[Federal Register Volume 61, Number 89 (Tuesday, May 7, 1996)]
[Rules and Regulations]
[Pages 20440-20447]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-11281]



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DEPARTMENT OF THE TREASURY
DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4

RIN 2900-AE41


Schedule for Rating Disabilities; Endocrine System Disabilities

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends that portion of the Department of 
Veterans Affairs (VA) Schedule for Rating Disabilities that addresses 
the Endocrine System. The effect of this action is to update the 
endocrine portion of the rating schedule to ensure that it uses current 
medical terminology and unambiguous criteria, and that it reflects 
medical advances which have occurred since the last review.

DATES: This amendment is effective June 6, 1996.

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Regulations Staff (211B), Compensation and Pension Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Avenue NW, Washington, DC 20420, (202) 273-7210.

SUPPLEMENTARY INFORMATION: As part of the first comprehensive review of 
the rating schedule since 1945, VA published a proposal to amend 38 CFR 
4.119, which addresses the endocrine system, in the Federal Register of 
January 22, 1993 (58 FR 5691-95). Interested persons were invited to 
submit written comments on or before March 23, 1993. We received 
comments from The American Legion, Disabled American Veterans, Veterans 
of Foreign Wars, Paralyzed Veterans of America, and VA employees.
    There were a number of general comments. Two commenters requested 
that we establish more objective criteria, especially for thyroid 
disease, parathyroid disease, and diabetes mellitus. One of them noted 
that a substantial number of subjective descriptors remained. The other 
recommended that we remove ambiguous and undefined terms. One commenter 
said that the schedule should eliminate, as much as possible, the 
potential for inconsistency and error. Another suggested that removing 
comparative descriptions such as ``severe,'' ``moderate'', etc., would 
not disturb the remaining criteria and would result in more uniform 
rating decisions.
    Although the commenters offered no specific alternatives for 
consideration, VA agrees that objective rating criteria help assure 
consistency of evaluations. With that in mind, we have revised the 
proposed criteria. In some cases we have simply removed subjective 
terms such as ``marked'', ``increasingly severe'', and ``pronounced'' 
when they did not substantively explain or clarify the evaluation 
criteria. In other cases, we have supplied objective definitions of 
terms. In still others, establishing more objective, consistent, and 
unambiguous criteria required more detailed modification of the 
proposed criteria, which will be discussed under the affected 
diagnostic codes.
    One commenter, while agreeing with the removal of ambiguous words 
such as ``severe,'' urged that the rules not be made too concrete and 
thus sterile.
    We believe that providing clear and objective criteria is the best 
way to assure that disabilities will be evaluated fairly and 
consistently. Judgment and flexibility are required in the evaluation 
process, since patients do not commonly present as textbook models of 
disease, and those evaluating disabilities always have the task of 
assessing which evaluation level best represents the overall picture. 
(See 38 CFR 4.7.)
    One commenter stated that it would be helpful to have additional 
notes, such as the note under DC 7913 on the evaluation of the 
complications of diabetes mellitus, discussing pertinent clinical and 
nonclinical factors to be considered in assigning evaluations.
    In general, we have retained or expanded upon such notes. Where it 
seemed more appropriate, we have incorporated the content of notes into 
the evaluation criteria. We have not added notes containing background 
material, such as general medical information that is available in 
standard textbooks, or other material that neither prescribes VA policy 
nor establishes procedures a rating board must follow, because such 
material is not appropriate in a regulation.
    We have revised hyperthyroidism, DC 7900, in response to the 
comment suggesting more objectivity. The proposed criteria required 
``severe tachycardia'' at the 100 percent level and ``tachycardia'' at 
all other levels. According to ``The Merck Manual'' (463, 16th ed. 
1992), tachycardia is a heart rate greater than 100 beats per minute, 
but the medical literature does not define ``severe'' tachycardia. 
Using the word ``severe'' therefore imposed upon the rater the burden 
of subjectively determining its meaning, and we have removed ``severe'' 
at the 100 percent level. We have also made the criteria more objective 
by indicating that tachycardia means more than 100 beats per minute.
    We proposed that the criteria for hyperthyroidism include ``marked 
sympathetic nervous system, cardiovascular, or gastrointestinal 
symptoms'' at the 100 percent level and ``marked emotional 
instability'' at the 60 percent level. In both cases, we have removed 
the indefinite word ``marked'' because it does not substantively 
explain or clarify the evaluation criteria, and the criteria are clear 
without it.
    One commenter suggested that we specify the symptoms of the 
sympathetic nervous system proposed as criteria at the 100 percent 
level of evaluation under DC 7900.
    VA does not concur. The sympathetic nervous system innervates 
thoracic, abdominal, and pelvic viscera as well as blood vessel walls. 
Therefore, exaggerated sympathetic nervous system activity can have 
widespread manifestations including, but not limited to, elevated blood 
pressure, increased cardiac output, increased metabolic rate, sweating, 
nervousness, weight loss, tachycardia, palpitations, increased 
frequency of bowel movements, and heat intolerance. Certain conditions, 
hyperthyroidism among them, are known as sympathomimetic conditions 
because they mimic the effects of increased activity of the sympathetic 
nervous system, although the sympathetic nervous system itself is 
normal. Since the particular signs and symptoms that might be exhibited 
vary widely from individual to individual, limiting the criteria at the 
100 percent level to a few selected symptoms of the sympathetic nervous 
system would be inappropriate.
    We proposed that increased pulse pressure be one of the criteria 
for the 60 percent and 30 percent levels of hyperthyroidism. One 
commenter questioned the use of pulse pressure as a criterion, stating 
that it is not a diagnostic marker and is not routinely recorded on an 
examination report.
    Pulse pressure is the difference between the systolic and diastolic 
blood pressures, and it is readily available for anyone who has had a 
blood pressure recorded. Hyperthyroidism is one of a number of diseases 
that may produce an increased (or widened) pulse pressure, which 
results from an elevated systolic blood pressure and a lowered 
diastolic blood pressure. Because increased pulse pressure is a common 
sign of hyperthyroidism, it is an appropriate criterion to use in 
evaluating hyperthyroidism.
    One commenter suggested that tremor (one of several proposed 
criteria for hyperthyroidism at the 10 and 30

