic codes 7000–7007, 

7011, and 7015: 

Three issues within this section were 

highlighted by multiple commenters. 

One commenter asked why it was 

necessary to wait for significant 

debilitation before compensation is 

awarded when using disease 

classification as a basis for 

compensation. VA notes current law 

requires that VA adopt and apply ‘‘a 

schedule of ratings of reductions in 

earning capacity from specific injuries 

or combination of injuries’’ that are 

based upon the average impairments of 

earning capacity from injuries or 

disabilities related to military service in 

civil occupations. See 38 U.S.C. 1155. 

Second, disease classification is not a 

consistently accurate predictor of either 

disability or loss in earnings capacity. 

VA makes no changes based on this 

comment. 

Another commenter asked what are 

the alternatives that can be used instead 

of metabolic equivalent of task (METs) 

when METs testing is contraindicated 

for diagnostic codes using the General 

Rating Formula for Diseases of the 

Heart. VA notes that under certain 

evaluation criteria within the General 

Rating Formula for Diseases of the 

Heart, medication and selected 

echocardiogram findings may be used. 

In addition, Note 2 of the General Rating 

Formula, as proposed, states that 

examiners are permitted to estimate 

METs level based on an interview when 

testing cannot be conducted. VA makes 

no changes based on this comment. 

Three commenters objected to the 

removal of congestive heart failure 

(CHF) and left ventricular ejection 

fraction (LVEF). One commenter stated 

that instead of removing CHF and LVEF, 

VA should require medical examiners to 

provide a full picture of the heart 

disability, including explaining if CHF 

or LVEF is not caused by the heart 

condition, in accordance with § 4.10. 

Another commenter questioned the 

rationale for removing CHF and LVEF 

because VA argued for including those 

metrics in a 2002 proposed rule. The 

commenter also stated that removing 

these metrics would be overly restrictive 

and burdensome to veterans with 

limited access to care. The last 

commenter objected to the removal of 

CHF and LVEF and cited a 2017 medical 

journal article which concluded that 

LVEF was the best metric for functional 

and structural cardiac remodeling. VA 

appreciates these comments but 

continues with the proposed changes 

without modification for the following 

reasons. 

First, under certain evaluation criteria 

within the General Rating Formula for 

Diseases of the Heart, medication and 

selected echocardiogram findings may 

be used instead of METs. Second, it 

should be noted that § 4.10 requires in 

part ‘‘full description of the effects of 

disability upon the person’s ordinary 

activity.’’ CHF is actually a medical 

diagnosis, and does not, in and of itself, 

describe disability. Additionally, 

‘‘ejection fraction (LVEF) is poorly 

related to exercise tolerance (which is 

measured in METS).’’ Topol, E.J., 

‘‘Textbook of Cardiovascular Medicine, 

3rd Edition, pg. 1349 (2007). MET, on 

the other hand, is a metric used to 

describe functional capacity or exercise 

tolerance of an individual performing 

activities, for some of which the 

difficulty with or inability to perform 

has a profoundly negative effect on 

earnings capacity. As VA explained in 

the proposed rule, LVEF and CHF are 

unreliable tools for assessing functional 

limitation and disability due to cardiac 

disease because they may be influenced 

by numerous factors not directly 

associated with the underlying 

cardiovascular disease. 84 FR at 37595. 

Third, on August 22, 2002, VA 

published proposed changes to § 4.100 

that, while providing a basis to include 

consideration of LVEF and CHF in the 

cardiac disability evaluation, also 

clarified that VA does not require all 

three tests (i.e., METs, CHF, and LVEF) 

in order to evaluate a cardiac disability. 

See 67 FR 54394. At the time, VA stated 

that ‘‘[o]ur intent in providing 

alternative criteria was to avoid the 

need for a veteran to undergo additional 

tests that might be invasive, risky, 

costly, or time-consuming, if one or 

more objective and reliable tests or 

findings suitable for evaluation 

purposes are already of record.’’ Id. at 

54395. These proposed changes were 

finalized in 2006. See 71 FR 52457. VA 

does not consider removing CHF and 

LVEF as inconsistent with its stated 

intention in 2002. VA’s intent has 

consistently been to avoid, whenever 

possible, invasive, risky, costly, or timeconsuming tests when ascertaining level 

of impairment and METs testing is the 

least invasive procedure compared to 

CHF and LVEF testing. Further, 

although one commenter raised the 

issue of local accessibility of certain 

testing, VA notes that METs can be 

obtained via provider interview, 

observation, or actual physical testing. 

Finally, a commenter who objected to 

the removal of CHF and LEVF also cited 

a 2017 medical journal article that 

involves functional and structural 

phenotyping of failing hearts to better 

diagnose, treat, and otherwise manage 

heart failure. The article does not, 

however, address residual disability 

leading to loss in earnings capacity, 

which is the primary focus of the ratings 

schedule. 

§ 4.104, Schedule of ratingscardiovascular system: 

Two commenters raised three issues 

specific to this section. One commenter 

agreed with VA’s continued recognition 

of palpitations and arrhythmias as 

elements within selected evaluation 

criteria. VA thanks the commenter for 

their input. One commenter disagreed 

with using METs, claiming they are 

inaccurate within key situations (e.g., 

normal METs values despite cardiac 

abnormalities; symptomatic only with 

activities requiring greater than 10 

METs; and METs are inaccurate for 

sustained activities). Finally, in place of 

METs, that commenter noted that 

disease is the limiting factor, and should 

be both measured as well as classified 

to determine compensation levels. 

