20440 Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations

[FR Doc. 96–11275 Filed 5–6–96; 8:45 am]

BILLING CODE 8320–01–P

38 CFR Part 4

RIN 2900–AE41

Schedule for Rating Disabilities;

Endocrine System Disabilities

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

SUMMARY: This document amends that

portion of the Department of Veterans

Affairs (VA) Schedule for Rating

Disabilities 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
Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations 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 serviceconnected 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 serviceconnecting 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
20442 Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations

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

hypoparathyroidism—cataracts 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

manifestations—convulsions, muscular

spasms (tetany), and laryngeal

stridor—in 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
Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations 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 nearcontinuous 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
20444 Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations

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

§ 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 reevaluation 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
Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations 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

§ 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 § 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

§ 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

§ 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

§ 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 § 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
20446 Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations

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:

§ 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

Rating

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
Federal Register / Vol. 61, No. 89 / Tuesday, May 7, 1996 / Rules and Regulations 20447

Rating

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 § 4.88b. Assign

the higher rating.

7912 Pluriglandular syndrome

Evaluate according to major manifestations.

7913 Diabetes mellitus

Rating

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

§ 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

Rating

NOTE: A rating of 100 percent shall

continue beyond the cessation of

any surgical, X-ray, antineoplastic

chemotherapy or other therapeutic

procedure. Six months after discontinuance of such treatment, the

appropriate disability rating shall

be determined by mandatory VA

examination. Any change in evaluation based upon that or any

subsequent examination shall be

subject to the provisions of

§ 3.105(e) of this chapter. If there

has been no local recurrence or

metastasis, rate on residuals.

[FR Doc. 96–11281 Filed 5–6–96; 8:45 am]

BILLING CODE 8320–01–P

Board of Veterans’ Appeals

38 CFR Parts 19 and 20

RIN 2900–AH16

Appeals Regulations, Rules of

Practice: Single Member and Panel

Decisions; Reconsiderations; Order of

Consideration

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

SUMMARY: This document amends the

Appeals Regulations and Rules of

Practice of the Board of Veterans’’

Appeals. The amendments incorporate

recent statutory changes (including

provisions to allow matters to be

decided by individual Board members),

set forth procedures regarding

reconsideration of decisions, change

office names and designations due to

administrative changes within the

Board, and make other nonsubstantive

changes.

DATES: Effective Date: This final rule is

effective May 7, 1996.

Applicability Dates: The

incorporation of statutory provisions

and statutory interpretations contained

in this final rule will be applied

retroactively from the effective dates of

the statutory provisions. For more

information concerning the application

of the provisions of this final rule, see

the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT:

Steven L. Keller, Chief Counsel, Board

of Veterans’ Appeals, Department of

Veterans Affairs, 810 Vermont Avenue,

NW, Washington, DC 20420 (202–565–

5978).

SUPPLEMENTARY INFORMATION: This

document amends the Appeals

Regulations, 38 CFR Part 19, and the

Rules of Practice, 38 CFR Part 20, of the