[[Page 20441]]

percent levels of evaluation) be evaluated as a secondary condition 
with a minimum evaluation of 20 percent, even for involvement of only 
one hand, because it is an employment handicap.
    VA does not concur. There are several types of tremors, and it 
appears that the commenter may have based his suggestion on the 
observation of an individual with a tremor other than the type 
characteristic of hyperthyroidism. The tremor of hyperthyroidism is a 
fine tremor most noticeable in the outstretched hands. It is 
characterized as a physiologic tremor, i.e., one that is an 
exaggeration of the normal physiologic tremor that virtually everyone 
experiences at times (``Harrison's Principles of Internal Medicine'' 
167 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)), and is not 
severely disabling. Including tremor as one of the requirements at the 
10 and 30 percent levels of evaluation for hyperthyroidism takes into 
account the type and severity of the characteristic hyperthyroid-
induced tremor. In our judgment, the presence of such a tremor would 
not, in and of itself, warrant the 20 percent evaluation the commenter 
suggests.
    One commenter suggested that emotional disorders and 
gastrointestinal and cardiovascular symptoms due to thyroid conditions 
(hyperthyroidism, DC 7900; toxic adenoma of thyroid gland, DC 7901; 
hypothyroidism, DC 7903) be evaluated separately rather than being part 
of the evaluation criteria for thyroid conditions.
    Severe thyroid disease may produce distinct secondary conditions, 
including certain mental disorders, and such conditions can always be 
service-connected and separately evaluated (see 38 CFR 3.310(a)). Some 
secondary conditions, e.g., dementia under hypothyroidism (DC 7903), 
are specifically included in the evaluation criteria for the 60- or 
100-percent levels of thyroid disease. This does not exclude the 
possibility of service-connecting and separately evaluating the 
secondary condition, but provides an alternative means of evaluation by 
allowing the secondary condition to be used to support the 60- or 100-
percent evaluation level of thyroid disease. However, the same 
condition cannot be separately evaluated and concurrently used to 
evaluate the primary condition (DC's 7900, 7901, or 7903). (See 4.14 of 
this part.) This is comparable to the evaluation of diabetes mellitus 
(DC 7913), where compensable complications of diabetes may be either 
separately evaluated or used to support a 100-percent evaluation.
    The request for separate evaluation of symptoms is a different 
issue. Because of the widespread effects of thyroid hormone, the 
symptoms of thyroid disease are diverse, reflecting effects on multiple 
body systems. However, the presence of such symptoms (e.g., 
gastrointestinal symptoms under hyperthyroidism (DC 7900)) can be an 
inherent part of thyroid disease and does not ordinarily indicate that 
a separate and distinct secondary condition is present. Unless they are 
clearly part of a distinct condition secondary to thyroid disease, the 
symptoms must be used in the overall evaluation criteria for the 
thyroid condition. The evaluation of secondary conditions is discussed 
in the preceding paragraph.
    In the previous schedule, nontoxic adenoma of the thyroid (DC 7902) 
was evaluated on the basis of pressure symptoms or marked 
disfigurement. We proposed that it be evaluated at the 20 percent level 
if there is ``marked disfigurement of the head or neck.'' One commenter 
suggested that nontoxic adenoma of the thyroid be rated analogous to DC 
7800 (scars, disfiguring, head, face, or neck).
    We do not concur. Disfigurement from a nontoxic adenoma of the 
thyroid is not a skin phenomenon but an enlargement of the thyroid that 
produces an unsightly neck mass through sheer bulk. Factors that are 
used to evaluate skin conditions, such as discoloration and color 
contrast, are not appropriate for evaluating that type of 
disfigurement. In response to the general request for more objective 
criteria previously mentioned, we have removed the word ``marked'', 
leaving ``with disfigurement of the head or neck'' as the sole 
criterion for a 20 percent evaluation. In our judgment, any adenoma 
that is substantial enough to be disfiguring warrants a 20 percent 
evaluation. This does not represent a substantive change from the 
proposed criteria.
    The proposed note under DC 7902 stated to rate as impairment of 
affected organ if a higher evaluation is warranted. For the sake of 
clarity, we have revised the note to state that if there are symptoms 
due to pressure on adjacent organs such as the trachea, larynx, or 
esophagus, nontoxic adenoma of the thyroid will be evaluated under the 
diagnostic code for disability of that organ, if doing so would result 
in a higher evaluation. This does not represent a substantive change 
from the proposed note.
    We proposed to delete the zero percent level of evaluation for 
nontoxic adenoma (DC 7902) that was present in the previous schedule. 
However, to clarify that not all nontoxic adenomas are considered 
disfiguring, we have restored the zero percent level for those 
``without disfigurement of the head or neck.'' This does not represent 
a substantive change.
    For the sake of clarity, we have also removed the indefinite word 
``severe'' before ``cold intolerance'' in the proposed criteria for a 
100 percent evaluation for hypothyroidism (DC 7903) and revised the 
indefinite criterion ``slow pulse'' to the more precise medical term 
``bradycardia'', which is defined as less than 60 beats per minute. We 
have also revised the requirement of ``mental symptoms'' to ``mental 
disturbance,'' since some of the possible manifestations are symptoms 
but others are distinct mental disorders. These are not substantive 
changes.
    One commenter, stating that obesity is such a pervasive problem in 
American society that weight gain is not a true measure or mark of a 
specific disorder, felt that weight gain should not be included in the 
criteria for the 60 percent evaluation for hypothyroidism (DC 7903).
    VA does not concur. There are special characteristics of the weight 
gain associated with hypothyroidism that distinguish it from the weight 
gain seen in simple obesity. The weight gain in hypothyroidism is 
largely due to fluid retention, which appears as ascites, pleural 
effusion, edema of the extremities, or even edema of the nervous system 
(``Williams Textbook of Endocrinology'' 447-48 (Jean D. Wilson, M.D. 
and Daniel W. Foster, M.D. eds., 8th ed. 1992)). This type of weight 
gain is unlikely to be confused with obesity. For this reason, we 
believe that weight gain is appropriate as part of the overall criteria 
for the evaluation of hypothyroidism, and we have retained it among the 
criteria for the 60 percent level.
    The previous schedule included ``sluggish mentality and other 
indications of myxedema'' in the criteria for the 30 percent evaluation 
level of hypothyroidism (DC 7903). We proposed to retain mental 
sluggishness as one of the criteria, but to delete the term myxedema. A 
commenter objected to the removal of myxedema, saying there is no basis 
for our contention that myxedema is seldom encountered.
    The term myxedema is sometimes used loosely to refer to 
hypothyroidism in general, but in its stricter meaning, it is full-
blown hypothyroidism with fluid retention. Hypothyroidism may present 
at any level of severity, including a subclinical form, and myxedema in 
the strict sense is found only in severe disease, when hypothyroidism 
is

