Proposed Rule2024-25665
Schedule for Rating Disabilities: Neurological Conditions and Convulsive Disorders
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Published
November 12, 2024
Issuing agencies
Veterans Affairs Department
Abstract
The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule) that addresses neurological conditions and convulsive disorders. The purpose of these changes is to incorporate medical advancements that have occurred since the last revision, update current medical terminology, and provide clear evaluation criteria. The proposed rule reflects advances in medical knowledge and recommendations contained in the report from the Institute of Medicine, part of the National Academy of Sciences, titled "A 21st Century System for Evaluating Veterans for Disability Benefits," National Academies Press, 2007.
Full Text
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[Federal Register Volume 89, Number 218 (Tuesday, November 12, 2024)]
[Proposed Rules]
[Pages 88917-88940]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2024-25665]
[[Page 88917]]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Parts 3 and 4
RIN 2900-AQ73
Schedule for Rating Disabilities: Neurological Conditions and
Convulsive Disorders
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the
portion of the VA Schedule for Rating Disabilities (VASRD or Rating
Schedule) that addresses neurological conditions and convulsive
disorders. The purpose of these changes is to incorporate medical
advancements that have occurred since the last revision, update current
medical terminology, and provide clear evaluation criteria. The
proposed rule reflects advances in medical knowledge and
recommendations contained in the report from the Institute of Medicine,
part of the National Academy of Sciences, titled ``A 21st Century
System for Evaluating Veterans for Disability Benefits,'' National
Academies Press, 2007.
DATES: Comments must be received on or before January 13, 2025.
ADDRESSES: Comments must be submitted through <a href="http://www.regulations.gov">www.regulations.gov</a>.
Except as provided below, comments received before the close of the
comment period will be available at <a href="http://www.regulations.gov">www.regulations.gov</a> for public
viewing, inspection, or copying, including any personally identifiable
or confidential business information that is included in a comment. We
post the comments received before the close of the comment period on
<a href="http://www.regulations.gov">www.regulations.gov</a> as soon as possible after they have been received.
VA will not post on <a href="http://Regulations.gov">Regulations.gov</a> public comments that make threats
to individuals or institutions or suggest that the commenter will take
actions to harm an individual. VA encourages individuals not to submit
duplicative comments; however, we will post comments from multiple
unique commenters even if the content is identical or nearly identical
to other comments. Any public comment received after the comment
period's closing date is considered late and will not be considered in
the final rulemaking. In accordance with the Providing Accountability
Through Transparency Act of 2023, a plain language summary (not more
than 100 words in length) of this proposed rule is available at
<a href="http://www.regulations.gov">www.regulations.gov</a>, under RIN 2900-AQ73.
FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Medical Officer,
Part 4 VASRD Staff (218), Compensation Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW,
Washington, DC 20420, <a href="/cdn-cgi/l/email-protection#2210131a7463717066726f6d0c746063616d6254430c454d54"><span class="__cf_email__" data-cfemail="3f0d0e07697e6c6d7b6f727011697d7e7c707f495e11585049">[email protected]</span></a>, (202) 461-9700. (This
is not a toll-free telephone number.)
SUPPLEMENTARY INFORMATION: VA has periodically revised portions of the
Schedule for Rating Disabilities, to include the Neurological
Conditions and Convulsive Disorders (herein referred to as the
Neurological body system), since it was created in 1919. Important
advances in the neurological sciences--particularly in the areas
related to biochemistry, genetics, physiopathology, as well as
electrodiagnosis and imaging of the nervous system--have produced
drastic changes in the understanding of neurological diseases since the
second half of the 20th century. The extent and repercussion of these
advances triggered profound changes in approaches to diagnosis,
classification of disease, and care of patients with neurological
illnesses. As part of VA's ongoing revision of the VA Schedule for
Rating Disabilities (VASRD or rating schedule), VA proposes changes to
38 Code of Federal Regulations (38 CFR) Sec. Sec. 4.120 and 4.123-
4.124a, which pertain to the neurological conditions and convulsive
disorders. The proposed changes will: (1) update the medical
terminology of certain neurological conditions and convulsive
disorders; (2) add medical conditions frequently encountered but not
currently found in the rating schedule; (3) refine evaluation criteria
based on medical advances that have occurred since the last revision
and current understanding of functional changes associated with or
resulting from disease or injury (pathophysiology), and; (4) remove or
modify certain diagnostic codes (DC) that are outdated or obsolete.
I. Retitle and Revise Sec. Sec. 4.120 Evaluations by Comparison, 4.123
Neuritis, Cranial or Peripheral, and 4.124 Neuralgia, Cranial or
Peripheral
VA proposes to retitle and revise Sec. 4.120, Evaluations by
comparison, because the approach to evaluating neurologic conditions
has evolved over the time since this section was included in the 1945
rating schedule. See 29 FR 6718, 6749-6750 (May 22, 1964). As medical
understanding has increased, the additional knowledge permits VA to
develop evaluation criteria within the individual diagnostic codes that
more accurately consider motor, sensory, and mental impairment. The
instructions contained in the last sentence of Sec. 4.120, which apply
to peripheral nerves, will be updated to better align with modern
medical knowledge and relocated to the revised Sec. 4.123, titled
``Cranial and peripheral nerve impairment,'' paragraph (a)(1). VA
proposes to relocate instructions relating to organic diseases of the
central nervous system to Sec. 4.120. See section II B. Orgranic
diseases of the central nervous system below for additional detail.
VA also proposes to retitle and revise Sec. Sec. 4.123 Neuritis,
cranial or peripheral and 4.124 Neuralgia, cranial or peripheral. These
sections provide information regarding symptoms and evaluations
associated with neuritis and neuralgia. Neuritis and neuralgia are used
to describe symptoms associated with motor and sensory neuropathy
involving cranial and peripheral nerves. However, VA proposes their
removal in favor of more objective criteria to assess disability in the
cranial and peripheral nerves.
In the 1940s, the term neuritis was advanced by Dr. S.A. Kinnier
Wilson as an all-encompassing term for most peripheral nerve
conditions. Dr. S.A. Kinnier Wilson, ``Neurology,'' 279 (Ninian Bruce
ed., 1970). As the field of peripheral neuropathology evolved, it
became apparent that use of the term neuritis was obsolete and should
be replaced by neuropathy, the preferred term for peripheral nerve
diseases. While neuritis is sometimes used as a synonym for neuropathy,
this use is erroneous and should only be used for certain specified
inflammatory diseases. Drs. A.K. Asbury & Peter Johnson, ``Neurology,''
258 (James Bennington ed., 1978). While the term neuragia is still used
today, for compensation purposes, VA evaluates nerves affected by
neuralgia by the sensory impairment caused by neuralgia, not the
diagnosis itself. To that end, and as discussed in more detail below,
VA proposes to remove neuritis as a separate ratable condition for both
cranial nerves (DC series 8300) and peripheral nerves (DC series 8600)
and neuralgia as a separate ratable condition for both cranial nerves
(DC series 8400) and peripheral nerves (DC series 8700). VA will
address evaluations for motor neuropathy and sensory neuropathy in
revised Sec. 4.123, as discussed below.
The underlying purpose behind the Sec. 4.123 revision is to
provide a central location for instructions specific to cranial and
peripheral nerve conditions. This revision will promote rating
[[Page 88918]]
quality and consistency. First, VA proposes to retitle the section as
``Cranial and peripheral nerve impairment.'' Next, VA proposes
informational language explaining, generally, how disabilities from
cranial and peripheral nerve impairment are evaluated. After that, VA
proposes to describe how disability from motor neuropathy (complete and
incomplete paralysis) will be evaluated. Finally, VA proposes to
describe how disability from sensory neuropathy will be evaluated.
Concerning the general instructions described in the revised Sec.
4.123, VA proposes to relocate to this section several instructions
that are currently located in multiple areas. The current VASRD
contains an instruction directly above diagnostic code 8205; this
instruction explains that disability from lesions of peripheral
portions of first, second, third, fourth, sixth, and eighth nerves are
rated under the Organs of Special Sense. Additionally, it explains that
the ratings for the cranial nerves are for unilateral involvement; when
bilateral, combine but without the bilateral factor. VA proposes to
revise these two sentences, add an additional sentence, and include
them in Sec. 4.123. Specifically, proposed Sec. 4.123(a)(3) explains
that a cranial nerve will be evaluated strictly as a cranial nerve,
regardless of any portions which lie outside the cranium (skull). This
is consistent with current medical practice which considers cranial
nerves outside of the cranium as separate and distinct from other
peripheral nerves. Proposed Sec. 4.123(a)(3) further explains that the
evaluations in the rating schedule for the cranial nerves are for
unilateral involvement; when bilateral involvement occurs, evaluate
separately, then combine under Sec. 4.25 without using the bilateral
factor. While all cranial nerves begin inside the cranium, most exit
the cranium to insert at various destinations, where they function in a
manner similar to peripheral nerves. Nevertheless, VA proposes to
evaluate the entire nerve, uniformly, as a cranial nerve. Proposed
Sec. 4.123(a)(2) explains that disability from impairments of the
first, second, third, fourth, sixth, and eighth cranial nerves will be
rated under the Organs of Special Sense. Additionally, the current
VASRD contains an instruction directly above diagnostic code 8510; this
instruction states, in part, that ratings for the peripheral nerves are
for unilateral involvement; when bilateral, combine with application of
the bilateral factor. VA will add a reference to evaluate bilateral
disabilities separately, then combine using Sec. 4.25 whenever
bilateral involvement occurs; this will specify, as opposed to merely
imply, how bilateral disabilities are to be evaluated. Additionally, VA
will move the instruction to Sec. 4.123(a)(4) because it is a general
instruction since it applies to both motor and sensory impairment.
Section 4.120 currently includes a sentence explaining that when rating
peripheral nerve injuries and their residuals, attention should be
given to the site and character of the injury, the relative impairment
in motor function, trophic changes, or sensory disturbances. VA
proposes the following changes to this sentence: clarify that the
sentence applies to cranial and peripheral nerves; remove the reference
to trophic changes, which do not consistently correlate to disability;
replace the reference to motor function with a reference to movement or
muscle strength, corresponding with the proposed evaluation criteria
for cranial and peripheral motor nerve function, respectively; and
relocate the sentence to Sec. 4.123(a)(1). The purpose of these
changes is to remedy confusion and inconsistent application of the
instructions caused by the current placement of instructions in
multiple locations. Therefore, VA proposes to combine them into a
centralized location.
Motor nerve impairment affects muscle function (typically by
decreased muscle strength), which can have a significant impact on
movement activities, including, but not limited to, walking and
grasping. Therefore, VA proposes to focus the complete and incomplete
paralysis sections of each cranial and peripheral nerve on motor nerve
impairment.
Concerning incomplete paralysis of cranial motor nerves, VA
proposes to evaluate disability by replacing the current ``severe''
with ``[a]ttempted movement with inability to complete such movement
(muscle twitching present).'' Additionally, VA proposes to revise the
cranial evaluation criteria for ``moderate'' incomplete paralysis with
``[m]uscle movement intact, but task performed with difficulty.'' The
proposed revisions replace subjective criteria with objective and
measurable criteria, which will promote rating consistency and
accuracy.
Regarding cranial nerve notes, in the current VASRD, each cranial
nerve criteria set contains a note describing functions of that
particular nerve. These notes are currently placed after the
``paralysis, incomplete'' diagnostic code section of the individual
nerve. VA proposes to update the notes to provide more detailed
examples of affected nerve functions and move them, placing them below
the evaluation criteria of each individual cranial nerve. VA proposes
this change because each note applies to both sensory and motor
impairment of the particular cranial nerve.
Concerning peripheral motor nerves, VA proposes to evaluate
disability by replacing the current rating criteria, which refer to
complete and incomplete paralysis at the severe, moderate, and mild
incomplete paralysis level, with criteria that align with the Medical
Research Council (MRC) Scale for Muscle Strength (this is also commonly
referred to as manual muscle testing). This scale is universally known
and used throughout the medical community to evaluate peripheral
nerves. ``How to Assess Muscle Strength,'' Merck Manual, <a href="https://www.merckmanuals.com/professional/neurologic-disorders/neurologic-examination/how-to-assess-muscle-strength?query=Medical">https://www.merckmanuals.com/professional/neurologic-disorders/neurologic-examination/how-to-assess-muscle-strength?query=Medical</a>, (last reviewed
February 2018). The MRC grades muscle strength on a range from ``0''
(completely paralyzed) to ``5'' (normal muscle function). ``To
distinguish among the various degrees of muscle strength within a given
level, this scale has been modified with the addition of intermediate
levels (e.g., 4+ and 4-).'' Frontera, W.R. ``Delisa's Physical Medicine
& Rehabilitation: Principles and Practice,'' 5th Edition, p 74 (2010).
Instead of ``mild,'' VA will use Grade 4 muscle strength. This
represents measurable muscle weakness. Instead of ``moderate,'' VA will
use Grade 3 muscle strength. This represents muscle strength that can
oppose gravity, but cannot oppose resistance greater than gravity.
Instead of ``moderately severe,'' VA will use Grade 2+ muscle strength.
This represents muscle strength that is unable to oppose gravity
completely, though muscle strength with gravity eliminated is present.
That is, muscle strength that is greater than Grade 2, but less than
Grade 3. Only the sciatic nerve has a ``moderately severe'' category.
Instead of ``severe,'' VA will use Grade 2 muscle strength. This
represents muscle strength that, though present, cannot oppose gravity
at all. Complete paralysis will be identified as Grade 0 muscle
strength (no muscle contraction or complete paralysis) or Grade 1
muscle strength (meaning a flicker or trace of contraction). Id. The
proposed revisions replace subjective criteria with objective and
measurable criteria, which will promote rating consistency and
accuracy.
Regarding peripheral nerve instructions, in the current VASRD,
there is a three-sentence instruction
[[Page 88919]]
directly above DC 8510; this instruction explains, in part, that
incomplete paralysis with peripheral nerve injuries indicates a degree
of impaired function substantially less than the type picture for
complete paralysis, whether due to varied level of the nerve lesion or
to partial regeneration. VA proposes to leave this sentence intact with
two aesthetic revisions. These revisions involve changing ``picture''
to ``pictured'' and ``level'' to ``levels.'' VA believes these
revisions will enable the verbiage to flow more smoothly without
changing the meaning. The third sentence will remain intact, with the
addition of a reference to Sec. 4.25 in the third sentence, as
discussed above. Both sentences will be moved to this instructional
section. The remaining sentence will be removed, as it refers to
sensory nerve evaluation criteria that VA is proposing to revise. The
purpose of these changes is to remedy confusion and inconsistent
application of the instructions caused by the current placement of
instructions in multiple locations. Therefore, VA proposes to combine
them into the most appropriate location.
