[Federal Register Volume 62, Number 238 (Thursday, December 11, 1997)]
[Rules and Regulations]
[Pages 65207-65224]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-32413]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AE40
Schedule for Rating Disabilities; The Cardiovascular System
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
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SUMMARY: This document amends that portion of the Department of
Veterans Affairs (VA) Schedule for Rating Disabilities addressing the
cardiovascular system. The effect of this action is to update the
cardiovascular system portion of the rating schedule to ensure that it
uses current medical terminology and unambiguous criteria, and that it
reflects medical advances that have occurred since the last review.
EFFECTIVE DATE: This amendment is effective January 12, 1998.
FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,
Regulations Staff (213A), Compensation and Pension Service, Veterans
Benefits Administration, Department of Veterans Affairs, 810 Vermont
Avenue NW, Washington, DC 20420, (202) 273-7230.
SUPPLEMENTARY INFORMATION: As part of a comprehensive review of the
rating schedule, VA published, in the Federal Register of January 19,
1993 (58 FR 4954-60), a proposal to amend 38 CFR 4.100, 4.101, 4.102,
and 4.104. Interested persons were invited to submit written comments,
suggestions, or objections on or before March 22, 1993. We received
comments from the Disabled American Veterans, the Veterans of Foreign
Wars, the Paralyzed Veterans of America, the American Legion, and
several VA employees.
One commenter, stating that the primary objective of the review is
to update the medical terminology and criteria used to evaluate
disabilities rather than to amend the percentage evaluations,
contended, without being specific, that a substantial number of the
proposed changes go beyond the stated purpose and expressed general
opposition to any changes that are inconsistent with the stated
objective. The commenter also stated that the proposed criteria retain,
and in some cases expand upon, the vague, indefinite, and arbitrary
elements previously found in the schedule and felt that substantial
revision of the proposed rules is required.
The purpose of the review was to update the cardiovascular system
portion of the rating schedule to ensure that it uses current medical
terminology and unambiguous criteria, and that it reflects medical
advances that have occurred since the last review. The proposed
revisions published January 19, 1993, were intended to update the
medical terminology; revise the criteria, including the length of
convalescence evaluations, based on medical advances; and make criteria
more objective, i.e., less ambiguous and, thereby, assure more
consistent ratings. These proposed changes were consistent with the
stated purposes of the revision. However, since establishing less
ambiguous criteria to assure consistent evaluations is one of the
purposes of this revision, and a number of commenters stated that the
proposed criteria contained language that is too subjective to provide
effective guidance in evaluating cardiovascular disabilities, we have
further revised the proposed evaluation criteria to eliminate
indefinite terminology and establish more objective and quantifiable
criteria wherever possible. These changes will be discussed in detail
under the individual codes affected.
One commenter suggested that the proposed criteria will
discriminate against veterans of Desert Storm and future veterans
because their conditions will be evaluated under criteria that he
perceived as less generous than those in the prior rating schedule.
Significant medical advances, including new surgical and anesthetic
techniques, new medications, and earlier diagnoses, have occurred,
which we must take into account in revising the rating schedule. Doing
so is, in fact, one of the primary reasons for conducting this review.
Since recently discharged veterans clearly benefit from the application
of these new techniques, in our judgment they are not discriminated
against by having their disabilities evaluated under criteria which
reflect the effects of these same medical advances.
One commenter objected that the rating schedule fails to take into
consideration the disabling effects of the veteran's shortened life
expectancy.
To consider a factor so far removed from ``the average impairments
of earning capacity'' as the effect of various conditions on life
expectancy would clearly exceed the parameters established by Congress
in 38 U.S.C. 1155.
One commenter, citing a statistical economic validation study from
the 1960s, implied that statistical studies may justify increased
disability evaluations.
The statute (38 U.S.C. 1155) authorizing establishment of the
rating schedule directs that ``[t]he Secretary shall from time to time
readjust the schedule of ratings in accordance with experience''
(emphasis supplied). Rather than requiring statistical studies or any
other specific type of data, the statute clearly leaves the nature of
the experience which warrants an adjustment, and by extension the
manner in which any review is conducted, to the discretion of the
Secretary. Although during the 1970s VA considered adjusting the rating
schedule based on the same statistical studies cited by the commenter,
that approach proved to be unsatisfactory, and the proposed changes
based on that study were not adopted.
One commenter agreed that ambiguous words such as ``severe'' should
be deleted, but cautioned against making the evaluation criteria too
objective.
Providing clear and objective criteria is the best way to assure
that disabilities will be evaluated fairly and consistently. Judgment
and flexibility cannot be eliminated from the evaluation process,
however, because patients do not commonly present as textbook models of
disease, and rating agencies have the task of assessing which
evaluation level best represents the overall disability picture. (See
Sec. 4.7.)
The previous schedule provided convalescence evaluations for six
[[Page 65208]]
months for the following conditions: rheumatic heart disease (DC 7000);
arteriosclerotic heart disease, following coronary occlusion (DC 7005);
myocardial infarction (DC 7006); and soft tissue sarcoma (of vascular
origin) (DC 7123). It provided convalescence evaluations for one year
for the following conditions: Auriculoventricular block, with
implantation of a pacemaker (DC 7015); heart valve replacement (DC
7016); coronary artery bypass (DC 7017); and aortic aneurysm, following
surgical correction (DC 7110). We proposed to change the duration of
convalescence evaluations for DC 7000, DC 7005, and DC 7006 to three
months; for DC 7018 (pacemaker implantation, formerly DC 7015) to two
months; and for DC 7017 to three months. We proposed an indefinite
period of convalescence evaluation with an examination at six months
for DC 7016, DC 7110, DC 7011 (now ventricular arrhythmias), DC 7111
(aneurysm of any large artery), and DC 7123. We also proposed an
indefinite period of convalescence evaluation, but with an examination
at one year, for cardiac transplantation (DC 7019).
One commenter stated that VA should justify the proposed changes in
periods of convalescence evaluation by citing medical experts or texts.
A report from Jefferson Medical College that included a clinical
review of the cardiovascular portion of the rating schedule and
recommendations for changes was available to us when we undertook the
revision of this body system. In addition, we received advice from the
Veterans Health Administration and consulted standard medical texts
such as ``Cecil Textbook of Medicine'' (James B. Wyngaarden, M.D. et
al. eds., 19th ed. 1992), ``Heart Disease'' (Eugene Braunwald, M.D.
ed., 4th ed. 1992), and ``The Heart'' (J. Willis Hurst, M.D. et al.
eds., 7th ed. 1990). We published the proposed revision only after
reviewing all of these sources of information. We have provided
specific citations supporting many of the changes in the length of
convalescence evaluations later in this document under the discussions
of convalescence evaluation periods that have been changed.