VA makes no changes based on the 

immediately preceding comments for 

the following reasons. VA disagrees 

with the commenter’s conclusion that 

METs are inaccurate in situations 

involving normal function despite 

anatomic abnormalities and during 

sustained activities. Regardless of 

whether any anatomic/medical/ 


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structural abnormalities exist, if they are 

not associated with a specific disability 

or disabilities, then such abnormalities 

are not a basis for disability 

compensation. Second, the 

Compendium of Physical Activities, 

which is ‘‘a coding scheme that 

classifies specific physical activity . . . 

by rate of energy expenditure,’’ https:// 

pubmed.ncbi.nlm.nih.gov/10993420/, 

shows that while the amount of energy 

expended depends on the duration of 

the activity, the rate of energy 

expenditure is unchanged regardless of 

how long the energy is expended. 

Finally, VA notes that the fact that a 

disease classification system functions 

well in terms of guiding treatment or 

predicting prognosis does not 

necessarily imply it is an adequate tool 

for rating disabilities. Pursuant to 38 

U.S.C. 1155, VA’s rating schedule is 

intended to reflect reductions in earning 

capacity from specific injuries or 

disabilities incurred in or due to 

military service, so any proposed 

classification system must fulfill that 

requirement. 

Specific Diagnostic Codes (DCs) 

Proposed new DC 7009, bradycardia 

(bradyarrhythmia), symptomatic, 

requiring permanent pacemaker 

implantation and current DC 7018, 

implantable cardiac pacemakers: 

One commenter asked if a 100-percent 

evaluation for implanted pacemakers 

could be prolonged if recovery time was 

greater than one month. VA proposed to 

add a new DC 7009 for bradycardia 

requiring permanent pacemaker 

implantation that would provide a 100- 

percent evaluation for one month 

following hospitalization for 

implantation or re-implantation. 

Residuals after the following initial 

month will be evaluated using the 

General Rating Formula. Aside from 

total (100 percent) evaluations provided 

in the rating schedule, VA also provides 

temporary 100-percent evaluation 

ratings for any service-connected 

disability that requires hospitalization 

longer than 21 days or more or requires 

at least one month of convalescence for 

surgery (or immobilization by cast of 

one major joint or more), if the evidence 

shows that it is warranted. See 38 CFR 

4.29–4.30. Since VA has provisions in 

place for post-operative or surgical total 

evaluations for such instances, VA 

makes no changes based on this 

comment. 

Proposed new DC 7009, bradycardia 

(bradyarrhythmia), symptomatic, 

requiring permanent pacemaker 

implantation and current DCs 7010, 

supraventricular arrhythmias, 7011, 

ventricular arrhythmias (sustained), and 

7015, atrioventricular block: 

The proposed rule stated that, for 

conditions under these DCs, ‘‘a single 

evaluation will be assigned under the 

diagnostic code that reflects the 

predominant disability picture.’’ One 

commenter asked how a ‘‘medical 

professional’’ could ‘‘appeal[ ] or 

otherwise alter[ ]’’ the diagnostic code to 

the extent that person disagrees with 

that instruction. VA clarifies that 

‘‘predominant disability picture’’ is a 

term of art that generally describes the 

disability that allows for the highest 

compensable evaluation. To the extent 

the commenter means to ask whether an 

examiner can provide additional 

information beyond what he or she 

believes is contemplated by the 

applicable diagnostic code, the answer 

is that an examiner should always strive 

to provide a complete picture of the 

claimant’s disability, including any 

salient details, and provide medical 

reasoning to justify any conclusions 

drawn, which is consistent with the 

examiner’s obligations under 38 CFR 

4.10. If a veteran is service connected 

for two of these disabilities, a VA rating 

specialist will consider the probative 

value of this report in selecting the 

disability that warrants the highest 

evaluation to evaluate both conditions, 

consistent with the rater’s obligation ‘‘to 

interpret reports of examination in the 

light of the whole recorded history, 

reconciling the various reports into a 

consistent picture so that the current 

rating may accurately reflect the 

elements of disability present.’’ 38 CFR 

4.2. 

If the claimant or the claimant’s 

representative believes another serviceconnected condition is more disabling 

to the point that it warrants a higher 

evaluation than the original condition, 

the claimant or the claimant’s 

representative may present evidence in 

support of that argument in whatever 

posture is most appropriate at the time. 

For example, the claimant may raise 

that argument in a notice of 

disagreement if filed within one year of 

the rating decision notification letter 

containing the disputed disability 

picture assessment, or the claimant may 

file an increased rating claim if the other 

service-connected condition has become 

the prominent disability any time after 

the initial rating decision becomes final. 

At that time, if the rating specialist 

determines the evidence supports the 

claimant’s argument, VA will assign a 

new higher evaluation to reflect the 

appropriate disability picture. VA 

makes no changes based on this 

comment. 

DC 7010, Supraventricular 

Arrythmias: 

Four different commenters raised 

multiple concerns with this DC. Two 

commenters raised the issue of 

hospitalizations, one objecting to the 

use in the revised evaluation criteria 

and the other asking what level of 

hospitalization is required to receive an 

evaluation. VA used the term 

‘‘hospitalizations’’ in giving a general 

description of the evaluation criteria 

revisions, but the proposed rule goes on 

to state VA’s actual intent, which was to 

use specific treatment interventions 

such as intravenous pharmacologic 

adjustment, cardioversion, and/or 

ablation from a provider that are 

intended to treat acutely disabling 

symptoms. Hospitalization may or may 

not be associated with these treatment 

interventions, so it was excluded as a 

description within the evaluation 

criteria. VA regrets any confusion 

resulting from the use of the word 

‘‘hospitalizations’’ in association with 

this DC and continues with the 

proposed changes without modification. 