Currently, each peripheral nerve includes a description in the
entry for complete paralysis. For example, the entry for complete
paralysis for DC 8510 for the upper radicular group (fifth and sixth
cervicals) contains a description of all shoulder and elbow movements
lost or severely affected, hand and wrist movements not affected. VA
proposes to remove all peripheral nerve descriptions. Since VA is
changing the subjective criteria to objective criteria and examiners
are aware of the muscles affected by each nerve, VA believes the
descriptions are no longer needed.
Concerning sensory neuropathy, sensory nerve impairment affects the
ability to notice sensations, to include but not limited to, sharpness,
heat, or coldness, and it can also produce abnormal spontaneous
sensations, to include but not limited to, burning, tingling, and pain
(pins and needles). Therefore, VA proposes to focus the sensory
neuropathy sections of each nerve on sensory nerve impairment and
remove neuritis and neuralgia as separate ratable conditions. Having
separate diagnostic codes for neuritis and neuralgia requires VA to
change the diagnostic code a veteran is rated under when the impairment
associated with the condition changes, which creates additional work
and complexity with no benefit to the veteran or VA. VA proposes to
remove the diagnostic codes for neuritis and neuralgia, retitle the
diagnostic codes addressing paralysis, and address motor and sensory
impairment as criteria under the retitled diagnostic codes.
Additionally, in light of the removal of DCs 8619 and 8719, VA proposes
to number the notes that will appear under DC 8519.
In the current VASRD, the instructions under Sec. 4.124,
Neuralgia, cranial or peripheral, consist of three sentences. The first
two sentences provide information regarding symptoms associated with
neuralgia and instructions regarding the maximum evaluations for
neuralgia. The last sentence provides rating instructions for tic
douloureux. VA proposes to address sensory impairments in a new
section, Sec. 4.123(c). Instead of defining neuralgia, Sec.
4.123(c)(1) will address altered sensation, with or without pain, on
the basis of incomplete or complete sensory neuropathy. VA proposes to
delete the last sentence of Sec. 4.124, which addresses tic
douloureux, because it is redundant. A note under the entry for the
fifth (trigeminal) cranial nerve provides instructions on how to
evaluate tic douloureux.
The current evaluation criteria focus on neuritis, neuralgia, and
degrees of paralysis, with a maximum rating for neuritis equal to
severe, incomplete, paralysis of the nerve involved, and a maximum
rating for neuralgia equal to moderate incomplete paralysis. There is
also an instruction at the beginning of the schedule of ratings for
diseases of the peripheral nerves indicating that the rating should be
for the mild, or at most, the moderate degree when the involvement is
wholly sensory. Certain cranial and all peripheral nerves are evaluated
using neuritis, neuralgia, and degrees of paralysis, regardless if the
nerve has only sensory function, only muscle function, or both sensory
function and muscle function (found in mixed nerves). There are several
problems with the current approach. While both neuritis and neuralgia
involve distorted sensation, the disability associated with these
distorted sensations cannot be quantified by objective diagnostic
testing and is unpredictable. Furthermore, the evaluation criteria for
pure sensory nerves are the same as for pure motor nerves and mixed
nerves, which is incorrect from a medical science perspective. For
example, the external cutaneous nerve of the thigh and the obturator
nerve have the same evaluation criteria (varying degrees of paralysis,
which currently form the basis for rating neuritis and neuralgia), even
though it is scientifically incorrect to evaluate a pure sensory nerve,
such as the external cutaneous nerve of the thigh, for paralysis. It is
this difficulty with measurement, unpredictability, and inappropriate
application of certain evaluation criteria that VA seeks to remedy with
the following proposed changes.
VA proposes to change the sensory evaluation criteria to a more
easily measured sensory deprivation standard. Impairment of sensory
function will be quantified as either incomplete or complete sensory
deprivation. This simplifies the evaluation criteria and is much more
easily measured during physical examination. These criteria will be
applied to certain cranial nerves as well as all peripheral nerves.
Muscle function in certain cranial nerves and all peripheral nerves
will be evaluated in isolation using the previously discussed methods.
Using the incomplete/complete characterization of sensory
deprivation described above, VA proposes to use a more straightforward
description for disability when sensory neuropathy is involved. VA will
consider sensory neuropathy as incomplete when sensation is impaired,
although not absent, or when unpleasant sensations are experienced by
the nerve such as dysesthesia, numbness, or paresthesia. Dysesthesia
refers to any unpleasant sensation produced by a stimulus that is
normally painless. Numbness refers to a sense of heaviness, weakness,
or deadness in part of the body. Paresthesia refers to abnormal
spontaneous sensations such as burning, tingling, pins and needles,
etc. Clinical Neurology, 11th Edition, 2021, Chapter 10: Sensory
Disorders. editors Greenberg, D.A., Aminoff, M.J., and Simon, R.P.
VA will consider sensory neuropathy complete when sensation is
absent. In cranial nerves, which have compensable evaluations at the
moderate evaluation level, VA will assign an evaluation at the moderate
evaluation level if there is incomplete or complete sensory neuropathy.
However, this will not be applied to the eleventh cranial nerve, also
known as the spinal accessory nerve, because it only has a muscle
function. For peripheral nerves, which mostly have compensable
evaluations at the mild evaluation level, VA will assign an evaluation
similar to the mild evaluation if there is incomplete sensory
neuropathy. VA will assign an evaluation similar to the moderate
evaluation if there is complete sensory neuropathy. Where the
evaluation of a peripheral nerve remains the same whether it is at the
mild or moderate evaluation level (DCs 8525, 8527, 8528, 8529, and
8530), VA will assign an evaluation at the moderate evaluation if there
is incomplete or complete sensory neuropathy.
[[Page 88920]]
II. Schedule of Ratings--Neurological Conditions and Convulsive
Disorders
A. Location of Section
Currently, the schedule of ratings for the Neurological body system
is located in 38 CFR 4.124a. When the 1945 VA Schedule for Rating
Disabilities was originally published in title 38 of the Code of
Federal Regulations in 1964, VA organized it such that specific body
systems started at specific locations. The Musculoskeletal body system,
for example, began in Sec. 4.40 even though the preceding section was
Sec. 4.31, leaving sections Sec. Sec. 4.32 through 4.39 without
content. See 29 FR 6718, 6722 (May 22, 1964). VA also designed the
Rating Schedule so that the Mental Disorders body system started with
Sec. 4.125; however, due to the number of sections necessary to
establish the Neurological body system, which precedes the Mental
Disorders body system, the schedule of ratings for neurological
conditions and convulsive disorders was placed in Sec. 4.124a. See 29
FR 6718, 6749-53 (May 22, 1964). As proposed above, disability
previously addressed in Sec. 4.124 will now be addressed in the
revision of Sec. 4.123, which makes Sec. 4.124 available. Therefore,
VA also proposes to relocate the Schedule of Ratings from Sec. 4.124a
to Sec. 4.124 and remove Sec. 4.124a. VA proposes corresponding
revisions to the references to Sec. 4.124a in 38 CFR 3.809(d) and 38
CFR 4.71a, DC 5244.
B. Organic Diseases of the Central Nervous System
Currently, the introductory instruction under Sec. 4.124a provides
guidance concerning how to evaluate residuals of organic diseases of
the central nervous system. There is a note currently located under DC
8025, Myasthenia gravis, which also provides guidance concerning how to
evaluate residuals of organic diseases of the central nervous system.
VA proposes to consolidate both notes, revising them and relocating
them to Sec. 4.120. VA further proposes to specify the diagnostic
codes to which the instructions apply in order to promote consistent
application of the VASRD.
First, VA proposes to clarify when ascertainable residuals are
required. For diagnostic codes 8000-8036, there are 2 categories of
diagnostic codes that consider minimum evaluations: unconditional and
conditional minimums. Unconditional minimum diagnostic codes are 8002,
8004, 8007, 8010, 8018, 8021, 8023, 8024, and 8025. The aforementioned
diagnostic codes do not require ascertainable residuals for a minimum
evaluation, and will not require ascertainable residuals in this
proposed regulation.
For DCs 8004 and 8007, which have unconditional minimums within the
proposed General Rating Formula, VA proposes Note (1) to direct the
rater to grant a minimum evaluation of 30 percent for Parkinson's
disease (8004), regardless of examination findings. VA proposes Note
(2) to direct the rater to grant a minimum evaluation of 10 percent for
stroke residuals (8007), regardless of examination findings. No minimum
evaluations will be available for DCs 8026, 8027, and 8028.
Conditional minimum DCs 8000, 8003, 8011, 8012, 8019, 8020, 8022,
and new 8036 all require ascertainable residuals. Examples of
ascertainable residuals to be considered include, but are not limited
to, psychotic manifestations, loss of use of an extremity (partial or
complete), as well as abnormal speech, vision, gait, or coordination.
Finally, in the portion of the instruction addressing determinations as
to the presence of residuals not capable of objective verification, VA
proposes to specify that such determinations must be approached on the
basis of disability related to the diagnosis recorded, rather than
simply the diagnosis recorded, as the current instruction provides. The
revised language is more consistent with 38 CFR 4.1, which provides
that the rating schedule is primarily a guide in the evaluation of
disability resulting from diseases and injuries encountered as a result
of or incident to military service.
In regard to peripheral nerves and paralysis, VA proposes to
replace the reference to mild, moderate, severe, or complete paralysis
of peripheral nerves with a reference to complete or incomplete
paralysis to account for changes in the way paralysis of peripheral
nerves will be evaluated as referenced above.
With respect to ratings in excess of the prescribed minimum
ratings, VA proposes to replace the current language directing raters
to cite the diagnostic codes utilized as bases of evaluation in
addition to the codes identifying the diagnoses with a reference to
Sec. 4.27, as that section includes instructions for the use of
diagnostic code numbers when a disease is rated on the basis of
residual conditions.
C. Diagnostic Code 8000, Encephalitis, Infectious
Current DC 8000 is titled ``Encephalitis, epidemic, chronic.'' The
use of the term ``epidemic'' was used to describe an outbreak of
encephalitis lethargica from 1918 to 1930. Dr. R.R. Dourmashkin, ``What
Caused the 1918-1930 Epidemic of Encephalitis Lethargica?,'' 90 Journal
of the Royal Society of Medicine 515, 515-520 (1997). Since that
outbreak, a recurrence of the epidemic has not been reported.
``Encephalitis Lethargica Information Page,'' National Institute of
Health--National Institute of Neurological Disorders and Stroke,
<a href="https://www.ninds.nih.gov/health-information/disorders/encephalitis">https://www.ninds.nih.gov/health-information/disorders/encephalitis</a>
(last visited September 18, 2024). Given the infrequency with which
this specific type of encephalitis occurs, VA proposes to rename DC
8000 as ``Encephalitis, infectious'' to better reflect the disabilities
currently evaluated under this DC.
As a broader disease category, infectious encephalitis refers to an
irritation and swelling of the brain caused by viral, bacterial,
fungal, or parasitic infection. Symptoms of this disease can be quite
severe and include loss of consciousness, seizures, paralysis, and
sudden change in mental functions. The residuals of infectious
encephalitis vary from full recovery to permanent disabilities and, in
some cases, death. ``Encephalitis,'' National Institute of Health--U.S.
National Library of Medicine (Aug. 31, 2016), <a href="https://medlineplus.gov/ency/article/001415.htm">https://medlineplus.gov/ency/article/001415.htm</a> (last visited April 3, 2018). No changes to the
evaluation criteria are proposed.
D. Diagnostic Code 8002, Brain, New Growth of, Malignant and Diagnostic
Code 8003, Brain, New Growth of, Benign
Current DC 8002 is titled ``Malignant,'' and current DC 8003 is
titled ``Benign, minimum.'' VA proposes changes to these diagnostic
codes to correct current poor formatting. Both are intended to be read
in conjunction with the general category of ``Brain, new growth of.''
To clarify the conditions covered under these DCs, VA proposes to
rename these disabilities as DC 8002, ``Brain, new growth of,
malignant,'' and DC 8003, ``Brain, new growth of, benign.''
Current DC 8002 also contains a note that is located between the
100 percent and the 30 percent evaluation levels. Previously, this
diagnostic code had a 100 percent evaluation level and its note
contained information regarding the 30 percent minimum rating. See 43
FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have
placed the note between the 100 percent and the 30 percent evaluation
levels. Notes are typically found after evaluative criteria. Therefore,
VA proposes to relocate this note after the 30 percent evaluation
[[Page 88921]]
level and to revise it to ensure that rating personnel understand how
it applies to the both the 100 percent and 30 percent evaluation
levels.
Current DC 8003 provides a minimum evaluation of 60 percent in the
presence of a benign growth of the brain and then directs raters to
evaluate based upon residuals, with a minimum evaluation of 10 percent.
VA proposes to clarify the 60 percent evaluation by indicating that it
applies during the presence of an active benign growth of the brain or
during active treatment. By adding this additional information to the
60 percent evaluation criteria, VA will promote consistency of
evaluations and avoid premature re-evaluation of the disability prior
to successful treatment of the benign growth. VA proposes no other
changes to these diagnostic codes.
E. Diagnostic Code 8004, Parkinson's Disease (Paralysis Agitans)
Current DC 8004 is titled ``Paralysis agitans,'' which is Latin for
shaking palsy. While these terms are accurate descriptors of the
disability, the more commonly used and accepted medical terminology is
Parkinson's disease (PD). To clarify the disability evaluated under
this diagnostic code as well as to make the VASRD more user-friendly to
non-medical personnel, VA proposes to rename this diagnostic code
``Parkinson's disease.'' VA proposes to preserve the historical
reference in parentheses.
VA also proposes to adopt evaluation criteria that reflect a modern
understanding of this condition within a proposed general rating
formula (GRF). VA proposes the creation of a GRF for certain movement
disorders within the neurological body system due to the similarities
of disabling effects and high frequency of misdiagnosis. By
implementing a GRF, the rating process will be standardized as well as
simplified based on disability presentation for a group of conditions.