One commenter stated that the proposed periods of convalescence
evaluation do not represent the average impairment, but only the
optimal recovery times. This commenter also stated that the changes in
the duration of convalescence evaluations do not take into account
advanced age, poor state of health, or the presence of etiologically
related or concomitant disease.
The periods of convalescence evaluation we have established
reflect, according to the sources noted above, the average periods of
recovery needed by the average person following certain procedures and
illnesses. These periods can be extended, when medically warranted,
under the authority of 38 CFR 4.29 and 4.30.
One commenter said that the proposed changes in the length of
convalescence evaluations appear to have been developed from a purely
economic perspective.
As previously discussed, revisions to periods of convalescence
evaluations were based on medical considerations rather than cost
projections.
One of the commenters suggested that where the length of
convalescence evaluations has been reduced to two, three, or six
months, all claims should be referred to the Adjudication Officer for a
possible extension of the convalescence rating under 38 CFR 4.30(b)(2).
The rating agency itself has the authority to extend the period of
convalescence evaluations for up to three months under the provisions
of Sec. 4.30; the approval of the Adjudication Officer is required only
when extending a convalescence evaluation for a longer period.
Referring claims to the Adjudication Officer when the medical evidence
does not warrant any extension, or when the rating agency can extend
the evaluation for a sufficient period on its own authority, would
cause needless delay, and we have made no change based on this
suggestion.
Several commenters objected to indefinite periods of convalescence
evaluation with a mandatory VA examination at a prescribed time. In our
judgment, however, this method of determining the length of the total
evaluation is both fairer and more accurate than assigning a total
evaluation for a specified length of time, since the evaluation will be
based on actual residual disability as documented by the examination,
and the veteran will receive advance notice of any change and have the
opportunity to submit additional evidence showing that the change is
not warranted.
One set of comments reflected the view that applying Sec. 3.105(e)
to indefinite periods of convalescence evaluations will cause
significant administrative problems and, in some instances,
significantly lengthen the period for which a convalescence evaluation
is assigned. These concerns appear to be based on the assumption that
if medical information justifying a certain period of convalescence
evaluation is not submitted until months or even years after the event,
the condition must be evaluated as totally disabling from the date
entitlement is established, through the entire intervening period, and
until such time as an examination can be performed, advance notice be
provided, and the effective date provisions of Sec. 3.105(e) be
observed.
Section 3.105(e) applies only to reductions in ``compensation
payments currently being made;'' it does not apply in cases where a
total evaluation is both assigned and reduced retroactively. We have
established convalescence evaluations for indefinite periods under
other portions of the rating schedule (See DC 7528, malignant neoplasms
of the genitourinary system, in 38 CFR 4.115b and DC 7627, malignant
neoplasms of gynecological system or breast, in 38 CFR 4.116), some
having been in effect for over two years, and there is no evidence that
they cause the type of administrative problems that the commenters
foresee.
There were three introductory sections to the cardiovascular system
in the previous rating schedule. Section 4.100, Necessity for complete
diagnosis, named common types of heart disease and discussed the need
for accurate diagnosis. Section 4.101, Rheumatic heart disease,
discussed the course of rheumatic heart disease, the significance of a
diagnosis of mitral insufficiency, possible etiologies for later
developing aortic insufficiency, and the need for accurate diagnosis of
a service-connected condition. Section 4.102, Varicose veins and
phlebitis, discussed the need to determine impairment of deep
circulation due to varicosities and included a requirement to assign a
higher evaluation when there is phlebitis or deep impairment of
circulation. We proposed to retitle the introductory sections: 4.100,
as ``Forms of heart disorder;'' 4.101, as ``Hypertension;'' and 4.102,
as ``Varicose veins.'' We proposed to include in Sec. 4.100 a list of
common forms of heart abnormalities, a discussion of how to evaluate
service-connected valvular heart disease or arrhythmia in the presence
of nonservice-connected arteriosclerotic heart disease, and a statement
that the identification of coronary artery disease (without occlusion
or thrombosis) early in service is not a basis for service connection,
but that any sudden development of coronary occlusion or thrombosis
during service would be service-connected. However, as explained below,
we have either deleted or relocated all of the material we had proposed
to include in Secs. 4.100, 4.101,
[[Page 65209]]
and 4.102, and we have, therefore, removed those sections and reserved
them for future use.
One commenter suggested that we remove all material in Secs. 4.100,
4.101, and 4.102 that refer to the issue of service connection because
it is inappropriate to place criteria for determining entitlement to
service connection in the rating schedule. A second commenter suggested
that the material about the identification of coronary artery disease
early in service not being a basis for service connection should be
removed because the provision violates the statutory presumption of
soundness at induction as set forth in 38 U.S.C. 1111.
The rules governing determinations of service connection are found
in the regulations beginning at 38 CFR 3.303, rather than in the rating
schedule, which is a guide to evaluating disabilities. We agree that
rules affecting determinations of service connection are inappropriate
in the rating schedule, and we have removed that portion of the
material in Sec. 4.100 that addressed the issue of service connection
for coronary artery disease for that reason. We have also removed other
provisions of Secs. 4.101 and 4.102 that addressed service connection
for cardiovascular conditions, as discussed below.
We had proposed including in Sec. 4.102, varicose veins, a
provision from VA's Adjudication Procedures Manual, M21-1, Part VI,
that if varicose veins developed during active service in one leg,
varicose veins developing in the other leg within three years, in the
absence of an intercurrent cause, will also be service-connected.
However, in response to this comment, we have determined that since it
addresses the issue of service connection, it is not appropriate in the
rating schedule, and we have removed it.
Two commenters suggested that these introductory sections specify
which cardiovascular diseases should be service-connected when they
develop subsequent to certain amputations.
38 CFR 3.310(b) provides that ``ischemic heart disease or other
cardiovascular diseases'' developing in veterans who have suffered a
service-connected amputation of one lower extremity at or above the
knee, or service-connected amputations of both lower extremities at or
above the ankles, shall be held to be the result of the service-
connected amputation or amputations. Since that issue is addressed
elsewhere in VA's regulations, it is unnecessary to address it here.
Furthermore, as previously discussed, it would be inappropriate to
include material about the determination of service connection in the
rating schedule.
One commenter recommended that we include more discussion of
pertinent clinical and nonclinical factors to be considered in
assigning evaluations within this portion of the rating schedule.
We have made a number of changes along these lines that will assist
in the evaluation of cardiovascular conditions. Most significantly, we
have adopted more objective evaluation criteria based on specific
clinical (and, in some cases, laboratory) findings, e.g., by using the
level of METs (metabolic equivalents, discussed in detail below) to
assess the severity of heart disease. In addition, we have retained or
added notes, as appropriate, containing clinical information, e.g., by
adding a note defining characteristic attacks of Raynaud's syndrome.