Three commenters proposed oral 

medication be used within evaluation 

criteria. One commenter proposed 

adding emergency room (ER) visits to 

the evaluation criteria. Still another 

commenter proposed adding vagal 

maneuvers to the evaluation criteria. VA 

agrees to incorporate oral medications 

and vagal maneuvers but declines to 

revise the evaluation criteria to 

incorporate ER visits. As previously 

stated, the evaluation criteria will be 

based on residual disability from 

treatment interventions to resolve 

disabling symptoms. ER visits do not 

necessarily require intravenous 

pharmacologic adjustment, 

cardioversion, or ablation to block or 

control the condition and any associated 

disability. When they do, the proposed 

evaluation criteria can accommodate 

this situation. 

Finally, two commenters stated that 

the criteria did not account for other 

symptoms associated with 

supraventricular tachycardia, 

specifically extreme fatigue and 

tachycardia that induces hypotension, 

shortness of breath, dizziness, and chest 

pain. VA declines to revise the 

evaluation criteria to incorporate 

symptoms of extreme fatigue, 

hypotension, shortness of breath, 

dizziness, and chest pain. This DC 

specifically addresses supraventricular 

tachycardia; however, if the condition 

also causes ventricular arrhythmias (i.e., 

tachycardia and bradycardia), an 

evaluation can be assigned using DC 

7011 under the general rating formula, 

which considers symptoms of fatigue, 


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syncope (hypotension), breathlessness, 

dizziness, and angina (chest pain). VA 

points to the instruction concerning DCs 

7009, 7010, 7011, and 7015, which only 

allow for a single evaluation for all four 

DCs based on the one that reflects the 

pre-dominant disability picture. 

DC 7011, Ventricular Arrhythmias 

(Sustained): 

One commenter recommended VA 

include ‘‘discharge from inpatient 

cardiac rehabilitation’’ as another event 

before waiting six months to conduct 

the mandatory reexamination for a 

sustained arrhythmia or ventricular 

aneurysmectomy. This recommendation 

was made to ensure VA claims 

processors do not disallow the 

application of the provisions of § 4.29 in 

cases where the veteran is receiving 

cardiac rehabilitation, which the 

commenter believed to be a mistake. 

The 100-percent evaluation under DC 

7011, which is assigned for sustained 

ventricular arrhythmias following 

discharge from inpatient 

hospitalization, already contemplates 

activities the veteran may be subject to 

after sustained arrhythmia or ventricular 

aneurysmectomy, such as cardiac 

rehabilitation. In addition, a 100-percent 

evaluation under DC 7011 is assigned 

for an indefinite period and can remain 

even after the initial six-month 

mandatory reexamination, if the 

findings of the VA examination 

contemplated in the Note to DC 7011 

warrant such a determination. Finally, 

VA confirms that it is appropriate to not 

apply the provisions of § 4.29 in cases 

where the veteran is currently receiving 

a temporary total rating for a disability 

for which hospitalization was required. 

Therefore, inpatient cardiac 

rehabilitation that occurs at any point 

during the indefinite assignment of a 

100-percent rating under this DC cannot 

also qualify for benefits under the 

provisions of § 4.29, which provide a 

temporary total disability rating for a 

service-connected disability requiring 

hospital treatment in a VA or VAapproved hospital for a period in excess 

of 21 days. Therefore, VA makes no 

changes based on this comment. VA 

does, however, take this opportunity to 

clarify that the hospitalization 

referenced in DC 7011 is intended to 

only apply to inpatient cardiac 

hospitalization. 

DC 7015, Atrioventricular Block: 

One commenter asked if a block can 

be reclassified between benign or nonbenign. The commenter 

mischaracterizes how an evaluation 

changes from benign to non-benign, so 

VA would like to clarify how a veteran 

receives an evaluation for an 

atrioventricular block and how that 

evaluation changes. An evaluation 

occurs whenever a veteran submits an 

electrocardiogram (ECG) with either 

benign or non-benign atrioventricular 

block findings. Instead of reclassification, it is during a follow-up 

examination when the ECG conversion 

to a non-benign atrioventricular block is 

identified. It is the submission of that 

second (non-benign) ECG that changes 

the evaluation from VA raters. VA 

makes no changes based on this 

comment. 

DC 7019, Cardiac Transplantation: 

One commenter sought clarification 

about the one-year time periods for 

rating and the mandatory evaluation. 

The commenter went on further to 

assert it did not make sense for VA to 

stipulate that the 100 percent evaluation 

under this DC only last for one year 

starting from the hospital admission but 

mandate reexamination one year after 

discharge. VA reiterates that it proposed 

to replace the phrase ‘‘for an indefinite 

period’’ concerning the length of the 100 

percent evaluation with the phrase ‘‘for 

a minimum of one year.’’ This means 

that the 100 percent evaluation can 

exceed one year depending on the 

circumstances of the case, including the 

date of discharge as well as the date of 

the reexamination. VA makes no 

changes based on this comment. 