Additionally, the use of a GRF for these movement disorders will ensure
the avoidance of pyramiding when more than one movement disorder is
service connected. Pyramiding occurs when two or more evaluation
percentages are awarded for the same disability under various
diagnoses. In accordance with 38 CFR 4.14, pyramiding must be avoided.
When two or more movement disorders are service-connected, unless none
of the symptomatology of a movement disorder is duplicative of or
overlapping with the symptomatology of another movement disorder, one
evaluation percentage will be awarded based on the highest level of
disability represented by the rating criteria that more nearly
approximates the disability picture attributable to the service-
connected movement disorders. 38 CFR 4.7. VA proposes to title the GRF
``General Rating Formula for Specified Neurologic Conditions (DCs 8004,
8007, 8026, 8027, and 8028)''. VA proposes 0, 10, 30, 60, and 100
percent evaluations to the newly proposed GRF, and it will be placed
immediately below DC 8004. Lastly, specific to PD, VA proposes to
continue the minimum 30 percent evaluation for a formal diagnosis of
PD, as explained in the first note following the proposed GRF.
Recent advances in the understanding of PD have produced several
assessment scales that describe discrete levels of increasing
disability. The Revised Unified Parkinson's Disease Rating Scale (2008)
is a sophisticated, complex scale widely used by clinicians. The level
of sophistication and specificity, however, is not required to describe
occupationally significant disability. The Hoehn-Yahr Parkinson's
Disease scale, which has been in use since 1967, is far simpler to use
and apply. VA proposes to base the disability criteria on this scale
with direct reference to Hoehn-Yahr stages and descriptions of
functional limitation associated with that severity of disease. VA
recognizes that this scale was specifically developed for PD. However,
other movement disorder evaluation tools are similar to Hoehn-Yahr.
Thus, it was determined this was a reliable tool to adapt to multiple
movement disorders. Parkinson's Resource Organization, The Five Stages
of Parkinson's Disease, <a href="http://www.parkinsonsresource.org/wp-content/uploads/2012/01/The-FIVE-Stages-of-Parkinsons-Disease.pdf">http://www.parkinsonsresource.org/wp-content/uploads/2012/01/The-FIVE-Stages-of-Parkinsons-Disease.pdf</a>, May 2002. In
addition, where appropriate, VA considered and incorporated features of
other movement disorder scales. Those additions are noted under the
specific movement disorder discussions below. The GRF will list the
evaluation criteria first, followed by several notes.
The first note will direct raters to evaluate all cases of PD with
a minimum rating of 30 percent. A second note is specific to stroke
residuals rated under DC 8007 and directs raters to evaluate stroke
residuals with a minimum rating of 10 percent. A third note defines
activities of daily living. A fourth note instructs the rater how to
evaluate symptoms versus separate and distinct diagnoses. For example,
when an impairment such as depression is noted as a symptom versus a
formal diagnosis, then it will be evaluated using the GRF for Specified
Neurologic Conditions. Conversely, if there is a formal diagnosis, then
the disorder will be evaluated separately under Sec. 4.130 (Schedule
of ratings--mental disorders). These instructions mirror the current
instructions related to the Residuals of Traumatic Brain Injury. The
fifth note addresses overlap of manifestations. It instructs rating
specialists to evaluate comorbid conditions together when they cannot
be delineated. These instructions also mirror the current instructions
related to the Residuals of Traumatic Brain Injury. The sixth note
reminds raters to consider special monthly compensation.
VA proposes the rating criteria under the GRF to consist of the
following. A 100 percent evaluation will be given for ``Hoehn-Yahr
stage 4 or stage 5, or; the inability to live independently because of
neurologically-related disability.'' A 60 percent evaluation will be
given for ``Impairment of mobility (e.g., transfers, balance, or gait)
requiring daily use of an assistive device such as a wheelchair,
brace(s), crutch(es), cane(s), or walker.'' A 30 percent evaluation
will be given for ``Hoehn-Yahr stage 3, or; impairment of mobility
(e.g., transfers, balance, or gait) requiring less than daily use of an
assistive device such as a wheelchair, brace(s), crutch(es), cane(s),
or walker.'' A 10 percent evaluation will be given for ``Hoehn-Yahr
stage 2, or; impairment in at least one of the following areas: facial
expression (e.g., masking, blinking, or eye motion abnormalities);
speech (e.g., soft voice, slurring, difficulty speaking or swallowing);
posture (e.g., stooping, instability); mobility not requiring an
assistive device (e.g., decreased speed with transfers, gait ataxia,
unstable balance); problems initiating or controlling motor movements
(e.g., stiffness, tremors); cognitive (e.g., memory or executive
problems); mental (e.g., anxiety, depression, social phobia); sensory
abnormalities (e.g., olfactory deficits); involuntary muscle
contractions resulting in pain and impairment, such as but not limited
to, spontaneous neck turning or writing difficulty.'' A 0 percent
evaluation will be given for ``Hoehn-Yahr stage 1, or; formal diagnosis
without impairment.''
F. Diagnostic Code 8007, Stroke (Ischemic, Hemorrhagic, or Thrombotic),
Including Cerebral Infarction or Cerebrovascular Accident (Brain,
Vessels, Embolism, Thrombosis, and Hemorrhage); Diagnostic Code 8008
Brain, Vessels, Thrombosis of (Delete); Diagnostic Code 8009 Brain,
Vessels, Hemorrhage From (Delete)
VA proposes to combine three DCs (8007, Brain, vessels, embolism
of; 8008, Brain, vessels, thrombosis of; and 8009, Brain, vessels,
hemorrhage from) under
[[Page 88922]]
DC 8007 and rename it as ``Stroke (ischemic, hemorrhagic, or
thrombotic), including cerebral infarction or cerebrovascular accident
(Brain, vessels, embolism, thrombosis, and hemorrhage).'' Since most
clinicians document the condition as ``stroke'' rather than embolism,
thrombosis, or hemorrhage, raters are unable to distinguish which title
most accurately aligns with ``stroke,'' which means there is a risk
that rating specialists will not consistently apply these DCs. For
example, three raters evaluate three veterans diagnosed with residuals
of a stroke. One rater chooses to use DC 8007; another uses DC 8008;
and the other uses DC 8009. All three disabilities currently have the
same evaluation criteria. Therefore, the veterans are not at a
disadvantage from receiving one DC over the other. However, for
statistical purposes, combining these three DCs would promote
consistency in future research associated with stroke residuals.
Because all three of the current diagnostic codes evaluate stroke
residuals in the same way, VA proposes to combine them in order to
create diagnostic code application consistency. Additionally, while the
distinction concerning the type of stroke is a medical necessity for
treatment purposes, it is irrelevant for rating purposes. This proposed
update will create more consistent data tracking for disability
compensation research purposes.
Currently, rating personnel grant a 100 percent evaluation for the
first six months, then assign a minimum rating of 10 percent for stroke
residuals, unless an evaluation of residuals under separate body
systems results in a higher evaluation. Under the proposed changes,
whenever diagnostic imaging, which is part of standard care for a
stroke, identifies a stroke, rating personnel will continue to grant a
100 percent evaluation for the first six months; they will also
continue to assign a minimum 10 percent for stroke residuals regardless
of examination findings. Rating personnel will assign evaluations
higher than the minimum in accordance with the General Rating Formula
for Specified Neurologic Conditions (GRF). As explained in the fourth
note of the GRF, if a residual is a symptom of the stroke, it will be
evaluated as such. Contrarily, if a residual has a separate and
distinct formal diagnosis, it will be service connected and evaluated
separately. For example, if depression is noted as a symptom, it will
be evaluated as part of the minimum 10 percent evaluation. However, if
depression is a separate and distinct formal diagnosis, it will be
service connected on a secondary basis and evaluated under Sec. 4.130
(Schedule of ratings--mental disorders). See DC 8004 for details about
the GRF.
G. Diagnostic Code 8018, Multiple Sclerosis and Other Demyelinating
Diseases of the Central Nervous System
VA proposes to revise the title for this diagnostic code. The new
title will be Multiple sclerosis (MS) and other demyelinating diseases
of the Central Nervous System. The underlying basis for this revision
is the existence of two conditions which present with disabilities
similar to MS. VA proposes to evaluate neuromyelitis optica spectrum
disorder (NMOSD) under this DC. Previously, NMOSD was rated analogously
with DC 8010, Myelitis. Myelin oligodendrocyte glycoprotein antibody--
associated disease (MOGAD) is the other condition to be captured with
this DC. Like NMOSD, MOGAD also presents with a similar disability
picture to MS. Wu, H. and Fisher, K., Current Diagnosis & Treatment
Pediatric Neurology, Chapter 35. 2023.
H. Diagnostic Code 8021, Spinal Cord, New Growths of, Malignant and
Diagnostic Code 8022, Spinal Cord, New Growths of, Benign
Current DC 8021 is titled ``Malignant,'' and current DC 8022 is
titled ``Benign.'' VA proposes changes to these DCs to correct current
poor formatting. Both were intended to be read in conjunction with the
general category ``Spinal cord, new growths of.'' For the same reasons
set forth above in the discussion for DC 8002, VA proposes to rename DC
8021 ``Spinal cord, new growths of, malignant,'' and DC 8022 ``Spinal
cord, new growths of, benign.'' VA also proposes to clarify the 60
percent evaluation criteria for DC 8022 for the same reasons set forth
in the discussion for DC 8003.
Additionally, current DC 8021 also contains a note that is located
between the 100 percent and the 30 percent evaluation levels.
Previously, this DC had a 100 percent evaluation level and its note
contained information regarding the 30 percent minimum rating. See 43
FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have
placed the note between the 100 percent and the 30 percent evaluation
levels. Notes are typically found after evaluative criteria. Therefore,
VA proposes to relocate this note after the 30 percent evaluation level
and to revise it to ensure that rating personnel understand how it
applies to the both the 100 percent and 30 percent evaluation levels.
VA proposes no other changes to these DCs.
I. Diagnostic Code 8025, Myasthenia Gravis
VA proposes to relocate and modify the note currently located
directly below the rating criteria of DC 8025. It will be relocated to
the introductory instruction under Sec. 4.124. Refer to the above
section, ``B. Organic diseases of the central nervous system,'' and
Sec. 4.124 for further details concerning this instruction.
J. New Diagnostic Code 8026, Parkinson's Plus, or Secondary
Parkinsonism Syndromes
VA proposes to add a new DC 8026, titled ``Parkinson's plus, or
secondary parkinsonism syndromes,'' in order to account for impairment
due to this condition in the veteran population. Parkinson's plus
syndromes cause similar symptoms and impairment to Parkinson's disease,
but have other features that make them different. Parkinson's plus
syndromes have several causes, which include but are not limited to
different location of protein buildup, brain injury, encephalitis,
meningitis, stroke, medications, and chemical poisonings. Parkinson's
plus syndromes can cause impairment in facial expressions, problems
with initiating or controlling motor movements, paralysis, vocal
impairment, stiffness, and tremor. Treatment for Parkinson's plus
syndromes, as well as the likelihood and extent of residual disability,
depends on the underlying cause of the disorder. This is in contrast to
primary Parkinson's, or Parkinson's disease, where there is a
predictable progression. For this reason, Parkinson's plus syndrome
will not have a minimum evaluation. ``Secondary Parkinsonism,''
National Institute of Health--U.S. National Library of Medicine (Jan.
19, 2018), <a href="https://medlineplus.gov/ency/article/000759.htm">https://medlineplus.gov/ency/article/000759.htm</a> (last
visited April 3, 2018). VA is proposing a specific diagnostic code for
Parkinson's plus syndromes to allow for proper tracking of Parkinson's
plus and Parkinson's disease in the veteran population. Parkinson's
plus will be evaluated under the General Rating Formula for Specified
Neurologic Conditions (GRF). See DC 8004 for details about the GRF.
K. New Diagnostic Code 8027, Essential Tremor
VA proposes to add a new DC 8027, titled ``Essential tremor,'' in
order to account for impairment due to this condition. There is
currently no standalone diagnostic code to account
[[Page 88923]]
for essential tremor, forcing rating personnel to rely on analogous
coding and leading to inconsistent evaluations.
``Tremor is defined as a rhythmical, involuntary, oscillatory
movement of a body part and is one of the most frequent movement
disorders.'' Teive, H.A.G., ``Essential Tremor: phenotypes,'' (18) S1,
pp 140-142, 140, Parkinsonism and Related Disorders (2012). ``Essential
tremor (ET) is one of the most common neurological diseases and the
[most common] cause of pathological tremor.'' Id. ``Historically[,] ET
was defined as a benign entity.'' Id. However, recently it ``was
suggested that it is time to remove the `benign' from the ET label, as
it has been shown to be progressive in nature and quite disabling for
most patients.'' Id. ``In the last [several] years[,] ET has evolved
into two different meanings.'' Id. First, ``the classical ET, as a
monosymptomatic disorder, and second, a heterogeneous disorder, the
Essential Tremors, or a family of diseases.'' Id. Currently, ``ET can
be classified with both motor and non-motor elements. Tremor may occur
also in the legs, feet, trunk, jaw, chin, tongue, and voice. Although
postural and kinetic tremors are the main features of ET, intentional
tremor and tremor at rest may also occur in some patients. Other motor
features described in patients with ET are gait ataxia, postural
instability[,] and eye-motion abnormalities. Non-motor features include
cognitive (memory and executive problems and dementia), psychiatric
(anxiety, depression[,] and social phobia), and sensory abnormalities
(olfactory deficits [and] hearing loss).'' Id.
In developing evaluation criteria for ET, one of the most
significant challenges is little, if any, outcomes research that would
assist in criteria development. However, there are two well-recognized
tools VA used to research this condition. The first tool is the
International Classification of Functioning, Disability, and Health
(2001), published by the World Health Organization, that provided
terminology and definitions. According to this resource, ET involves
the dysfunction of specific elements within the central nervous system.
The tremors with ET are the impairments resulting from that nervous
system dysfunction. Those tremors cause activity limitations and
participation restrictions that can lead to earnings loss. The second
tool is the 6th Edition Guides to the Evaluation of Permanent
Impairment (2008), published by the American Medical Association. The
guide has impairment tables for the upper extremities, gait, and
station. These tools were considered in the creation of a general
rating formula.