One commenter suggested that Sec. 4.100 discuss forms of heart
disorder, Sec. 4.101 discuss hypertension, and Sec. 4.102 discuss
varicose veins.
A regulation is an agency statement of general applicability and
future effect, which the agency intends to have the force and effect of
law, that is designed to implement, interpret, or prescribe law or
policy, or to describe the procedure or practice requirements of an
agency (Executive Order 12866, Regulatory Planning and Review).
Background material, such as general medical information that is
available in standard textbooks, or other material that neither
prescribes VA policy nor establishes procedures a rating activity must
follow, falls outside of those parameters and is, therefore, not
appropriate in a regulation. The material about the age of onset,
course, etc., of rheumatic fever in former Sec. 4.101 is general
medical information which has no bearing on evaluating the condition,
and we have deleted this material as not appropriate in a regulation.
Upon further review, we have deleted the list of heart abnormalities
from proposed Sec. 4.100 because it too is general medical information
that we do not intend to have the force and effect of law.
We proposed to retitle Sec. 4.101 ``Hypertension,'' and to revise
the content to include a prohibition against separately evaluating
hypertension that is secondary to thyroid or renal disease; and a
requirement that, in a veteran with service-connected hypertension,
arteriosclerotic manifestations are to be service-connected. One
commenter suggested adding more information to Sec. 4.101 about
secondary hypertension, to include specifying when secondary
hypertension can be evaluated separately from the condition causing it.
The rule regarding evaluation of hypertension secondary to renal
disease is included in the part of the rating schedule addressing the
genitourinary system at Sec. 4.115; secondary hypertension associated
with aortic insufficiency or thyroid disease, and isolated systolic
hypertension, which may be secondary to arteriosclerosis, are addressed
under DC 7101 (hypertensive vascular disease). Since the issue of
service connection of secondary hypertension is addressed in more
appropriate areas of the regulations, it should not be addressed here,
and rather than expanding this material, we have deleted it from
Sec. 4.101.
The material in proposed Sec. 4.101 about conditions that are
complications of hypertension or other medical conditions is also
general medical information available in standard texts. As discussed
above, it is not appropriate in a regulation, and we have, therefore,
removed it. The issue of service connection for conditions that are
proximately due to or the result of a service-connected condition is
addressed at 38 CFR 3.310(a). It is, therefore, unnecessary to address
the issue in Sec. 4.101, and we have removed that material also.
In the former schedule, Sec. 4.102, which was titled ``Varicose
veins and phlebitis,'' discussed the necessity of testing for
impairment of deep circulation in varicose veins. We proposed to
retitle it ``Varicose veins'' but to retain the material about deep
circulation. Under the revised evaluation criteria for varicose veins
adopted in this rule, however, determining whether the deep circulation
is impaired is unnecessary because the evaluation criteria focus on
functional impairment rather than the location of the venous
insufficiency. We have, therefore, deleted that material from
Sec. 4.102.
Another commenter requested that we address in Sec. 4.101 the
advances in medical science or objective foundation for requiring that
adjudicators attempt to apportion cardiac signs and symptoms that are
attributable to nonservice-connected arteriosclerotic heart disease
that is superimposed on service-connected rheumatic heart disease.
While it is often possible through modern technology to determine
the separate effects of coexisting heart diseases, such a determination
requires a medical assessment on a case-by-case basis and cannot be
determined by regulation. We have, therefore, revised the material to
require that the rating agency request a medical opinion when it is
necessary to determine whether
[[Page 65210]]
current signs and symptoms can be attributed to one of the coexisting
conditions. Since the material is not relevant to the entire
cardiovascular portion of the rating schedule, we have moved it to a
note under DC 7005, arteriosclerotic heart disease.
One commenter suggested adding a section to explain which
diagnostic codes should not be combined in the case of coexisting
cardiovascular diseases.
As in the case of coexisting heart diseases, determining whether
coexisting cardiovascular diseases have functional impairments that can
be separately evaluated must be determined on a case-by-case basis,
depending on the particular manifestations of each condition. We,
therefore, make no change based on this suggestion.
One commenter recommended that we include cor pulmonale in the
cardiovascular portion of the schedule.
Cor pulmonale is a combination of hypertrophy and dilatation of the
right ventricle secondary to pulmonary hypertension, which is due to
disease of the lung parenchyma or pulmonary vascular system (Braunwald,
1581). Since cor pulmonale is always secondary to a lung condition, and
since it is included in the evaluation criteria for various conditions
of the respiratory system, in our judgment it is not appropriate to
include it in the cardiovascular portion of the rating schedule. For
the sake of clarity, however, we have placed a note in Sec. 4.104
before DC 7000 instructing rating agencies to evaluate cor pulmonale as
part of the pulmonary condition that causes it.
The previous rating schedule provided a 100-percent evaluation for
rheumatic heart disease (DC 7000) ``as active disease and, with
ascertainable cardiac manifestation, for a period of six months.'' We
proposed to retitle DC 7000 ``valvular heart disease,'' and to provide
a 100-percent evaluation for ``active infections with valvular heart
damage for three months following cessation of therapy.''
Three commenters objected to the proposed change in the length of
the convalescence evaluation for DC 7000 (valvular heart disease).
Rheumatic fever is the condition most commonly associated with
valvular heart damage, and its acute phase rarely lasts longer than
three months (Braunwald, 1729). The level of activity following this
period depends on the severity of residual disease (Cecil, 1637). While
in the past patients with acute rheumatic fever were put to bed for
several months, bed rest is no longer considered necessary unless there
is significant carditis (Hurst, 1527). In addition, most rebounds of
rheumatic fever (that is, reappearances of clinical or laboratory
evidence of acute rheumatic fever following cessation of treatment)
occur within two weeks after cessation of therapy, and do not occur
more than five weeks after complete cessation of anti-rheumatic therapy
(Braunwald, 1730). In our judgment, three months following cessation of
therapy is a reasonable period to allow for stabilization of valvular
damage due to infection, and we have retained the convalescence
provision as proposed, except for minor editorial changes.
We proposed that valvular heart disease (DC 7000) be evaluated on
the basis of the level of physical activity, i.e., ``any,'',
``ordinary,'' or ``strenuous,'' required to produce cardiac symptoms,
such as ``dyspnea,'' ``fatigue,'' etc. We received three comments
objecting to the proposed criteria.
One commenter suggested that although the proposed general rating
formula for rheumatic heart disease (DC 7000), arteriosclerotic heart
disease (DC 7005), and ventricular arrhythmia (DC 7011) is consistent
with the classifications of the New York Heart Association, they are
mostly for subjective complaints, and the commenter suggested that the
current criteria be retained except for deleting words like
``characteristic'' and ``definitely.'' Another commenter stated that
the proposed criteria for valvular heart disease are highly subjective
and urged that we adopt objectively confirmable criteria at every
level.
