Change Date July 5, 2015 a. Considering Circumstances of Service Associated With Disorders If the issue is service connection (SC) for dysentery or other gastrointestinal disease, assign great weight to any service under the following conditions since these conditions may have been the etiological or aggravating factor tropical service imprisonment or internment under unsanitary conditions, or food deprivation. Reference: For more information on establishing SC for dysentery and other tropical diseases, see . b. Digestive Condition Evaluations Under 38 CFR 4.114 Which Will Not Be Combined With Each Other specifies that evaluations of digestive conditions under certain diagnostic codes (DCs) will not be combined with each other or assigned separate evaluations. Instead, a single evaluation should be assigned under the DC which reflects the predominant disability, with elevation to the next higher evaluation when the severity of the overall disability warrants such elevation. Do not combine separate evaluations of digestive conditions with each other under the following DCs 7301 to 7329, inclusive (meaning all the DCs from 7301 to 7329) 7331 7342, and 7345 to 7348, inclusive (meaning all the DCs from 7345 to 7348). Example: A Veteran with a duodenal ulcer, evaluated as 20 percent disabling under , and ulcerative colitis, evaluated as 30 percent disabling under , would be assigned a single 30-percent evaluation under as ulcerative colitis represents the predominant disability picture. Separate evaluations for the duodenal ulcer and ulcerative colitis are not permitted under . c. Establishing SC for Inguinal Hernia Do not assume the preexistence of a hernia. Determine preexistence on a factual basis. The following conditions are sufficient bases for SC in-service initial manifestation of hernial protrusion, and recurrence during service, by aggravation, of a hernia previously surgically repaired.
Note: Operation for repair of a preexisting inguinal hernia is not necessarily evidence of aggravation. Reference: For information on the presumption of soundness at entrance into service, see . d. Considering Recurrence of Hemorrhoids Initial awards of SC for hemorrhoids are governed by customary rules for SC included in . After SC is initially established, unless the award of SC for hemorrhoids was in error, consider recurrences after service as SC. Reference: For more information on reversing an erroneous decision, see 38 CFR 3.105(a) M21-1, Part III, Subpart iv, 2.B.4.a, and M21-1, Part IV, Subpart ii, 3.A.2. e. Causes of Liver Damage Hepatitis is the result of damage to the liver. The table below describes recognized causes of liver damage and provides examples of each cause. Cause of Liver Damage Example Infection Virus Systemic diseases Lupus Drugs Isoniazid Acetaminophen Phenytoin Toxic substances Alcohol f. Categories of Hepatitis Recognized for Rating Purposes There are three categories of hepatitis recognized for rating purposes. The table below describes each type of hepatitis and explains the transmission and prognosis for each. Type of Hepatitis Transmission Prognosis hepatitis A Virus (HAV), previously called infectious hepatitis fecal-oral route acute—seldom severe and does not leave residuals hepatitis B Virus (HBV), previously called serum hepatitis blood products sexual contact acute in 90-95 percent of cases, but acute disease can be severe and result in death chronic in 5-10 percent of cases
EIA positive supplemental test required RIBA positive diagnostic HCVRNA follow-up of chronic hepatitis C not needed for rating j. Risk Factors for HBV and HCV Risk factors for the development of HBV and HCV are similar. The table below describes the medically recognized risk factors for HBV and HCV infection, provides transmission information concerning those risk factors, and includes tips for rating hepatitis claims associated with the risk factors. Risk Factor Transmission Information Rating Tips transfusion of blood or blood product before 1992 for HCV, or before 1975 for HBV organ transplant before 1992, or hemodialysis Blood donor screening for HCV was not available until 1989 when HCV was identified. In 1992, more effective screening of blood became possible for HCV. If blood transfusion is a claimed risk factor, obtain the relevant hospital records from service, if possible. Look for evidence of blood transfusions in surgical reports, especially the anesthesia sheet surgical record operative clinical records, or post-operative clinical notes. tattoos body piercing, and acupuncture with needles transmitted through the use of unsterilized equipment Review for indications of tattoos or piercings on induction and separation exams to help determine whether tattooing or piercing took place in service. intravenous drug use transmitted through the use of shared instruments Records of drug treatment may reflect the type of drug abuse. high-risk sexual activity Transmission risk is relatively low but increases with multiple sexual partners. Periodic health assessments or records of treatment for sexually transmitted diseases may document a history of high-risk sexual activity or multiple sexual partners.