Another significant challenge in developing evaluation criteria for
ET is the high rate of misdiagnosis with other movement disorders, such
as dystonia and Parkinson's disease. Misdiagnosis occurs in up to 50
percent of cases, with Parkinson's disease (particularly in elderly
patients) and dystonia (tremulous cervical dystonia) being the most
common disorders mistaken for ET. Therefore, VA proposes the creation
and use of a General Rating Formula for Specified Neurologic Conditions
(GRF) for this and other movement disorders, allowing evaluation to
focus on the symptoms and impairment present, even when misdiagnosis
and/or a change in diagnosis occurs. See diagnostic code 8004 for
details about the GRF. Teive, H.A.G., ``Essential Tremor: phenotypes,''
(18) S1, pp 140-142, Parkinsonism and Related Disorders (2012).
L. New Diagnostic Code 8028, Dystonia
VA proposes to add a new DC 8028, titled ``Dystonia,'' in order to
account for impairment due to this condition. There is currently no
standalone diagnostic code to account for dystonia, forcing rating
personnel to rely on analogous coding and leading to inconsistent
evaluations.
Dystonia causes involuntary muscle contractions that lead to slow,
repetitive, and sometimes painful movement or abnormal posture.
Dystonia can affect only one muscle, groups of muscles (torticollis),
or muscles throughout the entire body. The specific symptoms and
impairment experienced depend highly on the type of dystonia and the
muscles affected, but can include difficulty walking, involuntary neck
turning, difficulty speaking, writing, and uncontrollable blinking.
Some cases of dystonia only affect a muscle group when performing a
specific action. ``Dystonias Fact Sheet,'' National Institute of
Health--National Institute of Neurological Disorders and Stroke (June
3, 2014), <a href="https://www.ninds.nih.gov/health-information/disorders/tremor#toc-where-can-i-find-more-information-about-tremor-">https://www.ninds.nih.gov/health-information/disorders/tremor#toc-where-can-i-find-more-information-about-tremor-</a> (last
visited September 18, 2024).
The Dystonia Study Group composed of renowned international
movement disorder experts developed the unified dystonia rating scale
and the global dystonia rating scale to serve as instruments to
medically assess dystonia severity. ``Rating Scales for Dystonia: A
Multicenter Assessment,'' Comella C et al., 2003 Movement Disorders 18
No.3 pp 303-12. These scales were considered during the creation of the
general rating formula. Due to similarity and overlap of symptoms with
other movement disorders, along with the high prevalence of
misdiagnosis, VA proposes application of a General Rating Formula for
Specified Neurologic Conditions (GRF). See DC 8004 for details about
the GRF.
M. New Diagnostic Code 8036, Primary Lateral Sclerosis
VA proposes to add a new DC 8036, titled ``Primary lateral
sclerosis,'' in order to account for impairment due to this condition.
There is currently no standalone diagnostic code to account for primary
lateral sclerosis (PLS). A standalone diagnostic code will permit more
accurate tracking of this condition, and its associated disability.
PLS is a motor neuron disease that affects the upper motor neurons
in the arms, legs, and face. Individuals with PLS first experience loss
of muscle control in the feet and legs, then the disease progresses up
the trunk and into the arms, hands, and the muscles that control
speech, swallowing, and chewing. PLS can be differentiated from
amyotrophic lateral sclerosis in that it only affects the upper motor
neurons and progresses gradually. While there is no cure for PLS, it is
not considered a fatal disease, and many individuals maintain the
ability to walk without assistance, although they may eventually need a
cane or walker due to the development of high degrees of spasticity.
Due to the wide range of symptoms and severity upon confirmation of
diagnosis, VA proposes to evaluate PLS according to the residual
impairment under the appropriate diagnostic code with a minimum rating
of 10 percent when there are ascertainable residuals. See R.
Ramanathan, et al., ``Demographics and clinical characteristics of
primary lateral sclerosis: case series and a review of literature,''
Neurodegener. Dis. Manag., vol 8(1), pp 17-23. 2018.
N. Diagnostic Code 8103, Hemifacial Spasm (Tic, Convulsive)
Current DC 8103 is titled ``Tic, convulsive,'' a facial nerve
disorder that causes involuntary spasms and contractions of the facial
nerves. For consistency, clarity, and ease of use of the VASRD by non-
medical personnel, VA proposes to rename this diagnostic code
``Hemifacial spasm.'' Hemifacial spasm, an alternative name for
convulsive tic, provides a much more explicit indication as to the
condition to be evaluated under this diagnostic code
[[Page 88924]]
in terms of the anatomical location to be considered. VA proposes to
preserve the historical reference to the nomenclature in parentheses.
VA proposes no other changes to this diagnostic code.
O. Diagnostic Code 8104, Paramyoclonus Multiplex (Convulsive State,
Myoclonic Type)
The current evaluation criteria for DC 8104, Paramyoclonus
multiplex (convulsive state, myoclonic type), directs rating personnel
to rate this condition as convulsive tic, which is DC 8103. As
discussed above, VA is updating this term to hemifacial spasm in order
to reflect current medical terminology. As such, VA proposes to replace
``tic; convulsive'' in the evaluation criteria of DC 8104 to maintain
consistency throughout this portion of the VASRD. VA proposes no other
changes to this DC.
P. Diagnostic Code 8107, Athetosis, Acquired
Current DC 8107, Athetosis, acquired, directs rating personnel to
evaluate this condition as chorea. To clarify these instructions and
promote consistency in evaluations, VA proposes to specify that this
condition should be evaluated as Sydenham's chorea, matching the title
of the DC that provides the appropriate evaluation criteria. VA
proposes no other changes to this DC.
Q. Title Changes to Certain Peripheral Nerves
To reflect current medical terminology, VA proposes to update the
names of the following peripheral nerves. The proposed titles are the
current accepted nomenclature to describe these nerves. VA proposes to
preserve the historical reference to the nomenclature in parentheses.
------------------------------------------------------------------------
Current title for Proposed title for
Diagnostic code nerve nerve
------------------------------------------------------------------------
8514........................ Musculospiral nerve Radial nerve
(radial nerve). (musculospiral).\1\
8518........................ Circumflex nerve.... Axillary nerve
(circumflex).\2\
8521........................ External popliteal Common peroneal
nerve (common nerve (external
peroneal). popliteal).\3\
8522........................ Musculocutaneous Superficial peroneal
nerve (superficial nerve
peroneal). (musculocutaneous).
\1\
8523........................ Anterior tibial Deep peroneal nerve
nerve (deep (anterior
peroneal). tibial).\1\
8524........................ Internal popliteal Tibial nerve
nerve (tibial). (internal
popliteal).\4\
8526........................ Anterior crural Femoral nerve
nerve (femoral). (anterior
crural).\5\
8527........................ Internal saphenous Saphenous nerve
nerve. (internal
saphenous).\1\
8529........................ External cutaneous Lateral cutaneous
nerve of thigh. nerve of the thigh
(external
cutaneous).\5\
------------------------------------------------------------------------
\1\ ``Dorland's Illustrated Medical Dictionary,'' 1123 (Douglas M.
Anderson et al. eds., 27th ed. 1988).
\2\ Wolf, J., ``Segmental Neurology'', page 20, 1981.
\3\ ``Common Peroneal Nerve Dysfunction,'' National Institute of Health--
U.S. National Library of Medicine (Aug. 7, 2017), <a href="https://medlineplus.gov/ency/article/000791.htm">https://medlineplus.gov/ency/article/000791.htm</a> (last visited April 3, 2018).
\4\ ``Dorland's Illustrated Medical Dictionary,'' 1124 (Douglas M.
Anderson et al. eds., 27th ed. 1988).
\5\ ``Dorland's Illustrated Medical Dictionary,'' 1120 (Douglas M.
Anderson et al. eds., 27th ed. 1988).
R. Diagnostic Code 8514, Paralysis of the Musculospiral (Radial) Nerve
Current DC 8514 addresses motor impairment from diseases affecting
the musculospiral nerve. The current evaluation criteria include a note
that references dissociation of extensor communis digitorum and
paralysis below the extensor communis digitorum, as well as instructing
evaluations of these findings should not exceed a moderate rating. As
stated previously, this nerve will be retitled as the radial nerve.
Additionally, the note will be revised, as the evaluation criteria will
be revised to employ the grade of muscle strength as the means to
distinguish evaluation levels, with the maximum evaluation level
corresponding to Grade 3 muscle strength for dissociation of extensor
communis digitorum and paralysis below the extensor communis digitorum.
S. Diagnostic Code 8520, Paralysis of the Sciatic Nerve
Current DC 8520 addresses motor impairment due to diseases of the
sciatic nerve. The nerve referenced by this diagnostic code stimulates
the muscles of the entire lower extremity. While all other peripheral
nerve criteria consist of mild, moderate, and severe, this one includes
an extra category labeled moderately severe. In order to preserve the
current evaluation levels and account for this extra category, VA
proposes to revise the incomplete paralysis criteria at the 60 percent,
40 percent, 20 percent, and 10 percent levels. A 60 percent evaluation
will be granted for muscles that have grade 2 strength (previously
labeled severe). A 40 percent evaluation will be granted for muscles
that have grade 2+ strength (previously labeled moderately severe). A
20 percent evaluation will be granted for muscles that have grade 3
strength (previously labeled moderate). A 10 percent evaluation will be
granted for muscles that have grade 4 strength (previously labeled
mild). Refer to the discussion above regarding Sec. 4.123 for further
details concerning the grading scale for motor impairment.
T. Diagnostic Code 8527, Sensory Neuropathy of the Internal Saphenous
Nerve
Current DC 8527 addresses paralysis of the internal saphenous
nerve. Paralysis refers to the lack of muscle function in muscle
fibers. Posterior roots of the spinal nerves, including the saphenous
nerve, do not have motor fibers, making it a pure sensory nerve. M. De
Maeseneer, et al., ``Normal Anatomy and Compression Areas of Nerves of
the Foot and Ankle: US and MR Imaging With Anatomic Correlation,''
Radiographics, vol 35, 1474-1475, 1469-1482 (2015). As a purely sensory
nerve, the saphenous nerve has no muscle involvement and therefore
using paralysis to describe impairment of this nerve is medically
inaccurate. VA proposes to retitle DC 8527 to improve medical accuracy,
and motor neuropathy will not be included in the criteria for this
nerve. Because this nerve currently has a compensable rating only at
the severe to complete paralysis level and sensory neuropathy, wholly
sensory evaluations, will only be rated up to the moderate level, this
nerve will no longer have a compensable rating.
U. Diagnostic Code 8529, Sensory Neuropathy of the External Cutaneous
Nerve of the Thigh
Current DC 8529 addresses paralysis of the external cutaneous nerve
of the thigh. Current medical terminology refers to this nerve as the
lateral cutaneous nerve of the thigh, or LCNT. This nerve is part of
the lumbar plexus. ``It functions primarily as a sensory nerve and its
composition varies among individuals with several different
[[Page 88925]]
combinations of lumbar nerves that originate from L1 to L3. The LCNT
then emerges at the lateral border of the psoas major, crosses the
iliacus, to the anterior superior iliac spine. The nerve then passes
under the inguinal ligament and over the sartorius muscle and enters
the thigh as it divides into an anterior and posterior branch.''
Cheatham, S., et al. ``Meralgia Paresthetica: A Review of the
Literature,'' International Journal of Sports Physical Therapy, 8(6):
884, December 2013. Paralysis refers to the lack of muscle function in
muscle fibers. This nerve lacks motor fibers. As a purely sensory
nerve, it has no muscle involvement and therefore using paralysis to
describe impairment of this nerve is medically inaccurate. VA proposes
to retitle DC 8529 to improve medical accuracy, and motor neuropathy
will not be included in the criteria for this nerve. Because this nerve
currently has a compensable rating only at the severe to complete
paralysis level and sensory neuropathy, wholly sensory evaluations,
will only be rated up to the moderate level, this nerve will no longer
have a compensable rating.
V. Diagnostic Code 8540, Soft Tissue Sarcoma of Neurogenic Origin
VA proposes to place a section subheading, ``Other Neoplasms of the
Neurological System,'' just above this diagnostic code as a separator
between diagnostic codes for peripheral nerves and other neoplasms of
the neurological system. No other changes are proposed for this DC.
W. Diagnostic Code 8910, Epilepsy, Grand Mal (Including Tonic-Clonic
Seizures)
Current DC 8910 is titled ``Epilepsy, grand mal.'' VA proposes to
update the title of this code to indicate that this includes tonic-
clonic seizures. Tonic-clonic seizures involve the entire body, and the
terminology is synonymous with grand mal seizures. ``Generalized tonic-
clonic seizure,'' National Institute of Health--U.S. National Library
of Medicine (September 3, 2019), <a href="https://medlineplus.gov/ency/article/000695.htm">https://medlineplus.gov/ency/article/000695.htm</a> (last visited September 10, 2019). VA proposes no other
changes to this DC.
X. Diagnostic Code 8911, Epilepsy, Petit Mal (Including Absence
Seizures)
Current DC 8911 is titled ``Epilepsy, petit mal.'' VA proposes to
update the title of this code to indicate that this includes absence
seizures. Absence seizures typically last only a few seconds and may
involve staring episodes, also called absence spells. Absence seizure
is used synonymously with petit mal seizures. ``Absence Seizure,''
National Institute of Health--U.S. National Library of Medicine
(September 3, 2019), <a href="http://www.nlm.nih.gov/medlineplus/ency/article/000696.htm">http://www.nlm.nih.gov/medlineplus/ency/article/000696.htm</a> (last visited September 10, 2019). VA proposes no other
changes to this DC.
Y. Non-Substantial Changes to Relocated 38 CFR 4.124a
VA will also make some non-substantial changes to relocated 38 CFR
4.124a. In 2008, DC 8045, Residuals of traumatic brain injury (TBI),
was revised to include a table titled ``Evaluation of Cognitive
Impairment and Other Residuals of TBI Not Otherwise Classified.'' See
73 FR 54693, 54705-54708 (September 23, 2008). This table was added
after the table titled ``Organic Diseases of the Central Nervous
System.'' This had the effect of placing DC 8046, Cerebral
arteriosclerosis, between the evaluation criteria of DC 8045, Residuals
of traumatic brain injury, and the newly added table for TBI residuals.
To improve readability and ease of use for both DCs 8045 and 8046, VA
proposes to relocate the table titled ``Evaluation of Cognitive
Impairment and Other Residuals of TBI Not Otherwise Classified''
directly below the evaluation criteria for DC 8045.
Z. Military Occupational Blast Exposure
VA is currently in the process of investigating the potential
neurological residuals of repeated exposure to low-level military
occupational blasts or Military Occupational Blast Exposure. VA invites
public comment on this subject.