We agree that more objective criteria would result in more
consistent evaluations. In our judgment, however, simply removing such
terms as ``characteristic'' and ``definitely'' from the criteria in the
previous schedule would not have the intended effect. We have,
therefore, revised the criteria to incorporate objective measurements
of the level of physical activity, expressed in METs (metabolic
equivalents), at which cardiac symptoms develop. This does not
represent a substantive change in the method of evaluating cardiac
disabilities that we proposed, i.e., basing evaluations on the level of
physical activity that causes symptoms, but is an objective method for
measuring the level of activity that causes symptoms.
The exercise capacity of skeletal muscle depends on the ability of
the cardiovascular system to deliver oxygen to the muscle, and
measuring exercise capacity can, therefore, also measure cardiovascular
function. The most accurate measure of exercise capacity is the maximal
oxygen uptake, which is the amount of oxygen, in liters per minute,
transported from the lungs and used by skeletal muscle at peak effort
(Braunwald, 1382). Because measurement of the maximal oxygen uptake is
impractical, multiples of resting oxygen consumption (or METs) are used
to calculate the energy cost of physical activity. One MET is the
energy cost of standing quietly at rest and represents an oxygen uptake
of 3.5 milliliters per kilogram of body weight per minute. The
calculation of work activities in multiples of METs is a useful
measurement for assessing disability and standardizing the reporting of
exercise workloads when different exercise protocols are used
(Braunwald, 162).
We have revised the evaluation criteria for the major types of
heart disease based on: the level of physical activity, expressed in
METs, that leads to cardiac symptoms; whether there is heart failure;
the extent of any left ventricular dysfunction; the presence of cardiac
hypertrophy or dilatation; and the need for continuous medication. We
had proposed that valvular heart disease (DC 7000) be evaluated on the
basis of the level of physical activity that produces symptoms--100
percent if ``any,'' 60 percent if ``ordinary,'' and 30 percent if
``strenuous'' activity produces symptoms. We have revised those
criteria to assign a 100-percent evaluation if a workload of three METs
or less produces dyspnea, fatigue, angina, dizziness, or syncope. A
workload of three METs represents such activities as level walking,
driving, and very light calisthenics. We have revised the criteria to
assign a 60-percent evaluation if a workload of greater than three METs
but not greater than five METs results in cardiac symptoms. Activities
that fall into this range include walking two and a half miles per
hour, social dancing, light carpentry, etc. We have revised the
criteria to assign a 30-percent evaluation if a workload of greater
than five METs but not greater than seven METs produces symptoms.
Activities that fall into this range include slow stair climbing,
gardening, shoveling light earth, skating, bicycling at a speed of nine
to ten miles per hour, carpentry, and swimming (Fox, S. M. III,
Naughton, J.P., Haskell, W.L.: Physical activity and the prevention of
coronary heart disease. Ann. Clin. Res., 3:404, 1971 and Goldman, L. et
al.: Comparative reproducibility and validity of systems for assessing
cardiovascular functional class: Advantages of a new specific activity
[[Page 65211]]
scale. Circulation 64:1227, 1981). METs are measured by means of a
treadmill exercise test, which is the most widely used test for
diagnosing coronary artery disease and for assessing the ability of the
coronary circulation to deliver oxygen according to the metabolic needs
of the myocardium (Cecil, 175 and Harrison, 966).
Administering a treadmill exercise test may not be feasible in some
instances, however, because of a medical contraindication, such as
unstable angina with pain at rest, advanced atrioventricular block, or
uncontrolled hypertension. We have, therefore, provided objective
alternative evaluation criteria, such as cardiac hypertrophy or
dilatation, decreased left ventricular ejection fraction, and
congestive heart failure, for use in those cases. We have also
indicated that when a treadmill test cannot be done for medical
reasons, the examiner's estimation of the level of activity, expressed
in METs and supported by examples of specific activities, such as slow
stair climbing or shoveling snow that results in dyspnea, fatigue,
angina, dizziness, or syncope, is acceptable.
The other objective criteria that we have added as alternatives to
the METs-based criteria for valvular heart disease are a left
ventricular ejection fraction of less than 30 percent or chronic
congestive heart failure for a 100-percent evaluation; a left
ventricular ejection fraction of 30 to 50 percent, or more than one
episode of acute congestive heart failure in the past year for a 60-
percent evaluation; evidence of cardiac hypertrophy or dilatation on
electrocardiogram, echocardiogram, or X-ray for a 30-percent
evaluation, and a requirement for continuous medication for a 10-
percent evaluation.
Since neurologic, gastrointestinal, and other cardiovascular
disorders may result in symptoms similar to those for valvular heart
disease, we have also added a requirement that valvular heart disease
be documented by findings on physical examination and by
echocardiogram, Doppler echocardiogram, or cardiac catheterization.
Another commenter felt that the proposed criteria for the 100-
percent level for valvular heart disease (DC 7000), arteriosclerotic
heart disease (DC 7005), and ventricular arrhythmias (DC 7011)--that
``any'' physical activity results in specified cardiac symptoms--
correlates not with total industrial impairment but with being
housebound or helpless. Similarly, the commenter objected that the
requirement for the 60-percent level--that ``ordinary'' physical
activity results in symptoms--actually represents total impairment.
The proposed criteria for the 100-percent level of these conditions
were meant to indicate a severe level of impairment, but the language
was imprecise and perhaps suggested a degree of impairment beyond total
impairment. Under the more objective criteria that we are adopting
here, a 100-percent evaluation requires that a workload of three METs
or less produces dyspnea, fatigue, angina, dizziness, or syncope. A
workload of three METs includes such activities as level walking,
driving, and very light calisthenics. While the development of cardiac
symptoms at this level of activities indicates total impairment, it
does not suggest that the patient is either housebound or helpless.
Similarly, under the more objective criteria, a 60-percent evaluation
requires that a workload of greater than three METs but not greater
than five METs produces cardiac symptoms. Since activities that fall
into this range include walking two and a half miles per hour, social
dancing, and light carpentry, this range does not represent total
impairment. In our judgment, by adopting more objective criteria, we
have eliminated the problem that the commenter identified.
The prior schedule assigned a 10-percent evaluation under DC 7000
(rheumatic heart disease, now designated as valvular heart disease),
when there was an identifiable valvular lesion, with little dyspnea and
no cardiomegaly. We proposed to delete the 10-percent level and to
evaluate the condition as zero percent disabling if it does not limit
physical activity.