can be internal radiation therapy, or brachytherapy, in which radioactive seeds are implanted in the prostate. high dose radiation (HDR) seeds are implanted for less than a day and then removed. Radiation is present only while seeds are in place. low dose radiation (LDR) seeds are permanently implanted and give off radiation for weeks to months, depending on the radioisotope used. external radiation therapy, in which radiation is delivered by high-energy eternal radiation for six to eight weeks. gone by one year assign a 100 percent evaluation for one year, and schedule a review exam six months following the cessation of the treatment period. Note: If radiation is used only as palliative therapy in advanced cancer, the 100-percent evaluation will continue because the cancer will remain active. Therefore review for metastatic disease, and consider permanency. Hormone therapy is primarily for palliation of prostate cancer which is not confined to the prostate for the purpose of testosterone deprivation. Types of hormone therapy include orchiectomy, the removal of testes to prevent testosterone production luteinizing hormone releasing hormone after any hormone therapy hot flashes osteoporosis loss of muscle mass after orchiectomy impotence sterility loss of sex drive after anti-androgen therapy gastrointestinal upset breast tenderness gynecomastia Orchiectomy results in anatomical loss of a creative organ; therefore evaluate under , and award SMC. Hormone therapy may continue for many years; therefore review treatment records for expected duration of treatment, and consider permanence.
post-service) development of atypical hyperplasia associated with the fibrocystic breasts subsequent development of breast cancer, and nexus between the fibrocystic breasts with associated atypical hyperplasia and the development of breast cancer residuals under appropriate DCs including , or . e. Considering Claims for SC of Cervical Dysplasia Do not routinely award SC for cervical dysplasia, also referred to as cervical intraepithelial neoplasia (CIN). Cervical dysplasia/CIN is not a disease or injury. It is a cellular abnormality of the cervix revealed by Papanicolaou (Pap) smear testing that generally resolves without treatment or residuals. In these cases, there is an abnormal laboratory finding but no disability, and SC is not warranted. SC may be warranted if cervical dysplasia/CIN requires treatment that leaves residuals, or is linked to the subsequent development of cervical cancer. Use the table below to determine the appropriate actions to take when SC is claimed following an in-service confirmed finding of cervical dysplasia/CIN. If Medical Evidence Shows the Subsequent Development of… Then Award SC for… Additional Information to Consider chronic or severe dysplasia/CIN requiring treatment, and chronic residuals of the required treatment residuals of cervical dysplasia/CIN. Common procedures for treatment of chronic or severe dysplasia/CIN include cauterization laser surgery cryosurgery, or loop electrosurgical excision procedure (LEEP). cervical cancer, and cervical cancer and/or In-service cervical
arthritis leg ulcers, and acute attacks of pain. Note: The age of onset is generally early childhood. c. Definition: Bone Marrow Transplant and Stem Cell Transplant A bone marrow transplant, also called a stem cell transplant, is a procedure used to infuse healthy cells, called stem cells, into the body to replace damaged or diseased bone marrow. Important: There is no difference between a bone marrow transplant and a stem cell transplant; therefore, an SC hemic-lymphatic disability requiring a stem cell transplant should be evaluated by analogy to . Notes: Assign the 100-percent evaluation from the date of hospital admission and continue with a mandatory VA examination six months following hospital discharge. Any change in evaluation based on that or any subsequent examination shall be subject to the provisions of . If no local recurrence or metastasis has occurred, then evaluate on residuals. d. Inheritance of Sickle Cell Trait Inheritance of sickle cell trait may be from one or both parents. If sickle hemoglobin is inherited from one parent and normal hemoglobin from the other, the combination (Hb S + Hb A) is referred to as sickle cell trait. Note: Except for unusual circumstances, this is a benign asymptomatic condition and is not associated with increased morbidity. e. Inheritance of Sickle Cell Anemia The inheritance of sickle hemoglobin from each parent results in the combination (Hb S + Hb S), referred to as sickle cell anemia. Sickle cell anemia is usually accompanied by moderate to severe anemia, and appropriate clinical signs and symptoms, such as enlargement of the heart abnormalities of the musculoskeletal system bone and joint pain, and/or fever.