Executive Orders 12866, 13563 and 14094
Executive Order 12866 (Regulatory Planning and Review) directs
agencies to assess the costs and benefits of available regulatory
alternatives and, when regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, and other advantages;
distributive impacts; and equity). Executive Order 13563 (Improving
Regulation and Regulatory Review) emphasizes the importance of
quantifying both costs and benefits, reducing costs, harmonizing rules,
and promoting flexibility. Executive Order 14094 (Executive Order on
Modernizing Regulatory Review) supplements and reaffirms the
principles, structures, and definitions governing contemporary
regulatory review established in Executive Order 12866 of September 30,
1993 (Regulatory Planning and Review), and Executive Order 13563 of
January 18, 2011 (Improving Regulation and Regulatory Review). The
Office of Information and Regulatory Affairs has determined that this
rulemaking is a significant regulatory action under Executive Order
12866, Section 3(f)(1), as amended by Executive Order 14094. The
Regulatory Impact Analysis associated with this rulemaking can be found
as a supporting document at <a href="http://www.regulations.gov">www.regulations.gov</a>.
Regulatory Flexibility Act
The Secretary hereby certifies that this proposed rule would not
have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act (5
U.S.C. 601-612).
The factual basis for this certification is based on the fact that
no small entities or businesses determine the rating criteria revisions
or assign evaluations for disability claims. Therefore, pursuant to 5
U.S.C. 605(b), the initial and final regulatory flexibility analysis
requirements of 5 U.S.C. 603 and 604 do not apply.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in the expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any one year. This proposed rule would have no such
effect on State, local, and tribal governments, or on the private
sector.
Paperwork Reduction Act (PRA)
This proposed rule contains no provisions constituting a collection
of information under the Paperwork Reduction Act of 1995 (44 U.S.C.
3501-3521).
Assistance Listing
The Assistance Listing numbers and titles for the programs affected
by this document are 64.102, Compensation for Service-Connected Deaths
for Veterans' Dependents; 64.105, Pension to Veterans, Surviving
Spouses, and Children; 64.109, Veterans Compensation for Service-
Connected Disability; and 64.110, Veterans Dependency and Indemnity
Compensation for Service-Connected Death.
[[Page 88926]]
List of Subjects
38 CFR Part 3
Administrative practice and procedure, Claims, Disability benefits.
38 CFR Part 4
Disability benefits, Pensions, Veterans.
Signing Authority
Denis McDonough, Secretary of Veterans Affairs, approved and signed
this document on October 29, 2024, and authorized the undersigned to
sign and submit the document to the Office of the Federal Register for
publication electronically as an official document of the Department of
Veterans Affairs.
Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy &
Management, Office of General Counsel, Department of Veterans Affairs.
For the reasons stated in the preamble, VA proposes to amend 38 CFR
parts 3 and 4 as set forth below:
PART 3--ADJUDICATION
Subpart A--Pension, Compensation, and Dependency and Indemnity
Compensation
0
1. The authority citation for part 3 continues to read as follows:
Authority: 38 U.S.C. 501(a), unless otherwise noted.
0
2. Amend Sec. 3.809 by revising paragraph (d) to read as follows:
Sec. 3.809 Specially adapted housing under 38 U.S.C.
2101(a)(2)(A)(i).
* * * * *
(d) Amyotrophic lateral sclerosis. VA considers Sec. 3.809(b)
satisfied if the veteran or member of the Armed Forces serving on
active duty has service-connected amyotrophic lateral sclerosis rated
100 percent disabling under 38 CFR 4.124, diagnostic code 8017.
* * * * *
PART 4--SCHEDULE FOR RATING DISABILITIES
Subpart B--Disability Ratings
0
3. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
0
4. In Sec. 4.71a, amend the table The Spine by revising the entry for
diagnostic code 5244 under General Rating Formula for Diseases and
Injuries of the Spine to read as follows:
Sec. 4.71a Schedule of ratings--musculoskeletal system.
* * * * *
The Spine
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
General Rating Formula for Diseases and
Injuries of the Spine
* * * * * * *
5244 Traumatic paralysis, complete:
Paraplegia: Rate under diagnostic code
5110.
Quadriplegia: Rate separately under
diagnostic codes 5109 and 5110 and
combine evaluations in accordance with
Sec. 4.25.
Note: If traumatic paralysis does not
cause loss of use of both hands or both
feet, it is incomplete paralysis.
Evaluate residuals of incomplete
traumatic paralysis under the appropriate
diagnostic code (e.g., Sec. 4.124,
Diseases of the Peripheral Nerves).
* * * * * * *
------------------------------------------------------------------------
0
5. Revise Sec. 4.120 to read as follows:
Sec. 4.120 Minimum evaluations for organic diseases of the central
nervous system.
(a) Necessity of residuals for minimum evaluations. The minimum
evaluations for diagnostic codes 8002, 8004, 8007, 8010, 8018, 8021,
8023, 8024, and 8025 do not require ascertainable residuals. However,
ascertainable residuals are required to provide the minimum evaluation
for diagnostic codes 8000, 8003, 8011, 8012, 8019, 8020, 8022, and
8036.
(b) Definition. Ascertainable residuals include, but are not
limited to, psychotic manifestations, complete or partial loss of use
of one or more extremities, speech disturbances, impairment of vision,
disturbances of gait, tremors, visceral manifestations, etc., referring
to the appropriate bodily system of the schedule. With partial loss of
use of one or more extremities from neurological lesions, rate by
comparison with complete or incomplete paralysis of peripheral nerves.
Determinations as to the presence of subjective residuals not capable
of objective verification, e.g., headaches, dizziness, fatigability,
must be approached on the basis of disability related to the diagnosis
recorded. VA will only accept subjective residuals when they are
consistent with the disease and not more likely attributable to another
disease or no disease.
(c) Ratings in excess of the minimum evaluation. When one or more
compensable evaluations assigned for the residuals of the diagnostic
codes noted in this section meet or exceed the minimum evaluation for
that diagnostic code, then the minimum evaluation for that diagnostic
code is no longer applicable. When a rating in excess of the prescribed
minimum rating is assigned based on the presence of ascertainable
residuals, the diagnostic codes associated with the evaluation of those
residuals must be cited in accordance with Sec. 4.27.
0
6. Revise Sec. 4.123 to read as follows:
Sec. 4.123 Cranial and peripheral nerve impairment.
(a) General. (1) In rating cranial and peripheral nerve injuries
and their residuals, attention should be given to the site and
character of the injury, the relative impairment in movement or muscle
strength, and sensory disturbances.
(2) Disability from impairments of the first, second, third,
fourth, sixth, and eighth cranial nerves will be rated under the Organs
of Special Sense.
(3) A cranial nerve will be evaluated strictly as a cranial nerve,
regardless of any portions which lie outside the cranium (skull). The
evaluations in the rating schedule for the cranial nerves are for
unilateral involvement; when bilateral, evaluate separately, then
[[Page 88927]]
combine using Sec. 4.25 but without application of the bilateral
factor.
(4) The evaluations in the rating schedule for the peripheral
nerves are for unilateral involvement; when bilateral, evaluate
separately, then combine using Sec. 4.25 with application of the
bilateral factor.
(b) Motor neuropathy (complete and incomplete paralysis).
(1) General. The evaluation criteria for impairment to muscle
function, with or without pain, of both cranial and peripheral nerves
will be categorized as either complete paralysis or incomplete
paralysis.
(2) Cranial nerves. Complete paralysis for cranial nerves is
characterized by the complete inability to move. Incomplete paralysis
is characterized as either movement with difficulty, or attempted
movement with inability to complete such movement (muscle twitching
present).
(3) Peripheral nerves. VA will evaluate peripheral nerve motor
neuropathy using the Medical Research Council (MRC) Scale for Muscle
Strength (commonly referred to as manual muscle testing). Complete
paralysis for peripheral nerves will be identified as Grade 0 or Grade
1 muscle strength (no movement for Grade 0 and a flicker or trace of
contraction for Grade 1). Incomplete paralysis will be determined by
the following muscle strength grades: Grade 2 (only able to move if
gravity is eliminated; unable to move at all against gravity), Grade
2+, which only applies to DC 8520 Sciatic nerve, (muscle strength,
which, though present, can only partially move against gravity), Grade
3 (only able to move against gravity; unable to move against
resistance), or Grade 4 (weakness is present, but able to move against
resistance and gravity). If muscle strength falls in between grades
(Grade + or -) for peripheral nerves other than Grade 2+ for DC 8520,
then evaluate as follows: (1). for a-grade, reduce the grade by one
integer (e.g., Grade 3- shall be evaluated as Grade 2), and (2.) for a
+ grade, maintain the current grade (e.g., a Grade 3+ shall be
evaluated as Grade 3). The term ``incomplete paralysis,'' with this and
other peripheral nerve injuries, indicates a degree of lost or impaired
function substantially less than the type pictured for complete
paralysis given with each nerve, whether due to varied levels of the
nerve lesion or to partial regeneration.
(4) Mixed nerves. When mixed nerves within a single diagnostic code
are involved, an evaluation for both motor and sensory neuropathy is
not permitted. The evaluation should be based on motor neuropathy with
or without sensory neuropathy involvement.
(c) Sensory neuropathy (complete and incomplete).
(1) General. Impairments, with or without pain, to the sensory
function of the cranial and peripheral nerves may be categorized as
either incomplete or complete sensory neuropathy.
(2) Complete sensory neuropathy. Complete sensory neuropathy is
characterized by the complete absence of sensation in an affected
nerve.
(3) Incomplete sensory neuropathy. Incomplete sensory neuropathy
involves sensation that is impaired, but not absent, or unpleasant
sensations experienced by the nerve such as dysesthesia, numbness, or
paresthesia. Dysesthesia refers to any unpleasant sensation produced by
a stimulus that is normally painless. Numbness refers to a sense of
heaviness, weakness, or deadness in part of the body. Paresthesia
refers to abnormal spontaneous sensations such as burning, tingling,
pins and needles, etc. VA will only accept subjective sensations when
they are consistent with the disease and not more likely attributable
to another disease or no disease.
Sec. 4.124 [Removed]
0
7. Remove Sec. 4.124.
Sec. 4.124a [Redesignated as Sec. 4.124]
0
8. Redesignate Sec. 4.124a as Sec. 4.124.
0
9. Revise and republish newly redesignated Sec. 4.124 to read as
follows:
Sec. 4.124 Schedule of ratings--Neurological conditions and
convulsive disorders.
Organic Diseases of the Central Nervous System
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Guidance for rating organic diseases of the central
nervous system is located under Sec. 4.120.
8000 Encephalitis, infectious:
As active febrile disease........................... 100
Rate residuals, minimum............................. 10
8002 Brain, new growth of, malignant.................... 100
Minimum rating...................................... 30
Note: The 100 percent evaluation will be continued for 2
years following cessation of surgical, chemotherapeutic
or other treatment modality. At this point, if the
residuals have stabilized, the rating will be made on
neurological residuals according to symptomatology or
the minimum rating, whichever results in a higher
evaluation.
8003 Brain, new growth of, benign:
Minimum during active disease or during a treatment 60
phase..............................................
Rate residuals, minimum............................. 10
General Rating Formula for Specified Neurologic
Conditions (DCs 8004, 8007, 8026, 8027, and 8028):
Hoehn-Yahr stage 4 or stage 5, or; the inability to 100
live independently because of neurologically-
related disability.................................
Impairment of mobility (e.g., transfers, balance, or 60
gait) requiring daily use of an assistive device
such as a wheelchair, brace(s), crutch(es),
cane(s), or walker.................................
Hoehn-Yahr stage 3, or; impairment of mobility 30
(e.g., transfers, balance, or gait) requiring less
than daily use of an assistive device such as a
wheelchair, brace(s), crutch(es), cane(s), or
walker.............................................
Hoehn-Yahr stage 2, or; impairment in at least one 10
of the following areas:............................
<bullet> facial expression (e.g., masking,
blinking, or eye motion abnormalities);
<bullet> speech (e.g., soft voice, slurring,
difficulty speaking or swallowing);
<bullet> posture (e.g., stooping, instability);
<bullet> mobility not requiring an assistive
device (e.g., decreased speed with transfers,
gait ataxia, unstable balance);
<bullet> problems initiating or controlling
motor movements (e.g., stiffness, tremors);
<bullet> cognitive (e.g., memory or executive
problems);
<bullet> mental (e.g., anxiety, depression,
social phobia);
<bullet> sensory abnormalities (e.g., olfactory
deficits);
<bullet> involuntary muscle contractions
resulting in pain and impairment, such as but
not limited to, spontaneous neck turning or
writing difficulty
Hoehn-Yahr stage 1, or; formal diagnosis without 0
impairment.........................................
[[Page 88928]]
Note (1): Regardless of examination findings, the
minimum rating for Parkinson's disease (DC 8004) shall
be 30 percent.
Note (2): Regardless of examination findings, the
minimum rating for stroke residuals (DC 8007) shall be
10 percent.
Note (3): Activities of daily living (ADLs) refers to
basic self-care and includes bathing or showering,
dressing, eating, getting in or out of bed or a chair,
and using the toilet.
Note (4): Evaluate any residual under the appropriate
body system when there is a formal diagnosis of a
condition. When there is no formal diagnosis, evaluate
the residual under the General Rating Formula for
Specified Neurologic Conditions. For example, evaluate
emotional dysfunction under Sec. 4.130 (Schedule of
ratings--mental disorders) when there is a diagnosis of
a mental disorder. When there is no diagnosis of a
mental disorder, evaluate emotional symptoms under the
General Rating Formula for Specified Neurologic
Conditions.
Note (5): There may be an overlap of manifestations of
conditions evaluated under the General Rating Formula
for Specified Neurologic Conditions with manifestations
of a comorbid mental or neurologic or other physical
disorder that can be separately evaluated under another
diagnostic code. In such cases, do not assign more than
one evaluation based on the same manifestations. If the
manifestations of two or more conditions cannot be
clearly separated, assign a single evaluation under
whichever set of diagnostic criteria allows the better
assessment of overall impaired functioning due to both
conditions. However, if the manifestations are clearly
separable, assign a separate evaluation for each
condition.
Note (6): Consider the need for special monthly
compensation.
Note (7): When evaluating a neurological condition under
the General Rating Formula for Specified Neurological
Conditions based on subjective symptoms and not a Hoehn-
Yahr stage, a medical opinion finding that the
subjectively reported symptom(s) is consistent with the
claimed disease and not another disease or no disease
is required.