Two commenters objected to the proposed deletion of a 10-percent
level of evaluation for valvular heart disease. One suggested a 10-
percent evaluation when dietary adjustments and medication are
necessary to control symptoms or prevent emboli; the other suggested a
10-percent evaluation for asymptomatic valvular heart disease or
arrhythmias that require medication.
Upon further consideration, we have added a 10-percent evaluation,
which will be assigned when symptoms develop at a workload of greater
than 7 METs but not greater than 10 METs. Activities that fall into
this range include jogging, playing basketball, digging ditches, and
sawing hardwood. When symptoms develop only during such activities,
there may be some impairment of earning capacity, but it is likely to
be slight. We have also established an alternative criterion for a 10-
percent evaluation--the need for continuous medication--consistent with
the 10-percent evaluations assigned under other body systems, e.g.,
gynecological and endocrine conditions, when continuous medication is
required. We have also deleted the zero-percent level of evaluation as
unnecessary, since zero percent may be assigned under any diagnostic
code when the criteria for a compensable evaluation are not met (38 CFR
4.31).
DC 7000 was titled ``rheumatic heart disease'' in the previous
schedule. We proposed to retitle it ``valvular heart disease,'' and to
specify that it included rheumatic heart disease, syphilitic heart
disease, and sequelae involving valvular heart damage from
endocarditis, pericarditis, or trauma. Because each of the conditions
listed under DC 7000 (except trauma) has its own diagnostic code and
criteria, we have revised the title to ``valvular heart disease
(including rheumatic heart disease)'' and deleted the list of
conditions. The term ``valvular heart disease'' encompasses all types
of valvular disease not otherwise specified, including those due to
trauma.
We proposed to require that endocarditis (DC 7001), pericarditis
(DC 7002), and pericardial adhesions (DC 7003) be rated as valvular
heart disease. We have instead repeated the evaluation criteria under
each diagnostic code to which they apply. We have also deleted the
three-month period of convalescence evaluation that would have been
available for pericardial adhesions if evaluated strictly under the
criteria for valvular heart disease (DC 7000); pericardial adhesions
are a chronic condition rather than an acute infection, and a
convalescence evaluation is, therefore, inappropriate.
We proposed that syphilitic heart disease (DC 7004) be evaluated
under the criteria for either valvular heart disease or aortic aneurysm
(DC 7110). We have now provided criteria for DC 7004 that are based on
the same objective measurements of the level of physical activity that
causes symptoms. We placed a note following this diagnostic code
directing that syphilitic aortic aneurysms be evaluated under DC 7110
(aortic aneurysm), since the criteria under DC 7110 apply to aortic
aneurysm of any etiology. Since syphilitic heart disease has no phase
of active infection, being the late result of a much earlier syphilitic
infection, we have omitted the criteria based on active infection, as
we did under DC 7003.
We proposed to revise the length of convalescence evaluation
following a myocardial infarction (DC 7005 or 7006) from six months to
three months. One commenter objected that three months represents the
optimal, rather than the
[[Page 65212]]
average, recovery period following myocardial infarction.
The interval between an uncomplicated myocardial infarction and
return to work is 70-90 days (Braunwald, 1390), and a return to work
evaluation can be performed within five weeks after an uncomplicated
myocardial infarction (``The Heart'' 1115 (J. Willis Hurst, M.D. et al.
eds., 7th ed. 1990)). Complete healing of the myocardium, i.e.,
replacement of the infarcted area by scar tissue, takes six to eight
weeks, and most patients will be able to return to work by 12 weeks,
many much earlier (``Harrison's Principles of Internal Medicine'' 956-
57 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)). This information
clearly establishes that most patients with myocardial infarction
recover within three months, and, in our judgment, that is an adequate
period for a convalescence evaluation.
Another individual said that three months is not an adequate length
of convalescence evaluation following myocardial infarction because it
takes six months, which according to the commenter is the normally
accepted recovery time, for ancillary circulation patterns to develop.
The development of collateral circulation represents a long-range
adaptation to ischemia due to coronary artery disease (Hurst, 944). It
is, therefore, more relevant in predicting whether an infarction will
occur or how severe it might be, than in determining the length of
convalescence after infarction, and we have made no change based on
this comment.
In response to requests for more objective criteria, we have
adopted criteria for the 10-, 30-, 60-, and 100-percent levels for
arteriosclerotic heart disease using the same METs-based criteria we
have adopted for DC 7000 (valvular heart disease). We have also adopted
similar alternative criteria based either on chronic or multiple
episodes of congestive heart failure, left ventricular dysfunction with
decreased ejection fraction percentages, or cardiac hypertrophy or
dilatation.
The prior rating schedule assigned 30-percent evaluations under DCs
7005 (arteriosclerotic heart disease) and 7006 (myocardium, infarction
of, due to thrombosis or embolism) ``following typical coronary
occlusion or thrombosis,'' or ``with history of substantiated anginal
attack, ordinary manual labor feasible,'' but provided neither a 10-
percent level nor specific criteria for a zero-percent evaluation. We
proposed to assign a 30-percent evaluation for those with cardiac
symptoms appearing after strenuous physical activity, and to establish
a zero-percent level for those with no limitation of physical activity.
Two commenters objected to the proposed changes. One suggested we
provide a 20-percent level under DC 7005 for some limitation of
activities and a 30-percent level for one or more symptoms. One felt
that 30 percent should be the minimum under DC 7005 or DC 7006 because
permanent disability results.
In keeping with the objective evaluation criteria we are adopting,
it is feasible to establish additional levels of impairment based on an
objective measurement of the workload at which symptoms develop. We
have added a 10-percent evaluation under DC's 7005 and 7006 for those
who have cardiac symptoms at a workload greater than 7 METs but not
greater than 10 METs, which includes such activities as gardening and
skating. The 10-percent evaluation may also be assigned when continuous
medication is required, which is consistent with the evaluation of
other heart conditions. As a result, if, for different conditions, the
same workload elicits symptoms, the conditions will be assigned the
same evaluation. A 30-percent minimum evaluation is not warranted.
Arteriosclerotic heart disease may be mild enough that it imposes
little or no functional impairment, and, in our judgment, the most
equitable way to evaluate the condition is to do so objectively
according to the physical workload that causes symptoms.
We proposed that arteriosclerotic heart disease (DC 7005) and
myocardial infarction (DC 7006) be evaluated under the same criteria.