[[Page 20442]]

untreated or has reached an advanced stage. We therefore replaced 
``sluggish mentality with other indications of myxedema'' at the 30 
percent level with less ambiguous criteria: fatigability, constipation, 
and mental sluggishness.
    The previous schedule assigned hyperthyroidism (DC 7900) and 
hypothyroidism (DC 7903) minimum ten percent evaluations when 
continuous medication is required for control. We proposed to delete 
the minimum evaluations, and three commenters objected.
    Upon further review, VA agrees that a ten percent evaluation is 
appropriate when continuous medication is required for control of these 
conditions because such treatment implies both the need for repeated 
medical evaluations and the possibility of side effects that may 
themselves require treatment. We have therefore restored the ten 
percent evaluation level under diagnostic codes 7900 and 7903 for those 
who require continuous medication. For the sake of consistency, we have 
also added a ten percent evaluation level under hyperparathyroidism (DC 
7904) for those who require continuous medication. We have recast the 
note under hypoparathyroidism (DC 7905) establishing a minimum 
evaluation of ten percent when continuous medication is required as ten 
percent evaluation criteria. The change under DC 7905 is editorial in 
nature and does not represent any substantive change to the criteria as 
proposed.
    ``Decreased levels of circulating thyroid hormones (T4 and/or T3 by 
specific assays)'' was one of the criteria for a 100 percent evaluation 
for hypothyroidism (DC 7903) in the previous schedule. We proposed a 
change to ``undetectable levels of circulating thyroid hormones'' as 
one of the criteria for the 100 percent level. Two commenters felt that 
the proposed change made the criteria too stringent.
    VA concurs. Therapy is instituted as soon as medical personnel 
learn that there are no detectable levels of hormone; the therapy 
produces a rapid reversion of hormone levels toward normal but leaves 
the clinical signs of disease to resolve more slowly. Although many 
endocrine conditions require laboratory confirmation of hormone levels 
for diagnosis, the hormone levels may not correlate with the severity 
of the clinical findings, and laboratory findings are therefore more 
useful for diagnosis than evaluation. For these reasons, we have 
removed: (1) ``undetectable levels of circulating thyroid hormones'' 
from the criteria for the 100 percent level of hypothyroidism (DC 
7903), (2) ``decreased levels of circulating thyroid hormone'' from the 
60 percent and 30 percent levels of hypothyroidism, (3) ``elevated 
levels of circulating thyroid hormones'' as a requirement for the 100 
and 60 percent levels of hyperthyroidism (DC 7900), and (4) ``elevated 
blood and urine calcium levels'' as a requirement for the 100 and 60 
percent levels of hyperparathyroidism (DC 7904).
    One commenter suggested that we quantify weight loss by indicating 
a percentage below normal weight or similar objective measure rather 
than using the term ``marked weight loss'' for the 100 and 60 percent 
levels of hyperparathyroidism (DC 7904).
    In addition to removing the references to laboratory findings, as 
discussed above, we have modified the criteria for hyperparathyroidism 
by removing ``marked weight loss'' from the criteria for the 100 and 60 
percent levels. Since severe hyperparathyroidism may manifest itself 
through a variety of gastrointestinal symptoms, weight loss being only 
one (Williams, 1431), we have replaced the separate requirement for 
weight loss with the more flexible requirement for ``gastrointestinal 
symptoms (nausea, vomiting, anorexia, constipation, weight loss, or 
peptic ulcer)'' at the 100 and 60 percent levels. This change 
recognizes that gastrointestinal symptoms are part of an overall 
pattern of abnormalities, but that any individual symptom, such as a 
specified amount of weight loss, is not required for either level of 
severity. This offers more flexibility than the proposed requirement 
for marked weight loss.
    We proposed that ocular disturbances be one of the criteria for 
both the 100 percent and 60 percent levels of evaluation for 
hypoparathyroidism (DC 7905). One commenter, while giving no reason, 
requested that ocular disturbances be removed as a criterion.
    There are two distinct types of ocular disturbance that may occur 
in hypoparathyroidismcataracts and papilledema (Williams, 1456-57; 
Harrison, 1915-16). Papilledema, if present, would be an indication of 
the increased intracranial pressure that sometimes occurs in 
hypoparathyroidism, but it is only one possible manifestation of 
increased intracranial pressure. Cataracts are unrelated to increased 
intracranial pressure. For the sake of making the criteria clearer and 
more objective, we have substituted ``cataract or evidence of increased 
intracranial pressure (such as papilledema)'' for ``ocular 
disturbances''.
    One commenter mentioned hypoparathyroidism as another example of a 
condition where objective criteria should be employed in place of 
ambiguous terms.
    Criteria we proposed for the 100 percent level of 
hypoparathyroidism, in addition to ocular disturbances, were: seizures 
or convulsions, muscular spasm (tetany), or marked neuromuscular 
excitability. Since muscular spasms and convulsions are themselves two 
specific manifestations of marked neuromuscular excitability, for more 
clarity and to eliminate redundancy, we have retained marked 
neuromuscular excitability as one of the criteria, giving its most 
common manifestationsconvulsions, muscular spasms (tetany), and 
laryngeal stridorin parentheses. By providing this list of conditions, 
we have made the meaning of ``marked'' definite enough that it 
substantively clarifies the degree of neuromuscular excitability needed 
to support a 100 percent evaluation.
    For the 60 percent level of hypoparathyroidism, the proposed 
criteria were: marked neuromuscular excitability, ocular disturbances, 
and constipation or numbness and tingling of the extremities. We have 
revised the proposed criteria by providing three alternative sets of 
criteria: marked neuromuscular excitability, a combination of 
paresthesias (of arms, legs, or circumoral area) and cataract, or a 
combination of paresthesias and increased intracranial pressure. While 
this represents a substantive change, it responds to the general 
comment that we eliminate, as much as possible, the potential for 
inconsistency and error. The proposed criteria appeared to be more 
stringent at the 60 percent level than at the 100 percent level, and 
there also could have been confusion about which of the criteria listed 
were required and which were alternatives. The revision eliminates this 
confusion, affords more flexibility, and provides a clearer 
differentiation between the 100 and 60 percent levels.
    We deleted the word ``marked'', modifying loss of muscle strength, 
at the 100 percent level of Cushing's syndrome (DC 7907). This is more 
objective because the rater does not now have to estimate whether a 
reported loss of muscle strength is ``marked.'' The change allows any 
reported loss of muscle strength to serve as one of the requirements at 
the 100 percent level.
    We proposed to retain 100 and 60 percent levels of evaluation for 
Cushing's syndrome, as in the previous schedule. One commenter stated 
that the condition warrants additional levels of evaluation, especially 
when it is secondary to medication.
    VA agrees. Although secondary Cushing's syndrome (due to steroid