DC 7110, Aortic Aneurysm: 

Two commenters provided input for 

this DC. One commenter felt the 

evaluation criteria were confusing, 

particularly the criteria for the zeropercent evaluation. The other 

commenter asked if veterans previously 

receiving a 60-percent evaluation with 

an aortic aneurysm that precluded 

exertion would be evaluated under the 

proposed 100-percent evaluation. 

First, VA clarifies that a veteran 

previously receiving a 60-percent 

evaluation with an aortic aneurysm that 

precluded exertion will now be entitled 

to a 100-percent evaluation. Second, VA 

originally proposed to provide a 100- 

percent evaluation under this DC when 

the aneurysm size is five centimeters or 

larger or when the aneurysm is 

symptomatic (e.g., precludes exertion) 

and surgical correction was 

recommended. A zero-percent 

evaluation would have been assignable 

if surgery was not recommended and 

the aneurysm was smaller than five 

centimeters. Based on the comment, and 

to provide additional clarity, VA revises 

the evaluation criteria to specify that a 

100-percent evaluation applies when (1) 

the aneurysm is five centimeters or 

larger in diameter; (2) the aneurysm is 

symptomatic; or (3) surgical correction 

is required. The current note addressing 

the circumstances triggering mandatory 

VA examination will be edited for 

clarity and will indicate that the 100- 

percent evaluation period begins on the 

date the physician recommends surgical 

correction, as described in the proposed 

rule. 

DC 7120, Varicose Veins: 

One commenter noted the proposed 

criteria under DC 7120 states ‘‘evaluate 

under diagnostic code 7121;’’ however, 

DC 7121 was not listed in the proposed 

rating schedule. VA thanks the 

commenter for this comment. DC 7121 

was not listed in the proposed rule 

because there is no change to the criteria 

that currently exists under that DC. 

Technical Corrections: 

Several technical corrections were 

made for ease of reading or parity in 

rating schedule language to the 

following DCs: 7009, 7010, 7011, 7110, 

and 7124. These corrections were minor 

and non-substantive in nature and did 

not change the meaning or substance of 

the criteria or notes. 

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 a 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 final rule will not have a significant 

economic impact on a substantial 

number of small entities as they are 

defined in the Regulatory Flexibility Act 

(5 U.S.C. 601–612). 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 analysis 

requirements of 5 U.S.C. 603 and 604 do 

not apply. 


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Unfunded Mandates 

The Unfunded Mandates Reform Act 

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

agencies prepare an assessment of 

anticipated costs and benefits before 

issuing any rule that may result in the 

expenditure by State, local, and tribal 

governments, in the aggregate, or by the 

private sector, of $100 million or more 

(adjusted annually for inflation) in any 

year. This final rule would have no such 

effect on State, local, and tribal 

governments, or on the private sector. 

Paperwork Reduction Act 

This final rule contains no provisions 

constituting a collection of information 

under the Paperwork Reduction Act of 

1995 (44 U.S.C. 3501–3521). 

Catalog of Federal Domestic Assistance 

The Catalog of Federal Domestic 

Assistance program 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. 

Congressional Review Act 

Pursuant to the Congressional Review 

Act (5 U.S.C. 801 et seq.), the Office of 

Information and Regulatory Affairs 

designated this rule as not a major rule, 

as defined by 5 U.S.C. 804(2). 

List of Subjects in 38 CFR Part 4 

Disability benefits, Pensions, 

Veterans. 

Signing Authority 

Denis McDonough, Secretary of 

Veterans Affairs, approved this 

document on June 23, 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. 

Jeffrey M. Martin, 

Assistant Director, Office of Regulation Policy 

& Management, Office of the Secretary, 

Department of Veterans Affairs. 

For the reasons set out in the 

preamble, VA amends 38 CFR part 4 as 

follows: 

PART 4—SCHEDULE FOR RATING 

DISABILITIES 

■ 1. The authority citation for part 4 

continues to read as follows: 

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

otherwise noted. 

Subpart B—Disability Ratings 

■ 2. Amend § 4.100 by revising 

paragraph (b) and adding an authority at 

the end of the section to read as follows: 

§ 4.100 Application of the evaluation 

criteria for diagnostic codes 7000–7007, 

7011, and 7015–7020. 

* * * * * 

(b) Even if the requirement for a 10% 

(based on the need for continuous 

medication) or 30% (based on the 

presence of cardiac hypertrophy or 

dilatation) evaluation is met, METs 

testing is required in all cases except: 

(1) When there is a medical 

contraindication. 

(2) When a 100% evaluation can be 

assigned on another basis. 

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

■ 3. Amend § 4.104 by: 

■ a. Adding introductory text under the 

heading ‘‘Diseases of the Heart’’; 

■ b. Revising notes 1 and 2; 

■ c. Adding note 3; 

■ d. Adding an entry for ‘‘General 

Rating Formula for Diseases of the 

Heart’’ after note 3; 

■ e. Revising the entries for DCs 7000, 

7001, 7002, 7003, 7004, 7005, 7006, 

7007, and 7008; 

■ f. Adding an entry for DC 7009; 

■ g. Revising the entries for DCs 7010, 

7011, 7015, 7016, 7017, 7018, 7019, 

7020, 7110, 7111, 7113, 7114, 7115, 

7117, 7120, and 7122; and 

■ h. Adding DC 7124. 

The revisions and additions read as 

follows: 

§ 4.104 Schedule of ratings— 

cardiovascular system. 

DISEASES OF THE HEART

[Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.] 