That was reasonable under the subjective evaluation criteria that were
proposed, but there are some condition-specific differences that the
criteria must reflect. We have provided for a three-month convalescence
evaluation following a myocardial infarction (DC 7006), a condition of
sudden onset. Arteriosclerotic heart disease (DC 7005), on the other
hand, is a chronic condition that does not warrant a convalescence
evaluation. We have added a requirement to DC 7005 that the veteran
have ``documented'' coronary artery disease. Similarly, we have headed
DC 7006 with the statement ``with history of myocardial infarction,
documented by laboratory tests.'' This replaces the requirement that
the myocardial infarction be ``typical'' in order to assign the
convalescence evaluation. Since atypical myocardial infarctions may be
just as disabling as typical ones, we have revised the criteria for a
convalescence rating to require that an infarction be ``documented''
rather than ``typical.''
We have deleted the instruction proposed under DC 7005 that
cardiomyopathies (DC 7020) and hypertensive heart disease (DC 7007) are
to be rated as arteriosclerotic heart disease because we have provided
each of these conditions with criteria under its own diagnostic code.
We proposed that hypertensive heart disease (DC 7007) be evaluated
under the criteria for arteriosclerotic heart disease, i.e., percentage
evaluations based on the level of activity that causes symptoms, and we
have revised the criteria using the same objective evaluation criteria
as for arteriosclerotic heart disease.
We have made minor editorial changes under DC 7008 (hyperthyroid
heart disease).
We proposed that a 30-percent evaluation under DC 7010
(supraventricular arrhythmias) require paroxysmal atrial fibrillation
or other supraventricular tachycardia, with severe frequent attacks
despite therapy, and that the 10-percent evaluation require permanent
atrial fibrillation or infrequent or mild attacks documented by
electrocardiogram (ECG) or Holter monitor.
Two commenters pointed out that such phrases as ``severe, frequent
attacks'' are indefinite, and one suggested that we replace these terms
with more objective ones.
We agree and have revised the criteria to require more than four
episodes a year of paroxysmal atrial fibrillation or other
supraventricular tachycardia for the 30-percent level, and permanent
atrial fibrillation or one to four episodes a year of paroxysmal atrial
fibrillation or other supraventricular tachycardia for the 10-percent
level. Both sets of criteria require documentation by ECG or Holter
monitor.
We proposed to evaluate sustained ventricular arrhythmias (DC 7011)
according to whether ``ordinary'' or ``strenuous'' activity results in
palpitations or symptoms of arrhythmia. A commenter objected to the
subjectivity of the proposed criteria for DC 7011.
Based on this comment, we have revised the criteria using the same
objective measurements that we are using for arteriosclerotic heart
disease. We have, however, retained specific provisions for a total
evaluation while an Automatic Implantable Cardioverter-Defibrillator
(AICD) is in place. The use of AICDs is associated with the potential
for serious complications such as myocardial infarction, stroke,
cardiogenic shock, and complications
[[Page 65213]]
associated with the thoracotomy required for its insertion (Braunwald,
750). We have revised the language slightly to make it clear that a
100-percent evaluation will be assigned for as long as the AICD is in
place. We have also made other nonsubstantive changes in the language
at 100 percent for the sake of clarity.
The previous schedule provided a 100-percent evaluation for DC
7015, atrioventricular block, for one year following implantation of a
pacemaker when required by a complete heart block with attacks of
syncope, and a 60-percent evaluation for complete heart block with
Stokes-Adams attacks several times a year despite medication or a
pacemaker. We proposed to eliminate the 100-percent level while
retaining essentially the same criteria for the other levels.
One commenter stated that a 100-percent evaluation is warranted
under DC 7015 when there is a complete heart block with syncopal
attacks despite therapy or a pacemaker. Another commenter suggested
that we replace the requirement for ``several'' attacks a year for the
60-percent evaluation under DC 7015 with a definite number.
Upon further review, in response both to these comments and to the
requests for more objective criteria, we have revised the criteria for
DC 7015 by providing the same objective evaluation criteria we have
used for ventricular arrhythmias (DC 7011) and many other heart
conditions, since heart block may result in a variety of cardiac signs
and symptoms and a wide range of disabilities. This change restores the
100-percent evaluation level. These criteria replace evaluation
criteria based on the electrocardiographic designation of complete or
incomplete block. Because both complete and incomplete heart blocks can
differ in severity, basing evaluations on the degree of heart block
could lead to different evaluations for similar symptoms. In our
judgment, the revised criteria are a better measure of the disabling
effects of atrioventricular block than whether the block is complete or
incomplete.
The only difference in the criteria for atrioventricular block (DC
7015) and ventricular arrhythmias (DC 7011) is that a 10-percent
evaluation for DC 7015 will be assigned when either a pacemaker, a
common method of treatment for this condition, or continuous medication
is required. We have deleted the proposed zero-percent evaluation,
since under the provisions of 38 CFR 4.31a, a zero-percent evaluation
may be assigned when the findings are less than those needed for a
compensable level. We have also edited the note requiring that certain
unusual cases of associated arrhythmias are to be submitted to the
Director of the Compensation and Pension Service for evaluation, for
the sake of clarity.
The previous schedule established a minimum 30-percent evaluation
for heart valve replacement (DC 7016); we proposed a 30-percent
evaluation when strenuous activity causes specific cardiac symptoms,
and a zero-percent evaluation when the condition imposes no limitation
of physical activity. One commenter suggested that we retain the 30-
percent minimum evaluation, but gave no rationale for the suggestion.
The level of residual disability following valve replacement can
also be objectively determined based on the level of activity that
results in symptoms in the same manner as for valvular heart disease.
We have, therefore, revised the criteria to assign a 30-percent
evaluation when a workload of greater than 5 METs but not greater than
7 METs results in symptoms, or when there is evidence of cardiac
hypertrophy or dilatation. For the sake of consistency with the
evaluation criteria for other heart conditions evaluated based on the
level of physical activity that causes symptoms, we have added a ten-
percent evaluation when a workload of greater than 7 METs but not
greater than 10 METs results in symptoms. In our judgment, specific
symptoms warrant the same evaluation whether they occur before or after
valve replacement, and we are not aware of any special circumstances
following valve replacement that would justify a 30-percent minimum
evaluation.
We have edited the language of the note regarding the assignment of
100 percent following admission for heart valve replacement to assure
that the provisions of Sec. 3.105(e) will be followed whether the
reduction from the 100-percent evaluation is based upon the mandatory
examination six months following discharge or following a subsequent
examination.
The previous schedule called for a total evaluation for one year
following heart valve replacement (DC 7016). We proposed a total
evaluation for an indefinite period, with a mandatory VA examination
six months after the surgery, with any change in evaluation based on
that or any subsequent examination to be made under the provisions of
38 CFR 3.105(e).
One commenter objected to the proposed change, stating that heart
valve replacement is a high risk surgical procedure, and many patients
have post-operative congestive heart failure for a considerable time.
Another commenter said that the proposed reduction in length of the
convalescence evaluation is arbitrary, that it goes beyond the purpose
of the review, and that no justification has been provided.