8004 Parkinson's disease (paralysis agitans):
Rate under the General Rating Formula for Specified
Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
and 8028)..........................................
8005 Bulbar palsy....................................... 100
8007 Stroke (ischemic, hemorrhagic, or thrombotic),
including cerebral infarction or cerebrovascular
accident (Brain, vessels, embolism, thrombosis, and
hemorrhage):
During and for six months following a stroke, 100
documented by diagnostic imaging...................
Thereafter, rate under the General Rating Formula
for Specified Neurologic Conditions (DCs 8004,
8007, 8026, 8027, and 8028).
8010 Myelitis:
Minimum rating...................................... 10
8011 Poliomyelitis, anterior:
As active febrile disease........................... 100
Rate residuals, minimum............................. 10
8012 Hematomyelia:
For 6 months........................................ 100
Rate residuals, minimum............................. 10
8013 Syphilis, cerebrospinal.
8014 Syphilis, meningovascular.
8015 Tabes dorsalis.
Note: Rate upon the severity of convulsions,
paralysis, visual impairment or psychotic
involvement, etc.
8017 Amyotrophic lateral sclerosis...................... 100
Note: Consider the need for special monthly
compensation.
8018 Multiple sclerosis and and other demyelinating
diseases of the central nervous system:
Minimum rating...................................... 30
8019 Meningitis, cerebrospinal, epidemic:
As active febrile disease........................... 100
Rate residuals, minimum............................. 10
8020 Brain, abscess of:
As active disease................................... 100
Rate residuals, minimum............................. 10
8021 Spinal cord, new growths of, malignant............. 100
Minimum rating...................................... 30
Note: The 100 percent evaluation will be continued for 2
years following cessation of surgical, chemotherapeutic
or other treatment modality. At this point, if the
residuals have stabilized, the rating will be made on
neurological residuals according to symptomatology or
the minimum rating, whichever results in a higher
evaluation.
8022 Spinal cord, new growths of, benign:
Minimum during active disease or during a treatment 60
phase..............................................
Rate residuals, minimum............................. 10
8023 Progressive muscular atrophy:
Minimum rating...................................... 30
8024 Syringomyelia:
Minimum rating...................................... 30
8025 Myasthenia gravis:
Minimum rating...................................... 30
8026 Parkinson's plus, or secondary parkinsonism
syndromes.
Rate under the General Rating Formula for Specified
Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
and 8028)..........................................
8027 Essential tremor.
Rate under the General Rating Formula for Specified
Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
and 8028)..........................................
8028 Dystonia.
Rate under the General Rating Formula for Specified
Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
and 8028)..........................................
8036 Primary lateral sclerosis:
Rate residuals, minimum............................. 10
8045 Residuals of traumatic brain injury (TBI):
[[Page 88929]]
There are three main areas of dysfunction that may
result from TBI and have profound effects on
functioning: cognitive (which is common in varying
degrees after TBI), emotional/behavioral, and
physical. Each of these areas of dysfunction may
require evaluation.
Cognitive impairment is defined as decreased memory,
concentration, attention, and executive functions
of the brain. Executive functions are goal setting,
speed of information processing, planning,
organizing, prioritizing, self-monitoring, problem
solving, judgment, decision making, spontaneity,
and flexibility in changing actions when they are
not productive. Not all of these brain functions
may be affected in a given individual with
cognitive impairment, and some functions may be
affected more severely than others. In a given
individual, symptoms may fluctuate in severity from
day to day. Evaluate cognitive impairment under the
table titled ``Evaluation of Cognitive Impairment
and Other Residuals of TBI Not Otherwise
Classified.''
Subjective symptoms may be the only residual of TBI
or may be associated with cognitive impairment or
other areas of dysfunction. Evaluate subjective
symptoms that are residuals of TBI, whether or not
they are part of cognitive impairment, under the
subjective symptoms facet in the table titled
``Evaluation of Cognitive Impairment and Other
Residuals of TBI Not Otherwise Classified.''
However, separately evaluate any residual with a
distinct diagnosis that may be evaluated under
another diagnostic code, such as migraine headache
or Meniere's disease, even if that diagnosis is
based on subjective symptoms, rather than under the
``Evaluation of Cognitive Impairment and Other
Residuals of TBI Not Otherwise Classified'' table.
Evaluate emotional/behavioral dysfunction under Sec.
4.130 (Schedule of ratings--mental disorders)
when there is a diagnosis of a mental disorder.
When there is no diagnosis of a mental disorder,
evaluate emotional/behavioral symptoms under the
criteria in the table titled ``Evaluation of
Cognitive Impairment and Other Residuals of TBI Not
Otherwise Classified.''
Evaluate physical (including neurological)
dysfunction based on the following list, under an
appropriate diagnostic code: Motor and sensory
dysfunction, including pain, of the extremities and
face; visual impairment; hearing loss and tinnitus;
loss of sense of smell and taste; seizures; gait,
coordination, and balance problems; speech and
other communication difficulties, including aphasia
and related disorders, and dysarthria; neurogenic
bladder; neurogenic bowel; cranial nerve
dysfunctions; autonomic nerve dysfunctions; and
endocrine dysfunctions.
The preceding list of types of physical dysfunction
does not encompass all possible residuals of TBI.
For residuals not listed here that are reported on
an examination, evaluate under the most appropriate
diagnostic code. Evaluate each condition
separately, as long as the same signs and symptoms
are not used to support more than one evaluation,
and combine under Sec. 4.25 the evaluations for
each separately rated condition. The evaluation
assigned based on the ``Evaluation of Cognitive
Impairment and Other Residuals of TBI Not Otherwise
Classified'' table will be considered the
evaluation for a single condition for purposes of
combining with other disability evaluations.
Consider the need for special monthly compensation
for such problems as loss of use of an extremity,
certain sensory impairments, erectile dysfunction,
the need for aid and attendance (including for
protection from hazards or dangers incident to the
daily environment due to cognitive impairment),
being housebound, etc.
------------------------------------------------------------------------
Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified
----------------------------------------------------------------------------------------------------------------
Facets of cognitive impairment and other Level of
residuals of TBI not otherwise classified impairment Criteria
----------------------------------------------------------------------------------------------------------------
Memory, attention, concentration, executive 0 No complaints of impairment of memory, attention,
functions. concentration, or executive functions.
1 A complaint of mild loss of memory (such as
having difficulty following a conversation,
recalling recent conversations, remembering
names of new acquaintances, or finding words, or
often misplacing items), attention,
concentration, or executive functions, but
without objective evidence on testing.
2 Objective evidence on testing of mild impairment
of memory, attention, concentration, or
executive functions resulting in mild functional
impairment.
3 Objective evidence on testing of moderate
impairment of memory, attention, concentration,
or executive functions resulting in moderate
functional impairment.
Total Objective evidence on testing of severe
impairment of memory, attention, concentration,
or executive functions resulting in severe
functional impairment.
Judgment........................................ 0 Normal.
1 Mildly impaired judgment. For complex or
unfamiliar decisions, occasionally unable to
identify, understand, and weigh the
alternatives, understand the consequences of
choices, and make a reasonable decision.
2 Moderately impaired judgment. For complex or
unfamiliar decisions, usually unable to
identify, understand, and weigh the
alternatives, understand the consequences of
choices, and make a reasonable decision,
although has little difficulty with simple
decisions.
3 Moderately severely impaired judgment. For even
routine and familiar decisions, occasionally
unable to identify, understand, and weigh the
alternatives, understand the consequences of
choices, and make a reasonable decision.
Total Severely impaired judgment. For even routine and
familiar decisions, usually unable to identify,
understand, and weigh the alternatives,
understand the consequences of choices, and make
a reasonable decision. For example, unable to
determine appropriate clothing for current
weather conditions or judge when to avoid
dangerous situations or activities.
Social interaction.............................. 0 Social interaction is routinely appropriate.
1 Social interaction is occasionally inappropriate.
2 Social interaction is frequently inappropriate.
3 Social interaction is inappropriate most or all
of the time.
[[Page 88930]]
Orientation..................................... 0 Always oriented to person, time, place, and
situation.
1 Occasionally disoriented to one of the four
aspects (person, time, place, situation) of
orientation.
2 Occasionally disoriented to two of the four
aspects (person, time, place, situation) of
orientation or often disoriented to one aspect
of orientation.
3 Often disoriented to two or more of the four
aspects (person, time, place, situation) of
orientation.
Total Consistently disoriented to two or more of the
four aspects (person, time, place, situation) of
orientation.
Motor activity (with intact motor and sensory 0 Motor activity normal.
system).
1 Motor activity normal most of the time, but
mildly slowed at times due to apraxia (inability
to perform previously learned motor activities,
despite normal motor function).
2 Motor activity mildly decreased or with moderate
slowing due to apraxia.
3 Motor activity moderately decreased due to
apraxia.
Total Motor activity severely decreased due to apraxia.
Visual spatial orientation...................... 0 Normal.
1 Mildly impaired. Occasionally gets lost in
unfamiliar surroundings, has difficulty reading
maps or following directions. Is able to use
assistive devices such as GPS (global
positioning system).
2 Moderately impaired. Usually gets lost in
unfamiliar surroundings, has difficulty reading
maps, following directions, and judging
distance. Has difficulty using assistive devices
such as GPS (global positioning system).
3 Moderately severely impaired. Gets lost even in
familiar surroundings, unable to use assistive
devices such as GPS (global positioning system).
Total Severely impaired. May be unable to touch or name
own body parts when asked by the examiner,
identify the relative position in space of two
different objects, or find the way from one room
to another in a familiar environment.
Subjective symptoms............................. 0 Subjective symptoms that do not interfere with
work; instrumental activities of daily living;
or work, family, or other close relationships.
Examples are: mild or occasional headaches, mild
anxiety.
1 Three or more subjective symptoms that mildly
interfere with work; instrumental activities of
daily living; or work, family, or other close
relationships. Examples of findings that might
be seen at this level of impairment are:
intermittent dizziness, daily mild to moderate
headaches, tinnitus, frequent insomnia,
hypersensitivity to sound, hypersensitivity to
light.
2 Three or more subjective symptoms that moderately
interfere with work; instrumental activities of
daily living; or work, family, or other close
relationships. Examples of findings that might
be seen at this level of impairment are: marked
fatigability, blurred or double vision,
headaches requiring rest periods during most
days.
Neurobehavioral effects......................... 0 One or more neurobehavioral effects that do not
interfere with workplace interaction or social
interaction. Examples of neurobehavioral effects
are: Irritability, impulsivity,
unpredictability, lack of motivation, verbal
aggression, physical aggression, belligerence,
apathy, lack of empathy, moodiness, lack of
cooperation, inflexibility, and impaired
awareness of disability. Any of these effects
may range from slight to severe, although verbal
and physical aggression are likely to have a
more serious impact on workplace interaction and
social interaction than some of the other
effects.
1 One or more neurobehavioral effects that
occasionally interfere with workplace
interaction, social interaction, or both but do
not preclude them.
2 One or more neurobehavioral effects that
frequently interfere with workplace interaction,
social interaction, or both but do not preclude
them.
3 One or more neurobehavioral effects that
interfere with or preclude workplace
interaction, social interaction, or both on most
days or that occasionally require supervision
for safety of self or others.
Communication................................... 0 Able to communicate by spoken and written
language (expressive communication), and to
comprehend spoken and written language.
1 Comprehension or expression, or both, of either
spoken language or written language is only
occasionally impaired. Can communicate complex
ideas.
2 Inability to communicate either by spoken
language, written language, or both, more than
occasionally but less than half of the time, or
to comprehend spoken language, written language,
or both, more than occasionally but less than
half of the time. Can generally communicate
complex ideas.
3 Inability to communicate either by spoken
language, written language, or both, at least
half of the time but not all of the time, or to
comprehend spoken language, written language, or
both, at least half of the time but not all of
the time. May rely on gestures or other
alternative modes of communication. Able to
communicate basic needs.
Total Complete inability to communicate either by
spoken language, written language, or both, or
to comprehend spoken language, written language,
or both. Unable to communicate basic needs.
[[Page 88931]]
Consciousness................................... Total Persistently altered state of consciousness, such
as vegetative state, minimally responsive state,
coma.
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
8046 Cerebral arteriosclerosis:
Purely neurological disabilities, such as
hemiplegia, cranial nerve paralysis, etc., due to
cerebral arteriosclerosis will be rated under the
diagnostic codes dealing with such specific
disabilities, with citation of a hyphenated
diagnostic code (e.g., 8046-8207).
Purely subjective complaints such as headache,
dizziness, tinnitus, insomnia and irritability,
recognized as symptomatic of a properly diagnosed
cerebral arteriosclerosis, will be rated 10 percent
and no more under diagnostic code 9305. This 10
percent rating will not be combined with any other
rating for a disability due to cerebral or
generalized arteriosclerosis. Ratings in excess of
10 percent for cerebral arteriosclerosis under
diagnostic code 9305 are not assignable in the
absence of a diagnosis of multi-infarct dementia
with cerebral arteriosclerosis.
Note: The ratings under code 8046 apply only when the
diagnosis of cerebral arteriosclerosis is substantiated
by the entire clinical picture and not solely on
findings of retinal arteriosclerosis.
------------------------------------------------------------------------
Miscellaneous Diseases
------------------------------------------------------------------------
8100 Migraine:
With very frequent completely prostrating and 50
prolonged attacks productive of severe economic
inadaptability.....................................
With characteristic prostrating attacks occurring on 30
an average once a month over last several months...
With characteristic prostrating attacks averaging 10
one in 2 months over last several months...........
With less frequent attacks.......................... 0
8103 Hemifacial spasm (tic, convulsive):
Severe.............................................. 30
Moderate............................................ 10
Mild................................................ 0
Note: Depending upon frequency, severity, muscle groups
involved.
8104 Paramyoclonus multiplex (convulsive state,
myoclonic type):
Rate as hemifacial spasm; severe cases.............. 60
8105 Chorea, Sydenham's:
Pronounced, progressive grave types................. 100
Severe.............................................. 80
Moderately severe................................... 50
Moderate............................................ 30
Mild................................................ 10
Note: Consider rheumatic etiology and complications.
8106 Chorea, Huntington's.
Rate as Sydenham's chorea. This, though a familial
disease, has its onset in late adult life, and is
considered a ratable disability.
8107 Athetosis, acquired.
Rate as Sydenham's chorea.