[[Page 20443]]

therapy) has physical findings indistinguishable from primary Cushing's 
syndrome (Harrison, 1723), there is a wide range of severity depending 
on the dosage of steroids used, duration of therapy, etc. We have 
therefore added a 30 percent level of Cushing's syndrome for those with 
milder manifestations: striae, obesity, moon face, glucose intolerance, 
and vascular fragility.
    The previous schedule required increased intracranial pressure, 
hypertension, genital decline and atrophy, hypotrichosis, hypoglycemia, 
obesity, and asthenia for a 100 percent evaluation of acromegaly (DC 
7908). We proposed to revise the criteria by requiring increased 
intracranial pressure, arthropathy, glucose intolerance, hypertension, 
cardiomegaly, and visual impairment. One individual felt that 
represents a tightening of the requirements and recommended that 
cardiomegaly not be required at the 100 percent level.
    Upon further consideration, VA has revised the proposed criteria 
for the 100 percent level. Cardiomegaly is present in 80 percent of 
acromegalics and may be part of the generalized organomegaly that is 
sometimes seen (Williams, 272). It is therefore seen commonly enough to 
be an appropriate criterion. Hypertension occurs in approximately 20-40 
percent of acromegalics, and overactivity of the sympathetic nervous 
system has been suggested as a possible etiology. Hypertension and 
cardiomegaly are thus independent entities, with apparently different 
etiologies (although they may be associated when hypertension results 
in cardiomegaly). Because either may be a manifestation of acromegaly, 
instead of removing cardiomegaly, we have made cardiomegaly an 
alternative criterion to hypertension at the 100 percent level, rather 
than requiring both.
    The previous schedule required intracranial pressure as one of the 
criteria for the 100 percent level of acromegaly, and symptoms of 
intracranial pressure in the optic region for the 60 percent level. We 
proposed to require both increased intracranial pressure and visual 
impairment for the 100 percent level. One commenter, noting that 
increased intracranial pressure specifically impairs peripheral vision, 
stated that ``visual impairment'' is too broad a term. He said we 
should distinguish visual field loss from central visual acuity loss 
and other visual deficits.
    We agree. The term ``visual impairment'' can have many meanings, 
and not all types of visual impairment result from acromegaly. Those 
that do occur are the result of localized or generalized increased 
intracranial pressure because acromegaly is almost always due to a 
pituitary adenoma (Merck, 1064). There may, for example, be a visual 
field defect when the pituitary tumor presses on the optic chiasm. 
However, it is increased intracranial pressure from the tumor that is 
the underlying cause of any visual impairment that is present, and the 
increased pressure is at times manifested only by findings other than 
visual impairment. We have therefore revised the criteria by deleting 
the requirement for both increased intracranial pressure and visual 
impairment in favor of a more flexible, but also more specific, 
requirement for evidence of increased intracranial pressure ``such as 
visual field defect.'' This will allow other possible manifestations of 
increased intracranial pressure, such as papilledema, headaches, etc., 
to satisfy one of the requirements for a 100 percent level of 
evaluation and will exclude as criteria visual impairments that have no 
relationship to acromegaly.
    In further response to the general request for more objective 
criteria, we have revised the proposed criteria for diabetes insipidus 
(DC 7909) by removing the subjective terms ``excessive thirst'' and 
``severe polyuria'' wherever they occurred in favor of the more 
objective phrase ``polyuria with near-continuous thirst.'' We also 
revised the criteria for the 100 percent evaluation, which we proposed 
to be: ``excessive thirst and severe polyuria requiring parenteral 
hydration therapy, episodes of syncope, and low systolic and diastolic 
blood pressure'' to a requirement for ``polyuria with near-continuous 
thirst, and more than two documented episodes of dehydration requiring 
parenteral hydration in the past year.'' The excretion of large 
quantities of very dilute urine is the underlying abnormality in this 
condition, and this leads to dehydration and hypovolemia. Syncope and 
low blood pressure are not isolated separate signs but are common 
effects of dehydration, and these criteria therefore encompass both 
parenteral hydration therapy, used to treat dehydration, and two of the 
signs of dehydration (syncope and low blood pressure).
    The proposed criteria for the 60 percent level included excessive 
thirst, polyuria, dehydration, serum osmolality greater than 295 mOsm/
kg., and urine osmolality less than 38 mOsms/kg. We revised these to a 
requirement for one or two documented episodes of dehydration requiring 
parenteral hydration in the past year, in addition to the basic 
requirements of thirst and polyuria. Serum and urine osmolality levels 
are objective criteria, but osmolality levels were not proposed as 
criteria for the 20, 40, or 100 percent levels. The change in favor of 
specifying the number of episodes of dehydration provides criteria that 
are more parallel and comparable from one level to the next, and are 
objective enough that the additional laboratory tests are not needed to 
determine a 60 percent level of severity. Finally, we have changed the 
proposed requirement for the 40 percent level from ``polyuria, 
excessive thirst, and dehydration'' to ``polyuria with near-continuous 
thirst, and one or more episodes of dehydration in the past year not 
requiring parenteral hydration.''
    We have also deleted the words ``increasingly,'' ``severe,'' 
``pronounced,'' and ``marked'' wherever they occurred in the proposed 
evaluation criteria for Addison's disease (DC 7911). These words did 
not substantively explain or clarify the evaluation criteria, and the 
criteria are clear without them.
    The proposed criteria for the 20 percent level of Addison's disease 
required either corticosteroid therapy or a combination of weakness and 
fatigability. In response to the commenter who said that the schedule 
should eliminate the potential for inconsistency, we have added 
alternative criteria for the 20 percent level that are parallel to the 
higher levels. These criteria require one or two crises or two to four 
episodes during the past year, which assures consistency of evaluation 
for those with fewer crises or episodes. For further clarity of the 
criteria, we added two notes under DC 7911 that define Addisonian 
``crises'' and Addisonian ``episodes.''
    In the previous schedule, under diabetes mellitus (DC 7913), 
regulation or careful regulation of activities (defined as avoidance of 
strenuous occupational and recreational activities) was one of the 
criteria at the 100 percent and 40 percent evaluation levels. We 
proposed ``regulation of activities,'' not further defined, as a 
criterion at the 100, 60, and 40 percent levels. One commenter felt 
that the proposed change in language made the meaning less clear.
    We agree and have retained the definition used in the previous 
rating schedule, ``avoidance of strenuous occupational and recreational 
activities,'' and included it in the evaluation criteria for the 100 
percent level.
    The same commenter said that it is meaningless to include 
limitation of