Rating 

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

Note (2): One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 

milliliters per kilogram of body weight per minute. When the level of METs at which 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 (3): For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. 

GENERAL RATING FORMULA FOR DISEASES OF THE HEART: 

Workload of 3.0 METs or less results in heart failure symptoms ................................................................................................ 100 

Workload of 3.1–5.0 METs results in heart failure symptoms ..................................................................................................... 60 

Workload of 5.1–7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by 

echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging) ....................................... 30 

Workload of 7.1–10.0 METs results in heart failure symptoms; or continuous medication required for control ......................... 10 

7000 Valvular heart disease (including rheumatic heart disease), 

7001 Endocarditis, or 

7002 Pericarditis: 

During active infection with cardiac involvement and for three months following cessation of therapy for the active infection 100 

Thereafter, with diagnosis confirmed by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization, use the General Rating Formula. 

7003 Pericardial adhesions. 

7004 Syphilitic heart disease: 

Note: Evaluate syphilitic aortic aneurysms under DC 7110 (Aortic aneurysm: Ascending, thoracic, abdominal). 

7005 Arteriosclerotic heart disease (coronary artery disease). 

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

7006 Myocardial infarction: 

During and for three months following myocardial infarction, confirmed by laboratory tests ...................................................... 100 


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54094 Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 

DISEASES OF THE HEART—Continued 

[Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.] 

Rating 

Thereafter, use the General Rating Formula. 

7007 Hypertensive heart disease. 

7008 Hyperthyroid heart disease: 

Rate under the appropriate cardiovascular diagnostic code, depending on particular findings. 

For DCs 7009, 7010, 7011, and 7015, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture. 

7009 Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation: 

For one month following hospital discharge for implantation or re-implantation ......................................................................... 100 

Thereafter, use the General Rating Formula. 

Note (1): Bradycardia (bradyarrhythmia) refers to conduction abnormalities that produce a heart rate less than 60 beats/min. 

There are five general classes of bradyarrhythmia: Sinus bradycardia, including sinoatrial block; atrioventricular (AV) 

junctional (nodal) escape rhythm; AV heart block (second or third degree) or AV dissociation; atrial fibrillation or flutter with a 

slow ventricular response; and, idioventricular escape rhythm. 

Note (2): Asymptomatic bradycardia (bradyarrhythmia) is a medical finding only. It is not a disability subject to compensation.

7010 Supraventricular tachycardia: 

Confirmed by ECG, with five or more treatment interventions per year ...................................................................................... 30 

Confirmed by ECG, with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of 

oral medications to control or use of vagal maneuvers to control ........................................................................................... 10 

Note (1): Examples of supraventricular tachycardia include, but are not limited to: Atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. 

Note (2): For the purposes of this diagnostic code, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. 

7011 Ventricular arrhythmias (sustained): 

For an indefinite period from the date of inpatient hospital admission for initial medical therapy for a sustained ventricular 

arrhythmia; or, for an indefinite period from the date of inpatient hospital admission for ventricular aneurysmectomy; or, 

with an automatic implantable cardioverter-defibrillator (AICD) in place ................................................................................. 100 

Note: When inpatient hospitalization for sustained ventricular arrhythmia or ventricular aneurysmectomy is required, a 100-percent evaluation begins on the date of hospital admission with a mandatory VA examination six months following hospital discharge. Evaluate post-surgical residuals under the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter 

to any change in evaluation based upon that or any subsequent examination. 

7015 Atrioventricular block: 

Benign (First-Degree and Second-Degree, Type I): 

Evaluate under the General Rating Formula. 

Non-Benign (Second-Degree, Type II and Third-Degree): 

Evaluate under DC 7018 (implantable cardiac pacemakers). 

7016 Heart valve replacement (prosthesis): 

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

Thereafter, use the General Rating Formula. 

Note: Six months following discharge from inpatient hospitalization, disability evaluation shall be conducted by mandatory VA 

examination using the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation 

based upon that or any subsequent examination. 

7017 Coronary bypass surgery: 

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

Thereafter, use the General Rating Formula. 

7018 Implantable cardiac pacemakers: 

For one month following hospital discharge for implantation or re-implantation ......................................................................... 100 

Thereafter: 

Evaluate as supraventricular tachycardia (DC 7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC 

7015). 

Minimum ................................................................................................................................................................................ 10 

Note: Evaluate automatic implantable cardioverter-defibrillators (AICDs) under DC 7011. 

7019 Cardiac transplantation: 

For a minimum of one year from the date of hospital admission for cardiac transplantation ..................................................... 100 

Thereafter: 

Evaluate under the General Rating Formula. 

Minimum ................................................................................................................................................................................ 30 

Note: One year following discharge from inpatient hospitalization, determine the appropriate disability rating by mandatory VA 

examination. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 

7020 Cardiomyopathy. 

DISEASES OF THE ARTERIES AND VEINS 

*******

7110 Aortic aneurysm: Ascending, thoracic, or abdominal: 

Evaluate at 100 percent if the aneurysm is any one of the following: Five centimeters or larger in diameter; symptomatic 

(e.g., precludes exertion); or requires surgery ......................................................................................................................... 100 

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

Evaluate non-cardiovascular residuals of surgical correction according to organ systems affected. 


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Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 54095 

DISEASES OF THE HEART—Continued 

[Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.] 

Rating 

Note: When surgery is required, a 100-percent evaluation begins on the date a physician recommends surgical correction with 

a mandatory VA examination six months following hospital discharge. Evaluate post-surgical residuals under the General Rating Formula. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 

§ 3.105(e) of this chapter. 