8108 Narcolepsy.
Rate as for epilepsy, petit mal.
------------------------------------------------------------------------
Diseases of the Cranial Nerves
------------------------------------------------------------------------
Guidance for rating cranial nerves is located under Sec.
4.123.
Fifth (trigeminal) cranial nerve
8205 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 50
Incomplete paralysis:
Attempted movement with inability to complete 30
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Sensory neuropathy, complete or incomplete.......... 10
Note (1): Tic douloureux may be rated under DC 8205
in accordance with severity, up to complete
paralysis.
Note (2): Rate dependent upon relative loss of
sensation or muscle function. Examples of nerve
functions include, but are not limited to, movement
and sensation to the scalp, forehead, nose, cheeks,
lower eye lid, nasal mucosa, upper lip, upper
teeth, palate, anterior tongue, skin over mandible
and lower teeth, and muscles of mastication.
Seventh (facial) cranial nerve
8207 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 30
Incomplete paralysis:
Attempted movement with inability to complete 20
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Sensory neuropathy, complete, or incomplete......... 10
Note: Rate dependent upon relative loss of sensation
or muscle function. Examples of nerve functions
include, but are not limited to, facial
expressions, taste, and production/drainage of
tears.
[[Page 88932]]
Ninth (glossopharyngeal) cranial nerve
8209 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 30
Incomplete paralysis:
Attempted movement with inability to complete 20
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Sensory neuropathy, complete, or incomplete......... 10
Note: Rate dependent upon relative loss of ordinary
sensation or muscle function. Examples of nerve
functions include, but are not limited to, taste
and sensing carotid blood pressure.
Tenth (pneumogastric, vagus) cranial nerve
8210 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 50
Incomplete paralysis:
Attempted movement with inability to complete 30
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Sensory neuropathy, complete, or incomplete......... 10
Note: Rate dependent upon relative loss of sensation
or muscle function. Examples of nerve functions
include, but are not limited to, speech and taste,
along with movement and sensation to the larynx,
pharynx, thoracic viscera, and abdominal viscera.
Eleventh (spinal accessory, external branch) cranial
nerve
8211 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 30
Incomplete paralysis:
Attempted movement with inability to complete 20
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Note: Rate dependent upon relative loss of muscle
function. Examples of nerve functions include, but
are not limited to, movement of the
sternocleidomastoid and trapezius muscles.
Twelfth (hypoglossal) cranial nerve
8212 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis.................................. 50
Incomplete paralysis:
Attempted movement with inability to complete 30
such movement (muscle twitching present).......
Muscle movement intact, but task performed with 10
difficulty.....................................
Sensory neuropathy, complete, or incomplete......... 10
Note: Rate dependent upon relative loss of sensation
or muscle function. Examples of nerve functions
include, but are not limited to, movement and
sensation to the tongue.
------------------------------------------------------------------------
------------------------------------------------------------------------
Rating
Schedule of ratings -----------------
Major Minor
------------------------------------------------------------------------
Diseases of the Peripheral Nerves
------------------------------------------------------------------------
Guidance for rating peripheral nerves, along with a
description of the grading system, is located under
Sec. 4.123.
Upper radicular group (fifth and sixth cervicals)
8510 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 70 60
Incomplete paralysis:
Grade 2....................................... 50 40
Grade 3....................................... 40 30
Grade 4....................................... 20 20
Sensory neuropathy, complete...................... 40 30
Sensory neuropathy, incomplete.................... 20 20
Middle radicular group
8511 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 70 60
Incomplete paralysis:
Grade 2....................................... 50 40
Grade 3....................................... 40 30
Grade 4....................................... 20 20
Sensory neuropathy, complete...................... 40 30
Sensory neuropathy, incomplete.................... 20 20
Lower radicular group
8512 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 70 60
Incomplete paralysis:
Grade 2....................................... 50 40
Grade 3....................................... 40 30
Grade 4....................................... 20 20
Sensory neuropathy, complete...................... 40 30
Sensory neuropathy, incomplete.................... 20 20
[[Page 88933]]
All radicular groups
8513 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 90 80
Incomplete paralysis:
Grade 2....................................... 70 60
Grade 3....................................... 40 30
Grade 4....................................... 20 20
Sensory neuropathy, complete...................... 40 30
Sensory neuropathy, incomplete.................... 20 20
Radial nerve (musculospiral)
8514 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 70 60
Incomplete paralysis:
Grade 2....................................... 50 40
Grade 3....................................... 30 20
Grade 4....................................... 20 20
Sensory neuropathy, complete...................... 30 20
Sensory neuropathy, incomplete.................... 20 20
Note: Lesions involving only ``dissociation of
extensor communis digitorum'' and ``paralysis
below the extensor communis digitorum,'' will not
exceed Grade 3 for diagnostic code 8514.
The median nerve
8515 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 70 60
Incomplete paralysis:
Grade 2....................................... 50 40
Grade 3....................................... 30 20
Grade 4....................................... 10 10
Sensory neuropathy, complete...................... 30 20
Sensory neuropathy, incomplete.................... 10 10
The ulnar nerve
8516 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 60 50
Incomplete paralysis:
Grade 2....................................... 40 30
Grade 3....................................... 30 20
Grade 4....................................... 10 10
Sensory neuropathy, complete...................... 30 20
Sensory neuropathy, incomplete.................... 10 10
Musculocutaneous nerve
8517 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 30 20
Incomplete paralysis:
Grade 2....................................... 20 20
Grade 3....................................... 10 10
Grade 4....................................... 0 0
Sensory neuropathy, complete...................... 10 10
Sensory neuropathy, incomplete.................... 0 0
Axillary nerve (circumflex)
8518 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 50 40
Incomplete paralysis:
Grade 2....................................... 30 20
Grade 3....................................... 10 10
Grade 4....................................... 0 0
Sensory neuropathy, complete...................... 10 10
Sensory neuropathy, incomplete.................... 0 0
Long thoracic nerve
8519 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................. 30 20
Incomplete paralysis:
Grade 2....................................... 20 20
Grade 3....................................... 10 10
Grade 4....................................... 0 0
Sensory neuropathy, complete...................... 10 10
Sensory neuropathy, incomplete.................... 0 0
Note (1): Not to be combined with lost motion
above shoulder level.
Note (2): Combined nerve injuries should be rated
by reference to the major involvement, or if
sufficient in extent, consider radicular group
ratings.
------------------------------------------------------------------------
[[Page 88934]]
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Sciatic nerve
8520 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 80
Incomplete paralysis:
Grade 2......................................... 60
Grade 2+........................................ 40
Grade 3......................................... 20
Grade 4......................................... 10
Sensory neuropathy, complete........................ 20
Sensory neuropathy, incomplete...................... 10
Common peroneal nerve (external popliteal)
8521 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 40
Incomplete paralysis:
Grade 2......................................... 30
Grade 3......................................... 20
Grade 4......................................... 10
Sensory neuropathy, complete........................ 20
Sensory neuropathy, incomplete...................... 10
Superficial peroneal nerve (musculocutaneous)
8522 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 30
Incomplete paralysis:
Grade 2......................................... 20
Grade 3......................................... 10
Grade 4......................................... 0
Sensory neuropathy, complete........................ 10
Sensory neuropathy, incomplete...................... 0
Deep peroneal nerve (anterior tibial)
8523 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 30
Incomplete paralysis:
Grade 2......................................... 20
Grade 3......................................... 10
Grade 4......................................... 0
Sensory neuropathy, complete........................ 10
Sensory neuropathy, incomplete...................... 0
Tibial nerve (internal popliteal)
8524 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 40
Incomplete paralysis:
Grade 2......................................... 30
Grade 3......................................... 20
Grade 4......................................... 10
Sensory neuropathy, complete........................ 20
Sensory neuropathy, incomplete...................... 10
Posterior tibial nerve
8525 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 30
Incomplete paralysis:
Grade 2......................................... 20
Grade 3 or Grade 4.............................. 10
Sensory neuropathy, complete or incomplete.......... 10
Femoral nerve (anterior crural)
8526 Motor neuropathy (complete and incomplete
paralysis):
Complete paralysis (Grade 0 or 1)................... 40
Incomplete paralysis:
Grade 2......................................... 30
Grade 3......................................... 20
Grade 4......................................... 10
Sensory neuropathy, complete........................ 20
Sensory neuropathy, incomplete...................... 10
Saphenous nerve (internal saphenous)
8527 Sensory neuropathy, complete or incomplete......... 0
Obturator nerve
8528 Motor neuropathy (complete and incomplete
paralysis):
Grade 0, Grade 1, or Grade 2.................... 10
Grade 3 or Grade 4.............................. 0
Sensory neuropathy, complete or incomplete.......... 0
[[Page 88935]]
Lateral cutaneous nerve of the thigh (external
cutaneous)
8529 Sensory neuropathy, complete or incomplete......... 0
Ilio-inguinal nerve
8530 Motor neuropathy (complete and incomplete
paralysis):
Grade 0, Grade 1, or Grade 2.................... 10
Grade 3 or Grade 4.............................. 0
Sensory neuropathy, complete or incomplete.......... 0
------------------------------------------------------------------------
Other Neoplasms of the Neurological System
------------------------------------------------------------------------
8540 Soft-tissue sarcoma (of neurogenic origin)......... 100
Note: The 100 percent rating will be continued for 6
months following the cessation of surgical, X-ray,
antineoplastic chemotherapy or other therapeutic
procedure. At this point, if there has been no local
recurrence or metastases, the rating will be made on
residuals.
------------------------------------------------------------------------
The Epilepsies
------------------------------------------------------------------------
A thorough study of all material in Sec. Sec. 4.121
and 4.122 of the preface and under the ratings for
epilepsy is necessary prior to any rating action.
8910 Epilepsy, grand mal (including tonic-clonic
seizures).
Rate under the general rating formula for major
seizures.
8911 Epilepsy, petit mal (including absence seizures).
Rate under the general rating formula for minor
seizures.
Note (1): A major seizure is characterized by the
generalized tonic-clonic convulsion with
unconsciousness.
Note (2): A minor seizure consists of a brief
interruption in consciousness or conscious control
associated with staring or rhythmic blinking of the
eyes or nodding of the head (``pure'' petit mal),
or sudden jerking movements of the arms, trunk, or
head (myoclonic type) or sudden loss of postural
control (akinetic type).
General Rating Formula for Major and Minor Epileptic
Seizures:
Averaging at least 1 major seizure per month over 100
the last year......................................
Averaging at least 1 major seizure in 3 months over 80
the last year; or more than 10 minor seizures
weekly.............................................
Averaging at least 1 major seizure in 4 months over 60
the last year; or 9-10 minor seizures per week.....
At least 1 major seizure in the last 6 months or 2 40
in the last year; or averaging at least 5 to 8
minor seizures weekly..............................
At least 1 major seizure in the last 2 years; or at 20
least 2 minor seizures in the last 6 months........
A confirmed diagnosis of epilepsy with a history of 10
seizures...........................................
Note (1): When continuous medication is shown
necessary for the control of epilepsy, the minimum
evaluation will be 10 percent. This rating will not
be combined with any other rating for epilepsy.
Note (2): In the presence of major and minor
seizures, rate the predominating type.
Note (3): There will be no distinction between
diurnal and nocturnal major seizures.
8912 Epilepsy, Jacksonian and focal motor or sensory.
8913 Epilepsy, diencephalic.
Rate as minor seizures, except in the presence of
major and minor seizures, rate the predominating
type.
8914 Epilepsy, psychomotor.
Major seizures:
Psychomotor seizures will be rated as major
seizures under the general rating formula when
characterized by automatic states and/or
generalized convulsions with unconsciousness.
Minor seizures:
Psychomotor seizures will be rated as minor
seizures under the general rating formula when
characterized by brief transient episodes of
random motor movements, hallucinations,
perceptual illusions, abnormalities of
thinking, memory or mood, or autonomic
disturbances.
Mental Disorders in Epilepsies: A nonpsychotic organic brain syndrome
will be rated separately under the appropriate diagnostic code (e.g.,
9304 or 9326). In the absence of a diagnosis of non-psychotic organic
psychiatric disturbance (psychotic, psychoneurotic or personality
disorder) if diagnosed and shown to be secondary to or directly
associated with epilepsy will be rated separately. The psychotic or
psychroneurotic disorder will be rated under the appropriate diagnostic
code. The personality disorder will be rated as a dementia (e.g.,
diagnostic code 9304 or 9326).
Epilepsy and Unemployability: (1) Rating specialists must bear in mind
that the epileptic, although his or her seizures are controlled, may
find employment and rehabilitation difficult of attainment due to
employer reluctance to the hiring of the epileptic.
(2) Where a case is encountered with a definite history of unemployment,
full and complete development should be undertaken to ascertain whether
the epilepsy is the determining factor in his or her inability to
obtain employment.
(3) The assent of the claimant should first be obtained for permission
to conduct this economic and social survey. The purpose of this survey
is to secure all the relevant facts and data necessary to permit of a
true judgment as to the reason for his or her unemployment and should
include information as to:
(a) Education;
(b) Occupations prior and subsequent to service;
(c) Places of employment and reasons for termination;
(d) Wages received;
(e) Number of seizures.
(4) Upon completion of this survey and current examination, the case
should have rating board consideration. Where in the judgment of the
rating board the veteran's unemployability is due to epilepsy and
jurisdiction is not vested in that body by reason of schedular
evaluations, the case should be submitted to the Compensation Service
or the Director, Pension and Fiduciary Service.
------------------------------------------------------------------------
[[Page 88936]]
(Authority: 38 U.S.C. 1155)
0
10. Amend Appendix A to part 4 by:
0
a. Revising the entry for diagnostic code 5244;
0
b. Adding, in numerical order, entries for Sec. Sec. 4.120 and 4.123;
0
c. Redesignating the entries for Sec. 4.124a (all diagnostic codes
listed under Sec. 4.124a) as new entries for Sec. 4.124;
0
d. Revising and republishing newly redesignated Sec. 4.124; and
0
e. Adding, in numerical order, a new entry for Sec. 4.124a.
The revisions and additions read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
----------------------------------------------------------------------------------------------------------------
Sec. Diagnostic code No.
----------------------------------------------------------------------------------------------------------------
* * * * * * *
5244 Added February 7, 2021; note [Effective date
of final rule].
* * * * * * *
4.120...................................... .................... Title and revised [Effective date of final
rule].