[[Page 20444]]

activities as a factor in evaluating diabetes mellitus since 
information of this type is not provided in a VA examination.
    VA disagrees. VA's Physician's Guide for Disability Evaluation 
Examinations is meant to insure that all necessary tests are performed 
and that all findings are provided for diagnosis and/or evaluation to 
meet the specific requirements of the Schedule for Rating Disabilities 
and related programs. It is available to VA and fee-basis examiners 
conducting examinations for VA disability benefits. The Guide will be 
revised to provide detailed guidelines for examinations reflecting the 
revised provisions of the rating schedule. It is incumbent upon the 
rating board to return to the examiner reports that lack information 
necessary to apply the provisions of the rating schedule (see Sec. 4.2 
of 38 CFR).
    The proposed 100 percent level for diabetes mellitus required 
``repeated'' episodes of ketoacidosis or hypoglycemic reactions 
requiring, among other things, ``frequent'' hospital or physician 
treatment. We received one comment requesting that we clearly define 
``frequent treatment.''
    We concur and have revised that portion of the criteria to require 
``episodes of ketoacidosis or hypoglycemic reactions requiring at least 
three hospitalizations per year or weekly visits to a diabetic care 
provider.'' Similarly, for the 60 percent level we have changed the 
requirement from ``occasional'' episodes of ketoacidosis or 
hypoglycemic reactions to ``episodes of ketoacidosis or hypoglycemic 
reactions requiring one or two hospitalizations per year or twice a 
month visits to a diabetic care provider.'' The change from a 
requirement for physician treatment to a requirement for visits to a 
diabetic care provider reflects the fact that diabetics are usually 
under the care of a multidisciplinary diabetic team, and at any given 
visit may see a nurse practitioner, physician's assistant, etc.
    The previous schedule required ``severe complications'' as one of 
the alternative criteria for the 100 percent level of diabetes mellitus 
(DC 7913). The proposed revision instead required ``severe 
complications such as retinopathy, nephropathy, arteriosclerosis, or 
neuropathy'' as one of the alternatives. For the 60 percent level the 
previous schedule required ``mild complications, such as pruritus ani, 
mild vascular deficiencies, or beginning diabetic ocular 
disturbances.'' The proposed revision required ``mild complications 
such as mild vascular deficiencies or beginning diabetic ocular 
disturbances.''
    A commenter stated that the word ``severe,'' referring to 
complications at the 100 percent level of diabetes mellitus, is a 
subjective description that should be changed.
    VA agrees. We have revised the language at both the 60 and 100 
percent levels to make it more objective, consistent from level to 
level, and more precise. We have revised the 100 percent criteria to 
require complications that would be compensable if separately evaluated 
and the 60 percent criteria to require complications that would not be 
compensable if separately evaluated. This is also consistent with note 
(1), following DC 7913, that directs that compensable complications of 
diabetes mellitus are to be rated separately unless they support a 100 
percent evaluation and that noncompensable complications are considered 
part of the diabetic process under DC 7913.
    One commenter questioned whether a 10 percent evaluation included 
those with Type II (adult onset) diabetes without symptoms and not 
following a restricted diet.
    The criterion we proposed for the 10 percent level, ``controlled by 
restricted diet only,'' refers to anyone with diabetes mellitus mild 
enough not to require insulin or oral hypoglycemics. For the sake of 
greater clarity, we have revised the requirement for zero percent to 
``manageable by restricted diet only.'' This does not represent a 
substantive change.
    A proposed note under diabetes mellitus (DC 7913) stated that when 
diabetes mellitus has been definitely diagnosed, a glucose tolerance 
test need not be ordered solely for rating purposes. A commenter said 
that the term ``definitely diagnosed'' is an entirely subjective 
descriptor.
    To assure that there is no misunderstanding about the meaning, we 
have changed the term ``definitely diagnosed'' to ``conclusively 
diagnosed.'' The intent of the term ``conclusively diagnosed'' is to 
indicate those individuals who have a diagnosis of diabetes mellitus 
that has been established through the usual medical means, both 
clinical and laboratory, and to exclude those with insufficient 
evidence to support a clear diagnosis.
    One commenter stated that the revision should address the basic 
concept of lost earnings due to time lost from work. He suggested no 
alternatives.
    In our judgment, the evaluation criteria we have provided are 
clearly linked to lost earnings because they include such things as 
periods of hospitalization, episodes of incapacitating symptoms, 
muscular weakness, arthropathy, fatigability, etc., all of which may 
affect the ability to work. Furthermore, we have provided criteria for 
the 100 percent levels that indicate a degree of severity that would 
render the average person completely unable to work. Thus the proposed 
criteria do address the effects of time lost from work.
    An additional general comment was that recently discharged veterans 
would be discriminated against by being evaluated under the revised 
rating schedule, which he said is ``deliberalized''.
    VA disagrees. 38 U. S. C. gives the Secretary the authority to 
readjust the schedule of ratings from time to time in accordance with 
experience. The significant medical advances that have occurred since 
1945 form part of the experience that must be taken into account in 
revising the rating schedule. In order to assure fair and consistent 
evaluations for veterans, the schedule must reflect actual residuals of 
disease or injuries, not what residuals might have been in the past. 
Furthermore, Congress foresaw that evaluations might change when the 
rating schedule is revised and amended 38 U.S.C. 1155 to prohibit a 
reduction in a veteran's disability rating because of a readjustment of 
the rating schedule unless an improvement in the disability has been 
shown.
    The previous schedule had a 100 percent evaluation for one year 
following the cessation of treatment of malignancies. We proposed that 
the 100 percent evaluation continue indefinitely but that there be a 
mandatory VA examination six months following the cessation of 
treatment, with any change in evaluation based on that or any 
subsequent examination, to be implemented under the provisions of 38 
CFR 3.105(e). Three commenters recommended that VA retain the 
evaluation criteria from the previous schedule.
    We do not concur. An examination six months following the cessation 
of treatment affords sufficient time for convalescence and 
stabilization of residuals because the rule requires an examination, 
not a reduction, six months after the cessation of treatment. In fact, 
the rule precludes a reduction at that time because the process of re-
evaluation does not begin until then.
    First, there must be a VA examination six months after completion 
of treatment. If the results of that or any subsequent examination 
warrant a reduction in evaluation, the reduction will be implemented 
under the provisions of 38 CFR 3.105(e), which