We recognize that it ordinarily takes patients longer to recover
from valve replacement than from acute valvular infection,
endocarditis, or pericarditis and, therefore, proposed an indefinite
period of total evaluation. We believe that six months following
discharge from the hospital is a reasonable time at which to examine a
patient to determine whether the condition has stabilized and the
extent of residual disability. If the results of that or any subsequent
examination warrant a reduction in evaluation, the reduction will be
implemented under the notice and effective date provisions of 38 CFR
3.105(e), which require a 60-day notice before VA reduces an evaluation
and an additional 60-day notice before the reduced evaluation takes
effect. By requiring an examination, the revised procedure will assure
that all residuals are documented; it also ensures that the veteran
receive timely notice of any proposed action and have an opportunity to
present evidence showing that the proposed action should not be taken.
In our judgment, this method will better ensure that actual residual
disabilities and recuperation times are taken into account because they
will be documented on examination.
We proposed to change the length of the total evaluation following
coronary artery bypass surgery (DC 7017) from one year to three months.
One commenter objected, stating that unspecified medical textbooks
suggest resumption of sedentary activity over the two-to three-month
period following surgery, with resumption of full activity after three
months. Another expressed his belief that a reduction to three months
is unreasonably restrictive and does not reflect the average impairment
for those in poor health or those who have cardiomyopathies or
pulmonary and systemic organ congestion.
An article in the Journal of the American College of Cardiology
(1029 vol. 14, no. 4, Oct. 1989) entitled ``Insurability and
Employability of the Patient with Ischemic Heart Disease'' states that
return to work evaluations are appropriate seven weeks after bypass
surgery. Neither this article nor the unidentified information cited by
the commenter justifies the need for a convalescence evaluation longer
than three months. For the individual who requires a longer than
average period of convalescence, a total evaluation may be assigned for
a longer period under the provisions of Secs. 4.29 and 4.30 of the
[[Page 65214]]
rating schedule. We have, therefore, retained the provision assigning a
total evaluation for three months following surgery as proposed.
We proposed that coronary artery bypass surgery be evaluated using
the evaluation criteria for arteriosclerotic heart disease, which was
not a change from the previous schedule. One commenter suggested that
30 percent be the minimum evaluation following bypass surgery,
analogous to arteriosclerotic heart disease (DC 7005).
We have provided objective criteria for evaluation following
coronary bypass surgery that are the same as the criteria we have
provided for arteriosclerotic heart disease (DC 7005). The surgery
itself does not necessarily produce a 30-percent level of impairment;
in fact, it often alleviates the disability from arteriosclerotic heart
disease. In our judgment, an evaluation based on the workload at which
symptoms develop is a reasonable and consistent way to assess the
extent of disability; a 30-percent evaluation will be assigned if
symptoms develop at the same workload that warrants a 30-percent
evaluation for other cardiac conditions.
One commenter suggested that we add a convalescence evaluation
following balloon angioplasty for coronary artery disease.
Most patients who undergo balloon angioplasty are discharged from
the hospital 24 hours or less after surgery, and many can return to
work in a week or less after a successful and uncomplicated angioplasty
(Hurst, 2145 and Braunwald, 1367). In our judgment, a total evaluation
for a specified period to allow for convalescence is, therefore, not
warranted.
We proposed changing the duration of the total evaluation following
implantation of a cardiac pacemaker (currently Note (2) under DC 7015,
proposed as DC 7018) from one year to two months. One commenter said
that the total evaluation should continue for one year; another said
that pacemakers require close monitoring postoperatively and that
patients should not concern themselves with a return to activity sooner
than medically advisable.
Pacemaker implantation is not major surgery, nor is it associated
with debilitating or long-term residuals. Those who undergo a cardiac
pacemaker implantation are usually discharged from the hospital the
following day and are seen in follow-up two weeks after surgery to
check the wound and to test the pacing system (Hurst, 2103-4). They are
subsequently evaluated two months after implantation, and virtually all
patients will have definitive pacemaker programming for long-term
function at that time (Braunwald, 747). Thereafter, there is periodic
monitoring, often conducted by telephone. In our judgment, a two-month
convalescence evaluation is adequate for a normal recovery from
pacemaker implantation.
One commenter suggested that we add a 100-percent evaluation under
DC 7018, implantable cardiac pacemakers, for those patients who require
frequent follow-up and adjustment after pacemaker implant.
DC 7018 allows evaluation of a patient's condition following
implantation of a pacemaker under supraventricular arrhythmias (DC
7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC
7015), if appropriate. A 100-percent evaluation may, therefore, be
assigned based either on symptoms or on the number of episodes of
arrhythmia, depending on the diagnostic code used. These criteria are a
better indicator of residual disability than the frequency of
adjustments or follow-up, and we have made no change based on this
suggestion.
Another commenter felt that 30 percent should be the minimum
evaluation for DC 7018 after a pacemaker has been implanted.
A pacemaker requires regular checkups and monitoring, often by
telephone, but the patient may, in fact, be asymptomatic. An evaluation
of 10 percent rather than 30 percent is more appropriate for such
cases, and we have added a minimum evaluation of 10 percent to the
criteria under DC 7018. This is comparable to the assignment of 10
percent for other cardiac conditions when continuous medication is
required.
One commenter suggested that we add a caveat under pacemaker
implantation (DC 7018) that reimplantation or replacement of a
pacemaker does not warrant a 100-percent evaluation.
The total evaluation for two months following implantation of a
pacemaker is to provide a period of recuperation from the surgery and
any possible side-effects, as well as to provide a period to adjust the
device itself and test the response of the individual's heart. These
considerations apply as well to the replacement of a pacemaker, and, in
our judgment, limiting convalescence evaluations to the initial
implantation only is not warranted.
We proposed to add a new diagnostic code (DC 7019) for cardiac
transplantation allowing a total evaluation for an indefinite period
following the transplant, with a mandatory VA examination to be
conducted one year later. In the past, with no provision for cardiac
transplantation in the rating schedule, a fixed period of convalescence
evaluation for two years was assigned, analogous to what the rating
schedule provided following renal transplant prior to the revisions to
the genitourinary portion of the rating schedule published January 18,
1994.
One commenter stated that the total evaluation following cardiac
transplantation (DC 7019) should continue for two years because the
risk of rejection and survival data show that this is dangerous
surgery.
Because more than 85 percent of one-year survivors of a cardiac
transplant have been rehabilitated and return to work or to school by
the end of one year after transplant (Hurst, 2253-54), in our judgment,
one year following hospital discharge is a reasonable time to conduct
an examination in order to assess residual disability. As with other
indefinite periods of convalescence evaluation, any change in
evaluation based on the results of the examination will be implemented
under the notice and effective date provisions of Sec. 3.105(e), which
require VA to notify the claimant of any proposed reduction, once the
examination has been carried out and reviewed, and allows 60 days for
the claimant to provide additional evidence to show that a reduction
should not be carried out.