4.123...................................... .................... Title and revised [Effective date of final
rule].
4.124...................................... .................... Re-designated from Sec. 4.124a [Effective
date of final rule].
8000 Title [Effective date of final rule].
8002 Criteria September 22, 1978; title, note
[Effective date of final rule].
8003 Title, criteria [Effective date of final
rule].
8004 Title, criteria, notes [Effective date of
final rule].
8007 Title, criteria [Effective date of final
rule].
8008 Removed [Effective date of final rule].
8009 Removed [Effective date of final rule].
8018 Title [Effective date of final rule].
8021 Criteria September 22, 1978; criteria October
1, 1961; criteria March 10, 1976; criteria
March 1, 1989; title, note [Effective date
of final rule].
8022 Title, criteria [Effective date of final
rule].
8025 Note removed [Effective date of final rule].
8026 Added [Effective date of final rule].
8027 Added [Effective date of final rule].
8028 Added [Effective date of final rule].
8036 Added [Effective date of final rule].
8045 Criterion and evaluation October 23, 2008.
8046 Added October 1, 1961; criterion March 10,
1976; criterion March 1, 1989.
8100 Evaluation June 9, 1953.
8103 Title [Effective date of final rule].
8104 Criteria [Effective date of final rule].
8107 Criteria [Effective date of final rule].
8205 Title, criteria, notes [Effective date of
final rule].
8207 Title, criteria, note [Effective date of
final rule].
8209 Title, criteria, note [Effective date of
final rule].
8210 Title, criteria, note [Effective date of
final rule].
8211 Title, criteria, note [Effective date of
final rule].
8212 Title, criteria, note [Effective date of
final rule].
8305 Removed [Effective date of final rule].
8307 Removed [Effective date of final rule].
8309 Removed [Effective date of final rule].
8310 Removed [Effective date of final rule].
8311 Removed [Effective date of final rule].
8312 Removed [Effective date of final rule].
8405 Removed [Effective date of final rule].
8407 Removed [Effective date of final rule].
8409 Removed [Effective date of final rule].
8410 Removed [Effective date of final rule].
8411 Removed [Effective date of final rule].
8412 Removed [Effective date of final rule].
8510 Title, criteria [Effective date of final
rule].
8511 Title, criteria [Effective date of final
rule].
8512 Title, criteria [Effective date of final
rule].
8513 Title, criteria [Effective date of final
rule].
8514 Title, criteria, note [Effective date of
final rule].
8515 Title, criteria [Effective date of final
rule].
8516 Title, criteria [Effective date of final
rule].
8517 Title, criteria [Effective date of final
rule].
8518 Title, criteria [Effective date of final
rule].
8519 Title, criteria, notes [Effective date of
final rule].
8520 Title, criteria [Effective date of final
rule].
8521 Title, criteria [Effective date of final
rule].
8522 Title, criteria [Effective date of final
rule].
8523 Title, criteria [Effective date of final
rule].
8524 Title, criteria [Effective date of final
rule].
8525 Title, criteria [Effective date of final
rule].
[[Page 88937]]
8526 Title, criteria [Effective date of final
rule].
8527 Title, criteria [Effective date of final
rule].
8528 Title, criteria [Effective date of final
rule].
8529 Title, criteria [Effective date of final
rule].
8530 Title, criteria [Effective date of final
rule].
8610 Removed [Effective date of final rule].
8611 Removed [Effective date of final rule].
8612 Removed [Effective date of final rule].
8613 Removed [Effective date of final rule].
8614 Removed [Effective date of final rule].
8615 Removed [Effective date of final rule].
8616 Removed [Effective date of final rule].
8617 Removed [Effective date of final rule].
8618 Removed [Effective date of final rule].
8619 Removed [Effective date of final rule].
8620 Removed [Effective date of final rule].
8621 Removed [Effective date of final rule].
8622 Removed [Effective date of final rule].
8623 Removed [Effective date of final rule].
8624 Removed [Effective date of final rule].
8625 Removed [Effective date of final rule].
8626 Removed [Effective date of final rule].
8627 Removed [Effective date of final rule].
8628 Removed [Effective date of final rule].
8629 Removed [Effective date of final rule].
8630 Removed [Effective date of final rule].
8710 Removed [Effective date of final rule].
8711 Removed [Effective date of final rule].
8712 Removed [Effective date of final rule].
8713 Removed [Effective date of final rule].
8714 Removed [Effective date of final rule].
8715 Removed [Effective date of final rule].
8716 Removed [Effective date of final rule].
8717 Removed [Effective date of final rule].
8718 Removed [Effective date of final rule].
8719 Removed [Effective date of final rule].
8720 Removed [Effective date of final rule].
8721 Removed [Effective date of final rule].
8722 Removed [Effective date of final rule].
8723 Removed [Effective date of final rule].
8724 Removed [Effective date of final rule].
8725 Removed [Effective date of final rule].
8726 Removed [Effective date of final rule].
8727 Removed [Effective date of final rule].
8728 Removed [Effective date of final rule].
8729 Removed [Effective date of final rule].
8730 Removed [Effective date of final rule].
8910 Added October 1, 1961; evaluation September
9, 1975; title [Effective date of final
rule].
8911 Added October 1, 1961; evaluation September
9, 1975; title [Effective date of final
rule].
8912 Added October 1, 1961; evaluation September
9, 1975.
8913 Added October 1, 1961; evaluation September
9, 1975.
8914 Added October 1, 1961; evaluation September
9, 1975.
4.124a..................................... .................... Re-designated as Sec. 4.124 [Effective date
of final rule].
* * * * * * *
----------------------------------------------------------------------------------------------------------------
0
11. Amend Appendix B to part 4 by revising and republishing the entries
in the table under ``Neurological Conditions and Convulsive Disorders''
to read as follows:
[[Page 88938]]
Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
Neurological Conditions and Convulsive Disorders
------------------------------------------------------------------------
Organic Diseases of the Central Nervous System
------------------------------------------------------------------------
8000......................... Encephalitis, infectious.
8002......................... Brain, new growth of, malignant.
8003......................... Brain, new growth of, benign.
8004......................... Parkinson's disease (paralysis agitans).
8005......................... Bulbar palsy.
8007......................... Stroke (ischemic, hemorrhagic, or
thrombotic), including cerebral
infarction or cerebrovascular accident.
8010......................... Myelitis.
8011......................... Poliomyelitis, anterior.
8012......................... Hematomyelia.
8013......................... Syphilis, cerebrospinal.
8014......................... Syphilis, meningovascular
8015......................... Tabes dorsalis.
8017......................... Amyotrophic lateral sclerosis.
8018......................... Multiple sclerosis and neuromyelitis
optica spectrum disorder (NMOSD).
8019......................... Meningitis, cerebrospinal, epidemic.
8020......................... Brain, abscess.
8021......................... Spinal cord, new growths of, malignant.
8022......................... Spinal cord, new growths of, benign.
8023......................... Progressive muscular atrophy.
8024......................... Syringomyelia.
8025......................... Myasthenia gravis.
8026......................... Parkinson's plus, or secondary
parkinsonism syndromes.
8027......................... Essential tremor.
8028......................... Dystonia.
8036......................... Primary lateral sclerosis.
8045......................... Residuals of traumatic brain injury
(TBI).
8046......................... Cerebral arteriosclerosis.
------------------------------------------------------------------------
Miscellaneous Diseases
------------------------------------------------------------------------
8100......................... Migraine.
8103......................... Hemifacial spasm (tic, convulsive).
8104......................... Paramyoclonus multiplex (convulsive
state, myoclonic type).
8105......................... Chorea, Sydenham's.
8106......................... Chorea, Huntington's.
8107......................... Athetosis, acquired.
8108......................... Narcolepsy.
------------------------------------------------------------------------
The Cranial Nerves
------------------------------------------------------------------------
8205......................... Fifth (trigeminal), motor neuropathy.
8207......................... Seventh (facial), motor neuropathy.
8209......................... Ninth (glossopharyngeal), motor
neuropathy.
8210......................... Tenth (pneumogastric, vagus), motor
neuropathy.
8211......................... Eleventh (spinal accessory, external
branch), motor neuropathy.
8212......................... Twelfth (hypoglossal), motor neuropathy.
------------------------------------------------------------------------
Peripheral Nerves
------------------------------------------------------------------------
8510......................... Upper radicular group, motor neuropathy.
8511......................... Middle radicular group, motor neuropathy.
8512......................... Lower radicular group, motor neuropathy.
8513......................... All radicular groups, motor neuropathy.
8514......................... Radial nerve (musculospiral), motor
neuropathy.
8515......................... Median nerve, motor neuropathy.
8516......................... Ulnar nerve, motor neuropathy.
8517......................... Musculocutaneous nerve, motor neuropathy.
8518......................... Axillary nerve (circumflex), motor
neuropathy.
8519......................... Long thoracic nerve, motor neuropathy.
8520......................... Sciatic nerve, motor neuropathy.
8521......................... Common peroneal nerve (external
popliteal), motor neuropathy.
8522......................... Superficial peroneal nerve
(musculocutaneous), motor neuropathy.
8523......................... Deep peroneal nerve (anterior tibial),
motor neuropathy.
8524......................... Tibial nerve (internal popliteal), motor
neuropathy.
8525......................... Posterior tibial nerve, motor neuropathy.
8526......................... Femoral nerve (anterior crural), motor
neuropathy.
8527......................... Saphenous nerve (internal saphenous),
sensory neuropathy.
[[Page 88939]]
8528......................... Obturator nerve, motor neuropathy.
8529......................... Lateral cutaneous nerve of the thigh
(external cutaneous), sensory
neuropathy.
8530......................... Ilio-inguinal nerve, motor neuropathy.
------------------------------------------------------------------------
Other Neoplasms of the Neurological System
------------------------------------------------------------------------
8540......................... Soft tissue sarcoma (Neurogenic origin).
------------------------------------------------------------------------
The Epilepsies
------------------------------------------------------------------------
8910......................... Epilepsy, grand mal (includes tonic-
clonic seizures).
8911......................... Epilepsy, petit mal (includes absence
seizures).
8912......................... Jacksonian and focal motor or sensory.
8913......................... Diencephalic.
8914......................... Psychomotor.
* * * * * * *
------------------------------------------------------------------------
0
12. Amend Appendix C to part 4 by:
0
a. Adding, in alphabetical order, an entry for ``Dystonia'';
0
b. Removing the entry for ``Embolism, brain'';
0
c. Revising the entry for ``Encephalitis, epidemic'';
0
d. Under the entry for ``Epilepsies'', revising the entries for ``Grand
mal'' and ``Petit mal'';
0
e. Adding, in alphabetical order, entries for ``Essential tremor'' and
``Hemifacial spasm (tic, convulsive)'';
0
f. Removing the entry for ``Hemorrhage'';
0
g. Adding, in alphabetical order, an entry for ``Intraocular
hemorrhage'';
0
h. Adding, in alphabetical order, an entry for ``Motor/sensory
neuropathy'';
0
i. Revising the entry for ``Multiple sclerosis'';
0
j. Removing the entry for ``Neuralgia'';
0
k. Removing the entry for ``Neuritis'';
0
l. Adding an entry for ``Optic neuropathy'';
0
m. Under the entry for ``Paralysis'', removing the entry for
``Agitans'';
0
n. Removing the entry for ``Paralysis, nerve'';
0
o. Revising the entry for ``Paramyoclonus multiplex'';
0
p. Adding, in alphabetical order, entries for ``Parkinson's disease
(paralysis agitans)'', ``Parkinson's plus, or secondary parkinsonism
syndromes'', ``Primary lateral sclerosis'', and ``Stroke (ischemic,
hemorrhagic, or thrombotic), including cerebral infarction or
cerebrovascular accident''; and
0
q. Removing the entries for ``Thrombosis, brain'' and ``Tic,
convulsive''.
The revisions and additions read as follows:
Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * * * *
Dystonia.......................................... 8028
* * * * * * *
Encephalitis, infectious.......................... 8000
* * * * * * *
Epilepsies:
* * * * * * *
Grand mal (includes tonic-clonic seizures).... 8910
* * * * * * *
Petit mal (includes absence seizures)......... 8911
* * * * * * *
Essential tremor.................................. 8027
* * * * * * *
Hemifacial spasm (tic, convulsive)................ 8103
* * * * * * *
Intraocular hemorrhage............................ 6007
* * * * * * *
Motor/sensory neuropathy:
Cranial nerves:
Eleventh (spinal accessory, external 8211
branch)..................................
Fifth (trigeminal)........................ 8205
Ninth (glossopharyngeal).................. 8209
[[Page 88940]]
Seventh (facial).......................... 8207
Tenth (pneumogastric, vagus).............. 8210
Twelfth (hypoglossal)..................... 8212
Peripheral nerves:
All radicular groups...................... 8513
Axillary (circumflex)..................... 8518
Common peroneal (external popliteal)...... 8521
Deep peroneal (anterior tibial)........... 8523
Femoral (anterior crural)................. 8526
Ilio-inguinal............................. 8530
Lateral cutaneous nerve of the thigh 8529
(external cutaneous).....................
Long thoracic............................. 8519
Lower radicular group..................... 8512
Median.................................... 8515
Middle radicular group.................... 8511
Musculocutaneous.......................... 8517
Obturator................................. 8528
Posterior tibial.......................... 8525
Radial (musculospiral).................... 8514
Saphenous (internal saphenous)............ 8527
Sciatic................................... 8520
Superficial peroneal (musculocutaneous)... 8522
Tibial (internal popliteal)............... 8524
Ulnar..................................... 8516
Upper radicular group..................... 8510
* * * * * * *
Multiple sclerosis and other demyelinating 8018
diseases of the central nervous system...........
* * * * * * *
Optic neuropathy.................................. 6026
* * * * * * *
Paramyoclonus multiplex (convulsive state, 8104
myoclonic type)..................................
* * * * * * *
Parkinson's disease (paralysis agitans)........... 8004
Parkinson's plus, or secondary parkinsonism 8026
syndromes........................................
* * * * * * *
Primary lateral sclerosis......................... 8036
* * * * * * *
Stroke (ischemic, hemorrhagic, or thrombotic), 8007
including cerebral infarction or cerebrovascular
accident.........................................
* * * * * * *
------------------------------------------------------------------------
[FR Doc. 2024-25665 Filed 11-8-24; 8:45 am]
BILLING CODE 8320-01-P
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</html>Indexed from Federal Register on November 12, 2024.
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