7111 Aneurysm, any large artery: 

If symptomatic; or, for the period beginning on the date a physician recommends surgical correction and continuing for six 

months following discharge from inpatient hospital admission for surgical correction ............................................................ 100 

Following surgery: Evaluate under DC 7114 (peripheral arterial disease). 

Note: Six months following discharge from inpatient hospitalization for surgery, determine the appropriate disability rating 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. 

* * * * * * * 

7113 Arteriovenous fistula, traumatic: 

With high-output heart failure ....................................................................................................................................................... 100 

Without heart failure but with enlarged heart, wide pulse pressure, and tachycardia ................................................................. 60 

Without cardiac involvement but with chronic edema, stasis dermatitis, and either ulceration or cellulitis: 

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

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

Without cardiac involvement but with chronic edema or stasis dermatitis: 

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

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

7114 Peripheral arterial disease: 

At least one of the following: Ankle/brachial index less than or equal to 0.39; ankle pressure less than 50 mm Hg; toe pressure less than 30 mm Hg; or transcutaneous oxygen tension less than 30 mm Hg ............................................................... 100 

At least one of the following: Ankle/brachial index of 0.40–0.53; ankle pressure of 50–65 mm Hg; toe pressure of 30–39 

mm Hg; or transcutaneous oxygen tension of 30–39 mm Hg ................................................................................................. 60 

At least one of the following: Ankle/brachial index of 0.54–0.66; ankle pressure of 66–83 mm Hg; toe pressure of 40–49 

mm Hg; or transcutaneous oxygen tension of 40–49 mm Hg ................................................................................................. 40 

At least one of the following: Ankle/brachial index of 0.67–0.79; ankle pressure of 84–99 mm Hg; toe pressure of 50–59 

mm Hg; or transcutaneous oxygen tension of 50–59 mm Hg ................................................................................................. 20 

Note (1): The ankle/brachial index (ABI) is the ratio of the systolic blood pressure at the ankle divided by the simultaneous 

brachial artery systolic blood pressure. For the purposes of this diagnostic code, normal ABI will be greater than or equal to 

0.80. The ankle pressure (AP) is the systolic blood pressure measured at the ankle. Normal AP is greater than or equal to 

100 mm Hg. The toe pressure (TP) is the systolic blood pressure measured at the great toe. Normal TP is greater than or 

equal to 60 mm Hg. Transcutaneous oxygen tension (TcPO2) is measured at the first intercostal space on the foot. Normal 

TcPO2 is greater than or equal to 60 mm Hg. All measurements must be determined by objective testing. 

Note (2): Select the highest impairment value of ABI, AP, TP, or TcPO2 for evaluation. 

Note (3): Evaluate residuals of aortic and large arterial bypass surgery or arterial graft as peripheral arterial disease. 

Note (4): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. 

7115 Thrombo-angiitis obliterans (Buerger’s Disease): 

Lower extremity: Rate under DC 7114. 

Upper extremity: 

Deep ischemic ulcers and necrosis of the fingers with persistent coldness of the extremity, trophic changes with pains 

in the hand during physical activity, and diminished upper extremity pulses ................................................................... 100 

Persistent coldness of the extremity, trophic changes with pains in the hands during physical activity, and diminished 

upper extremity pulses ...................................................................................................................................................... 60 

Trophic changes with numbness and paresthesia at the tips of the fingers, and diminished upper extremity pulses ........ 40 

Diminished upper extremity pulses ....................................................................................................................................... 20 

Note (1): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. 

Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities). 

7117 Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon or secondary Raynaud’s): 

With two or more digital ulcers plus auto-amputation of one or more digits and history of characteristic attacks ..................... 100 

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

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

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

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

Note (1): For purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for Raynaud’s syndrome as a whole, regardless of the number of extremities involved or 

whether the nose and ears are involved. 

Note (2): This section is for evaluating Raynaud’s syndrome (secondary Raynaud’s phenomenon or secondary Raynaud’s). For 

evaluation of Raynaud’s disease (primary Raynaud’s), see DC 7124. 

* * * * * * * 

7120 Varicose veins: 

Evaluate under diagnostic code 7121. 


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54096 Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 

DISEASES OF THE HEART—Continued 

[Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.] 

Rating 

*******

7122 Cold injury residuals: 

With the following in affected parts: 

Arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: Tissue loss, nail abnormalities, 

color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular 

punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity 

of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal 

tunnel syndrome ................................................................................................................................................................ 30 

Arthralgia or other pain, numbness, or cold sensitivity plus one of the following: Tissue loss, nail abnormalities, color 

changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular 

punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity 

of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal 

tunnel syndrome ................................................................................................................................................................ 20 

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

Note (1): Separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of 

a cold injury scar or peripheral neuropathy, under other diagnostic codes. Separately evaluate other disabilities diagnosed as 

the residual effects of cold injury, such as Raynaud’s syndrome (which is otherwise known as secondary Raynaud’s phenomenon), muscle atrophy, etc., unless they are used to support an evaluation under diagnostic code 7122. 

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

§§ 4.25 and 4.26. 

* * * * * * * 

7124 Raynaud’s disease (also known as primary Raynaud’s): 

Characteristic attacks associated with trophic change(s), such as tight, shiny skin ................................................................... 10 

Characteristic attacks without trophic change(s) .......................................................................................................................... 0 

Note (1): For purposes of this section, characteristic attacks consist of intermittent and episodic color changes of the digits of 

one or more extremities, lasting minutes or longer, with occasional pain and paresthesias, and precipitated by exposure to 

cold or by emotional upsets. These evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved. 

Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities). 

Note (3): This section is for evaluating Raynaud’s disease (primary Raynaud’s). For evaluation of Raynaud’s syndrome (also 

known as secondary Raynaud’s phenomenon, or secondary Raynaud’s), see DC 7117. 

* * * * * 

■ 4. Amend appendix A to part 4 under 

4.104 by: 

■ a. Adding an entry for ‘‘General Rating 

Formula for Diseases of the Heart’’ 

above the entry for diagnostic code 

7000; 

■ b. Revising the entries for DCs 7000 

through 7008; 

■ c. Adding in numerical order an entry 

for DC 7009; 

■ d. Revising the entries for DCs 7010, 

7011, 7015 through 7020, 7110, 7111, 

7113 through 7115, 7117, 7120, and 

7122; and 

■ e. Adding in numerical order an entry 

for DC 7124. 

The additions and revisions read as 

follows: 

Appendix A to Part 4—Table of 

Amendments and Effective Dates Since 

1946 

Sec. Diagnostic 

code No. 

*******

4.104 .............. ........................ General Rating Formula for Diseases of the Heart November 14, 2021. 

7000 Evaluation July 6, 1950; evaluation September 22, 1978, evaluation January 12, 1998; criterion November 14, 

2021. 

7001 Evaluation January 12, 1998; criterion November 14, 2021. 

7002 Evaluation January 12, 1998; criterion November 14, 2021. 

7003 Evaluation January 12, 1998; criterion November 14, 2021. 

7004 Criterion September 22, 1978; evaluation January 12, 1998; criterion November 14, 2021. 

7005 Evaluation September 9, 1975; evaluation September 22, 1978; evaluation January 12, 1998; criterion November 14, 2021. 

7006 Evaluation January 12, 1998; criterion November 14, 2021. 

7007 Evaluation September 22, 1978; evaluation January 12, 1998; criterion November 14, 2021. 

7008 Evaluation January 12, 1998; criterion December 10, 2017; evaluation November 14, 2021. 

7009 Added November 14, 2021. 

7010 Evaluation January 12, 1998; title, criterion November 14, 2021. 

7011 Evaluation January 12, 1998; note, criterion November 14, 2021. 

*******

7015 Evaluation September 9, 1975; criterion January 12, 1998; criterion November 14, 2021. 

7016 Added September 9, 1975; criterion January 12, 1998; note, criterion November 14, 2021. 

7017 Added September 22, 1978; evaluation January 12, 1998; criterion November 14, 2021. 


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Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 54097 

Sec. Diagnostic 

code No. 

7018 Added January 12, 1998; criterion November 14, 2021. 

7019 Added January 12, 1998; note, criterion November 14, 2021. 

7020 Added January 12, 1998; criterion November 14, 2021. 

* * * * * * * 

7110 Evaluation September 9, 1975; evaluation January 12, 1998; title, criterion, note November 14, 2021. 

7111 Criterion September 9, 1975; evaluation January 12, 1998; note, criterion November 14, 2021. 

* * * * * * * 

7113 Evaluation January 12, 1998; criterion November 14, 2021. 

7114 Added June 9, 1952; evaluation January 12, 1998; title, criterion, note November 14, 2021. 

7115 Added June 9, 1952; evaluation January 12, 1998; note, criterion, evaluation November 14, 2021. 

* * * * * * * 

7117 Added June 9, 1952; evaluation January 12, 1998; title, note November 14, 2021. 

* * * * * * * 

7120 Note following July 6, 1950; evaluation January 12, 1998; criterion November 14, 2021. 

7122 Last sentence of Note following July 6, 1950; evaluation January 12, 1998; criterion August 13, 1998; criterion 

November 14, 2021. 

* * * * * * * 

7124 Added November 14, 2021. 

* * * * * * * 

■ 5. Amend appendix B to part 4 at 

‘‘The Cardiovascular System’’ section’’: 

■ a. Under the heading ‘‘Diseases of the 

Heart— 

■ i. By adding in numerical order an 

entry for diagnostic code 7009; and 

■ ii. By revising the entry for diagnostic 

code 7010; 

■ b. Under the heading ‘‘Diseases of the 

Arteries and Veins’’— 

■ i. By revising diagnostic codes 7110, 

7114, and 7117; and 

■ ii. By adding in numerical order an 

entry for diagnostic code 7124. 

The additions and revisions read as 

follows: 

Appendix B to Part 4—Numerical Index 

of Disabilities 

Diagnostic 

code No. 

*******

THE CARDIOVASCULAR SYSTEM 

Diseases of the Heart 

*******

7009 ............... Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation. 

7010 ............... Supraventricular tachycardia. 

*******

Diseases of the Arteries and Veins 

*******

7110 ............... Aortic aneurysm: ascending, thoracic, abdominal. 

*******

7114 ............... Peripheral arterial disease. 

*******

7117 ............... Raynaud’s syndrome (secondary Raynaud’s phenomenon, secondary Raynaud’s). 

*******

7124 ............... Raynaud’s disease (primary Raynaud’s). 