[[Page 20445]]

require a 60 day notice before VA reduces an evaluation and an 
additional 60 day notice before the reduced evaluation takes effect. 
The revision not only requires a current examination to assure that all 
residuals are documented, but also offers the veteran more 
contemporaneous notice of any proposed action and expands the veteran's 
opportunity to present evidence showing that the proposed action should 
not be taken. In our judgment, this method will better ensure that 
actual side-effects and recuperation times are taken into account 
because they will be noted on the required VA exam.
    Because of commenters' concerns, however, we have revised the note 
under this code so that it cannot be misinterpreted as requiring a 
reduction six months after treatment is terminated. We have also added 
to the note a direction to rate on residuals, if there has been no 
local recurrence or metastasis, in order to make these provisions 
consistent with those we provided for malignancies of the revised 
genitourinary system. This is not a substantive change, but has been 
made to provide further clarity, as well as internal consistency within 
the rating schedule.
    One commenter said that VA exceeded its mandate by proposing the 
change in convalescence.
    VA does not concur. VA's mandate arises from 38 U.S.C. 1155, which 
authorizes the Secretary to readjust the rating schedule from time to 
time in accordance with experience.
    Another commenter objected to the change in convalescence, saying 
that the average person would require at least 12 months of 
convalescence for brain surgery.
    VA does not agree. The convalescent periods adopted in this change 
represent, in our judgment, based on sound medical advice, neither the 
longest nor shortest periods that any individual patient might require 
for recovery, but the usual or normal periods during which a normal 
patient, under normal circumstances, would be expected to recover from 
a specific condition or surgical procedure. Furthermore, these 
convalescent periods represent the point at which the individual 
patient's condition is to be evaluated by examination, and do not 
preclude an extension of a total evaluation, if appropriate, based on 
the individual patient's condition.
    Another commenter said that the proposed changes in convalescent 
periods appear to be purely economically based.
    The myriad of advances in medicine that have occurred since 1945, 
such as early ambulation, better surgical techniques, new anesthetics, 
and better control of infectious diseases, have led to strikingly 
shorter periods of convalescence after both medical and surgical 
treatment. The revisions were proposed based on medical considerations; 
no cost studies or projections were conducted in conjunction with this 
review. Cost cutting was therefore not an issue.
    One commenter stated that applying Sec. 3.105(e) will cause 
significant problems from an administrative standpoint and will often 
significantly lengthen the periods for which a convalescent rate is 
paid.
    VA believes that the changes in convalescence following treatment 
of malignancy where Sec. 3.105(e) must be applied can be implemented 
without serious administrative problems. Similar changes are being made 
in each body system, and any procedural changes that may be necessary 
to implement the new process will be made as needed. We have included 
the implementation of the provisions of Sec. 3.105(e) to assure that 
veterans are afforded due process before convalescent ratings are 
reduced, and if administrative delays do occur from time to time, they 
cannot operate to the disadvantage of veterans. Also, since 
Sec. 3.105(e) applies only to reductions in ``compensation payments 
currently being made,'' it need not be applied in cases where a total 
evaluation will be assigned and reduced retroactively.
    One commenter urged that VA provide zero percent evaluations for 
all diagnostic codes.
    We do not agree. On October 6, 1993 VA revised its regulation 
addressing the issue of zero percent evaluations (38 CFR 4.31) to 
authorize assignment of a zero percent evaluation for any disability in 
the rating schedule when minimum requirements for a compensable 
evaluation are not met. In general, that regulatory provision precludes 
the need for zero percent evaluation criteria. We have retained zero 
percent evaluation criteria only when necessary to give the rater clear 
and unambiguous instructions on rating where it might otherwise be 
unclear whether commonly occurring minor findings warrant a compensable 
evaluation.
    One commenter noted that veterans are receiving diagnoses of 
hyperlipidemia, elevated triglycerides, and elevated cholesterol, and 
the commenter asked that we address the handling of claims for these 
findings.
    The diagnoses listed by the commenter are actually laboratory test 
results, and are not, in and of themselves, disabilities. They are, 
therefore, not appropriate entities for the rating schedule to address. 
In addition, they have no special relationship to the endocrine system.
    We have made several additional changes based on our own review of 
the proposed regulation. For example, we edited the proposed note under 
malignant neoplasm (DC 7914) by modifying the sentence ``Any change in 
evaluation based upon that examination shall be subject to the 
provisions of Sec. 3.105(e) of this chapter'' to ``Any change in 
evaluation based upon that or any subsequent examination shall be 
subject to the provisions of Sec. 3.105(e) of this chapter.'' The 
change assures that the veteran will be given the notices described 
above regardless of when an examination leading to a proposed change in 
evaluation is done and is consistent with changes we have made in the 
revision of other portions of the rating schedule. This represents no 
substantive change.
    The previous schedule had a note under DC 7900, hyperthyroidism, 
addressing the issue of evaluating hyperthyroid heart disease if 
disease of the heart predominates. We have expanded the note for 
clarity by adding ``if doing so would result in a higher evaluation 
than using the criteria above.''
    We also made a nonsubstantive editorial change in the note 
following pheochromocytoma (DC 7918) from the proposal to rate 
hyperpituitarism, hyperaldosteronism and pheochromocytoma as malignant 
or benign neoplasm under DC 7914 or 7915, whichever is applicable, to a 
direction to evaluate those conditions under benign or malignant 
neoplasms as appropriate.
    For the sake of greater clarity and ease of comparison, we 
rearranged the order of the criteria for diabetes mellitus (DC 7913) 
regarding need for insulin or an oral hypoglycemic agent, diet, and 
regulation of activities, putting them in the same order at all levels 
where they appear. This does not represent a substantive change.
    We proposed that constipation be one of the criteria for the 60 
percent level of hypoparathyroidism (DC 7905). However, because 
standard medical textbooks such as ``The Merck Manual'' and ``Williams 
Textbook of Endocrinology'' do not include it as a characteristic 
clinical manifestation of hypoparathyroidism, we have concluded that it 
is not appropriate as

[[Page 20446]]

part of VA's evaluation criteria, and we have, therefore, removed it.
    We proposed that DC 7901 (thyroid gland, toxic adenoma of) be rated 
as DC 7900 (hyperthyroidism). For the convenience of rating 
specialists, we have instead repeated the rating criteria for DC 7900 
under DC 7901. For the same reason, we have repeated the note under DC 
7914, which explains evaluation of malignant neoplasms, under C-cell 
hyperplasia of the thyroid (DC 7919), rather than instructing to rate 
C-cell hyperplasia of the thyroid as malignant neoplasm, as we 
proposed. These changes reduce the risk of error because the necessary 
criteria are closely associated with the diagnostic code rather than on 
another page, and they also save time for the rating specialist. They 
do not represent substantive changes.
    We have made additional nonsubstantive editorial changes in 
language by substituting ``evaluate'' for ``rate'' in several instances 
and by changing ``neoplasms'' to ``neoplasm'' in DC's 7914 and 7915, 
for internal consistency in the rating schedule.
    VA appreciates the comments submitted in response to the proposed 
rule, which is now adopted with the amendments noted above.
    The Secretary hereby certifies that this regulatory amendment will 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act (RFA), 5 
U.S.C. 601-612. The reason for this certification is that this 
amendment would not directly affect any small entities. Only VA 
beneficiaries could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604.
    This regulatory amendment has been reviewed by the Office of 
Management and Budget under the provisions of Executive Order 12866, 
Regulatory Planning and Review, dated September 30, 1993.
    The Catalog of Federal Domestic Assistance program numbers are 
64.104 and 64.109.

List of Subjects in 38 CFR Part 4

    Disability benefits, Individuals with disabilities, Pensions, 
Veterans.

    Approved: December 5, 1995.
Jesse Brown,
Secretary of Veterans Affairs.

    For the reasons set forth in the preamble, 38 CFR part 4, subpart 
B, is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority: 38 U.S.C. 1155.

Subpart B--Disability Ratings

    2. Section 4.119 is revised to read as follows:


Sec. 4.119  Schedule of ratings--endocrine system.

------------------------------------------------------------------------
                                                                  Rating
------------------------------------------------------------------------
7900  Hyperthyroidism                                                   
  Thyroid enlargement, tachycardia (more than 100 beats per             
   minute), eye involvement, muscular weakness, loss of weight,         
   and sympathetic nervous system, cardiovascular, or                   
   astrointestinal symptoms.....................................     100
  Emotional instability, tachycardia, fatigability, and                 
   increased pulse pressure or blood pressure...................      60
  Tachycardia, tremor, and increased pulse pressure or blood            
   pressure.....................................................      30
  Tachycardia, which may be intermittent, and tremor, or;               
   continuous medication required for control...................      10
  Note (1): If disease of the heart is the predominant finding,         
   evaluate as hyperthyroid heart disease (DC 7008) if doing so         
   would result in a higher evaluation than using the criteria          
   above.                                                               
  Note (2): If ophthalmopathy is the sole finding, evaluate as          
   field vision, impairment of (DC 6080); diplopia (DC 6090); or        
   impairment of central visual acuity (DC 6061-6079).                  
7901  Thyroid gland, toxic adenoma of                                   
  Thyroid enlargement, tachycardia (more than 100 beats per             
   minute), eye involvement, muscular weakness, loss of weight,         
   and sympathetic nervous system, cardiovascular, or                   
   gastrointestinal symptoms....................................     100
  Emotional instability, tachycardia, fatigability, and                 
   increased pulse pressure or blood pressure...................      60
  Tachycardia, tremor, and increased pulse pressure or blood            
   pressure.....................................................      30
  Tachycardia, which may be intermittent, and tremor, or;               
   continuous medication required for control...................      10
  Note (1): If disease of the heart is the predominant finding,         
   evaluate as hyperthyroid heart disease (DC 7008) if doing so         
   would result in a higher evaluation than using the criteria          
   above.                                                               
  Note (2): If ophthalmopathy is the sole finding, evaluate as          
   field vision, impairment of (DC 6080); diplopia (DC 6090); or        
   impairment of central visual acuity (DC 6061-6079).                  
7902  Thyroid gland, nontoxic adenoma of                                
  With disfigurement of the head or neck........................      20
  Without disfigurement of the head or neck.....................       0
  Note: If there are symptoms due to pressure on adjacent organs        
   such as the trachea, larynx, or esophagus, evaluate under the        
   diagnostic code for disability of that organ, if doing so            
   would result in a higher evaluation than using this                  
   diagnostic code.                                                     
7903  Hypothyroidism                                                    
  Cold intolerance, muscular weakness, cardiovascular                   
   involvement, mental disturbance (dementia, slowing of                
   thought, depression), bradycardia (less than 60 beats per            
   minute), and sleepiness......................................     100
  Muscular weakness, mental disturbance, and weight gain........      60
  Fatigability, constipation, and mental sluggishness...........      30
  Fatigability, or; continuous medication required for control..      10
7904  Hyperparathyroidism                                               
  Generalized decalcification of bones, kidney stones,                  
   gastrointestinal symptoms (nausea, vomiting, anorexia,               
   constipation, weight loss, or peptic ulcer), and weakness....     100
  Gastrointestinal symptoms and weakness........................      60
  Continuous medication required for control....................      10
  Note: Following surgery or treatment, evaluate as digestive,          
   skeletal, renal, or cardiovascular residuals or as endocrine         
   dysfunction.                                                         
7905  Hypoparathyroidism                                                
  Marked neuromuscular excitability (such as convulsions,               
   muscular spasms (tetany), or laryngeal stridor) plus either          
   cataract or evidence of increased intracranial pressure (such        
   as papilledema)..............................................     100
  Marked neuromuscular excitability, or; paresthesias (of arms,         
   legs, or circumoral area) plus either cataract or evidence of        
   increased intracranial pressure..............................      60
  Continuous medication required for control....................      10
7907  Cushing's syndrome                                                
  As active, progressive disease including loss of muscle               
   strength, areas of osteoporosis, hypertension, weakness, and         
   enlargement of pituitary or adrenal gland....................     100
  Loss of muscle strength and enlargement of pituitary or               
   adrenal gland................................................      60
  With striae, obesity, moon face, glucose intolerance, and             
   vascular fragility...........................................      30
  Note: With recovery or control, evaluate as residuals of              
   adrenal insufficiency or cardiovascular, psychiatric, skin,          
   or skeletal complications under appropriate diagnostic code.         
7908  Acromegaly                                                        