*******

■ 6. Amend appendix C to part 4 by: 

■ a. Revising the entry for ‘‘Aneurysm’’; 

■ b. Removing the entries for 

‘‘Arrhythmia’’ (with its sub-entries 

‘‘Supraventricular’’ and ‘‘Ventricular’’) 

and ‘‘Arteriosclerosis obliterans’’; 


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54098 Federal Register / Vol. 86, No. 187 / Thursday, September 30, 2021 / Rules and Regulations 

■ c. Adding in alphabetical order entries 

for ‘‘Bradycardia (Bradyarrhthmia), 

symptomatic, requiring permanent 

pacemaker implantation’’, ‘‘Peripheral 

arterial disease’’, and ‘‘Raynaud’s 

disease (primary Raynaud’s)’’; 

■ d. Revising the entry for Raynaud’s 

syndrome’’; and 

■ e. Adding entries for 

‘‘Supraventricular tachycardia’’ and 

‘‘Ventricular arrhythmia’’. 

The revisions and additions read as 

follows: 

Appendix C to Part 4—Alphabetical 

Index of Disabilities 

Diagnostic 

code No. 

*******

Aneurysm: 

Aortic: ascending, thoracic, abdominal ........................................................................................................................................ 7110 

Large artery .................................................................................................................................................................................. 7111 

Small artery .................................................................................................................................................................................. 7118 

* * * * * * * 

Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation ........................................................... 7009 

* * * * * * * 

Peripheral arterial disease ................................................................................................................................................................... 7114 

* * * * * * * 

Raynaud’s disease (primary Raynaud’s) ............................................................................................................................................. 7124 

Raynaud’s syndrome (secondary Raynaud’s phenomenon, secondary Raynaud’s) .......................................................................... 7117 

* * * * * * * 

Supraventricular tachycardia ............................................................................................................................................................... 7010 

* * * * * * * 

Ventricular arrhythmia .......................................................................................................................................................................... 7011 

* * * * * * * 

[FR Doc. 2021–19998 Filed 9–29–21; 8:45 am] 

BILLING CODE 8320–01–P 

ENVIRONMENTAL PROTECTION 

AGENCY 

40 CFR Part 52 

[EPA–R07–OAR–2021–0360; FRL–8707–02– 

R7] 

Air Plan Approval; Approval of 

Missouri Air Quality Implementation 

Plans; Revisions to St. Louis 2008 8- 

Hour Ozone Maintenance Plan 

AGENCY: Environmental Protection 

Agency (EPA). 

ACTION: Final rule. 

SUMMARY: The Environmental Protection 

Agency (EPA) is taking final action to 

approve a State Implementation Plan 

(SIP) revision submitted by the State of 

Missouri on November 12, 2019, 

revising the maintenance plan 

demonstrating continued maintenance 

of the 2008 ozone National Ambient Air 

Quality Standard (NAAQS), the 1979 1- 

Hour and 1997 8-Hour ozone standards 

in the St. Louis area. This revision 

demonstrates that the St. Louis area no 

longer needs to rely on the vehicle 

Inspection and Maintenance (I/M) 

program and the use of Reformulated 

Gasoline (RFG) for continued 

maintenance throughout the 

maintenance period for the 2008 8-Hour 

ozone NAAQS, the 1979 1-Hour ozone 

NAAQS and 1997 8-Hour ozone 

NAAQS. The EPA has determined that 

this revision meets the requirements of 

the Clean Air Act (CAA). 

DATES: This final rule is effective on 

November 1, 2021. 

ADDRESSES: The EPA has established a 

docket for this action under Docket ID 

No. EPA–R07–OAR–2021–0360. All 

documents in the docket are listed on 

the https://www.regulations.gov 

website. Although listed in the index, 

some information is not publicly 

available, i.e., confidential business 

information (CBI) or other information 

whose disclosure is restricted by statute. 

Certain other material, such as 

copyrighted material, is not placed on 

the internet and will be publicly 

available only in hard copy form. 

Publicly available docket materials are 

available through https://

www.regulations.gov or please contact 

the person identified in the FOR FURTHER

INFORMATION CONTACT section for 

additional information. 

FOR FURTHER INFORMATION CONTACT: 

Steven Brown, Environmental 

Protection Agency, Region 7 Office, Air 

Quality Planning Branch, 11201 Renner 

Boulevard, Lenexa, Kansas 66219; 

telephone number (913) 551–7718; 

email address: brown.steven@epa.gov. 

SUPPLEMENTARY INFORMATION: 

Throughout this document ‘‘we,’’ ‘‘us,’’ 

and ‘‘our’’ refer to EPA. 

Table of Contents 

I. What is being addressed in this document? 

II. Have the requirements for approval of a 

SIP revision been met? 

III. What Action is the EPA taking? 

IV. Statutory and executive order reviews 

I. What is being addressed in this 

document? 

The EPA is taking final action to 

approve SIP revisions submitted by the 

State of Missouri on November 12, 2019, 

revising the 2008 8-hour ozone 

maintenance plan previously approved 

on September 20, 2018 (83 FR 47572). 

This SIP revision demonstrates 

continued maintenance of the 2008 8- 

Hour ozone NAAQS, the 1979 1-Hour 

ozone NAAQS and 1997 8-Hour ozone 

NAAQS in the St. Louis area through 

the future year of 2030. The 

maintenance area boundary includes the 

Missouri counties of Franklin, Jefferson, 

St. Charles, and St. Louis along with the 

City of St. Louis. 

Since the 2008 ozone standard is 

more stringent than the 1979 and 1997 

ozone standards, and the boundary area 


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