[[Page 20447]]

                                                                        
  Evidence of increased intracranial pressure (such as visual           
   field defect), arthropathy, glucose intolerance, and either          
   hypertension or cardiomegaly.................................     100
  Arthropathy, glucose intolerance, and hypertension............      60
  Enlargement of acral parts or overgrowth of long bones, and           
   enlarged sella turcica.......................................      30
7909  Diabetes insipidus                                                
  Polyuria with near-continuous thirst, and more than two               
   documented episodes of dehydration requiring parenteral              
   hydration in the past year...................................     100
  Polyuria with near-continuous thirst, and one or two                  
   documented episodes of dehydration requiring parenteral              
   hydration in the past year...................................      60
  Polyuria with near-continuous thirst, and one or more episodes        
   of dehydration in the past year not requiring parenteral             
   hydration....................................................      40
  Polyuria with near-continuous thirst..........................      20
7911  Addison's disease (Adrenal Cortical Hypofunction)                 
  Four or more crises during the past year......................      60
  Three crises during the past year, or; five or more episodes          
   during the past year.........................................      40
  One or two crises during the past year, or; two to four               
   episodes during the past year, or; weakness and fatigability,        
   or; corticosteroid therapy required for control..............      20
  Note (1): An Addisonian ``crisis'' consists of the rapid onset        
   of peripheral vascular collapse (with acute hypotension and          
   shock), with findings that may include: anorexia; nausea;            
   vomiting; dehydration; profound weakness; pain in abdomen,           
   legs, and back; fever; apathy, and depressed mentation with          
   possible progression to coma, renal shutdown, and death.             
  Note (2): An Addisonian ``episode,'' for VA purposes, is a            
   less acute and less severe event than an Addisonian crisis           
   and may consist of anorexia, nausea, vomiting, diarrhea,             
   dehydration, weakness, malaise, orthostatic hypotension, or          
   hypoglycemia, but no peripheral vascular collapse.                   
  Note (3): Tuberculous Addison's disease will be evaluated as          
   active or inactive tuberculosis. If inactive, these                  
   evaluations are not to be combined with the graduated ratings        
   of 50 percent or 30 percent for non-pulmonary tuberculosis           
   specified under Sec.  4.88b. Assign the higher rating.               
7912  Pluriglandular syndrome                                           
  Evaluate according to major manifestations.                           
7913  Diabetes mellitus                                                 
  Requiring more than one daily injection of insulin, restricted        
   diet, and regulation of activities (avoidance of strenuous           
   occupational and recreational activities) with episodes of           
   ketoacidosis or hypoglycemic reactions requiring at least            
   three hospitalizations per year or weekly visits to a                
   diabetic care provider, plus either progressive loss of              
   weight and strength or complications that would be                   
   compensable if separately evaluated..........................     100
  Requiring insulin, restricted diet, and regulation of                 
   activities with episodes of ketoacidosis or hypoglycemic             
   reactions requiring one or two hospitalizations per year or          
   twice a month visits to a diabetic care provider, plus               
   complications that would not be compensable if separately            
   evaluated....................................................      60
  Requiring insulin, restricted diet, and regulation of                 
   activities...................................................      40
  Requiring insulin and restricted diet, or; oral hypoglycemic          
   agent and restricted diet....................................      20
  Manageable by restricted diet only............................      10
  Note (1): Evaluate compensable complications of diabetes              
   separately unless they are part of the criteria used to              
   support a 100 percent evaluation. Noncompensable                     
   complications are considered part of the diabetic process            
   under diagnostic code 7913.                                          
  Note (2): When diabetes mellitus has been conclusively                
   diagnosed, do not request a glucose tolerance test solely for        
   rating purposes.                                                     
7914  Neoplasm, malignant, any specified part of the endocrine          
 system.........................................................     100
  Note: A rating of 100 percent shall continue beyond the               
   cessation of any surgical, X-ray, antineoplastic chemotherapy        
   or other therapeutic procedure. Six months after                     
   discontinuance of such treatment, the appropriate disability         
   rating shall be determined by mandatory VA examination. Any          
   change in evaluation based upon that or any subsequent               
   examination shall be subject to the provisions of Sec.               
   3.105(e) of this chapter. If there has been no local                 
   recurrence or metastasis, rate on residuals.                         
7915  Neoplasm, benign, any specified part of the endocrine             
 system rate as residuals of endocrine dysfunction.                     
7916  Hyperpituitarism (prolactin secreting pituitary                   
 dysfunction)                                                           
7917  Hyperaldosteronism (benign or malignant)                          
7918  Pheochromocytoma (benign or malignant)                            
  Note: Evaluate diagnostic codes 7916, 7917, and 7918 as               
   malignant or benign neoplasm as appropriate.                         
7919  C-cell hyperplasia of the thyroid.........................     100
  Note: A rating of 100 percent shall continue beyond the               
   cessation of any surgical, X-ray, antineoplastic chemotherapy        
   or other therapeutic procedure. Six months after                     
   discontinuance of such treatment, the appropriate disability         
   rating shall be determined by mandatory VA examination. Any          
   change in evaluation based upon that or any subsequent               
   examination shall be subject to the provisions of Sec.               
   3.105(e) of this chapter. If there has been no local                 
   recurrence or metastasis, rate on residuals.                         
------------------------------------------------------------------------


[FR Doc. 96-11281 Filed 5-6-96; 8:45 am]
BILLING CODE 8320-01-P