We proposed to evaluate cardiac transplantation (DC 7019) under the
same criteria as arteriosclerotic heart disease (DC 7005), i.e.,
according to the level of activity that causes symptoms; we have,
therefore, revised the criteria using the same objective measurements
that we have adopted for evaluating arteriosclerotic heart disease. We
proposed a minimum 30-percent evaluation following cardiac
transplantation as long as the veteran is on immunosuppressive
medication. Because almost every patient will permanently require
immunosuppressive therapy following cardiac transplantation, we have
simply made 30 percent the minimum evaluation and deleted the
requirement that the veteran be taking immunosuppressive medication.
This is consistent with the minimum evaluation for kidney transplant
(DC 7531), which was published in the Federal Register of January 18,
1994 (59 FR 2523).
We also proposed to evaluate cardiomyopathy (DC 7020) under the
same criteria as arteriosclerotic heart disease (DC 7005), i.e.,
according to the level of activity that causes symptoms;
[[Page 65215]]
we have, therefore, revised the criteria using the same objective
measurements that we have adopted for evaluating arteriosclerotic heart
disease.
The previous schedule had a diagnostic code, DC 7100, for
generalized arteriosclerosis, which we proposed to delete. One
commenter objected, stating that this condition, which is often present
in geriatric cases, produces total industrial incapacity with
involutional changes such as cerebral ischemia with reduced mentation,
bone and muscle atrophy, etc.
The effects of generalized arteriosclerosis are so widespread that,
in our judgment, a single diagnostic code is neither appropriate nor
necessary. Many diagnostic codes, such as DC 7005, arteriosclerotic
heart disease, DC 7114, arteriosclerosis obliterans, and DC 9305,
multi-infarct dementia associated with cerebral arteriosclerosis,
represent potential effects of arteriosclerosis on end organs, and
evaluating each disability resulting from generalized arteriosclerosis
under an appropriate code will result in more accurate assessments of
the actual disabilities caused by the condition. We have, therefore,
made no change based on this comment.
Two commenters requested that we define the term hypertension (DC
7101).
In response to this comment, we have revised Note (1) under DC 7101
to state that, for purposes of this section, hypertension means that
the diastolic blood pressure is predominantly 90mm. or greater, and
that isolated systolic hypertension means that the systolic blood
pressure is predominantly 160mm. or greater with a diastolic blood
pressure of less than 90mm. (Cecil, 253, based on the 1988 report of
the Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure).
Since both essential hypertension and secondary types of
hypertension, such as isolated systolic hypertension due to
arteriosclerosis, may be evaluated under this diagnostic code, we have
revised the title of DC 7101 from Hypertensive vascular disease
(essential arterial hypertension) to Hypertensive vascular disease
(hypertension and isolated systolic hypertension).
In the previous schedule, Note (1) under DC 7101 (hypertensive
vascular disease) stated that the 40- and 60-percent evaluations
required careful attention to diagnosis and repeated blood pressure
readings. We proposed to revise the note to state that careful and
repeated measurements of blood pressure readings are required prior to
the assignment of any compensable evaluation.
Two commenters requested that we clarify the meaning of the note.
Standard medical texts recommend multiple blood pressure readings for
the diagnosis of hypertension, although the number of measurements
recommended varies, with ``at least three sets over at least a three-
month interval'' (Braunwald, 818) and ``at least two measurements on
two separate examinations'' (Harrison, 1001) among the specific
recommendations. We have revised the note to require that hypertension
be confirmed by readings taken two or more times on each of at least
three different days. This will assure that the existence of
hypertension is not conceded based solely on readings taken on a
single, perhaps unrepresentative, day.
In a note under DC 7101 (hypertensive vascular disease), the
previous schedule established a minimum evaluation of ten percent when
medication is necessary to control hypertension with a history of
diastolic blood pressure predominantly 100 or more. We proposed to keep
this note.
One commenter asked if 10 percent should be assigned whenever
continuous medication is required for any disorder; another asked if
the assignment of 10 percent for hypertension should depend on the
amount of medication required.
In our judgment, it would not be appropriate to assign a ten-
percent evaluation for every condition which requires continuous
treatment by medication. Whether a ten-percent evaluation is warranted
when continuous medication is required is based on a case-by-case
assessment of each condition and the usual effects of treatment. As to
the second comment, the evaluation for hypertension is based not on the
amount of medication required to control it, but on the level of
control that can be achieved. While there may be more side effects with
higher levels of medication or with combined antihypertensive
medications, the disabling side effects of medication may be separately
evaluated under the provisions of 38 CFR 3.310(a).
Since the provision concerning the assignment of a minimum ten-
percent evaluation when there is a history of diastolic pressure
predominantly 100 or more and continuous medication is required
represents part of the evaluation criteria, we have included it in the
criteria for a ten-percent evaluation, rather than in a separate note,
as proposed.
The previous schedule called for a 100-percent evaluation for
aortic aneurysm (DC 7110) when there are markedly disabling symptoms
and for one year following surgical correction. Because of a
typographical error, omission of a semicolon, the proposed criteria as
published implied that a total evaluation would be assigned following
surgery only if the aneurysm had been 5 cm. or more in diameter. One
commenter pointed out this error. We had intended to propose that
veterans be evaluated as totally disabled under either of two
circumstances: (1) If the aneurysm is 5 cm. or greater in diameter, or
(2) for six months following resection of an aneurysm of any size. We
have corrected the error in the final rule.
In addition, to assure internal consistency, we have revised the
criteria to allow a 100-percent evaluation under DC 7110 in an
additional situation: when an aortic aneurysm is symptomatic. Under DC
7111, aneurysm of any large artery is evaluated at 100 percent if it is
symptomatic. Since the aorta is the largest artery in the body, it
would be inconsistent and inequitable not to allow the same evaluation
that the schedule provides for symptomatic aneurysms of other large
arteries.
The previous schedule assigned a minimum 20-percent evaluation
following surgical correction of aortic aneurysm (DC 7110). We proposed
to evaluate residuals following surgical correction on actual residual
disability, according to the organ system affected, in lieu of
assigning a minimum evaluation. A commenter recommended that we retain
the 20-percent minimum evaluation following surgery, contending that
after such surgery individuals lead a tenuous and extremely sedentary
existence, often requiring revision of the graft.
There is a wide range of possible complications and residual
disability following surgical correction of an aortic aneurysm,
depending on such factors as the location of the aneurysm, its type
(dissecting or not), etc. Because some would warrant a higher, and some
a lower, evaluation than 20 percent, in our judgment it is preferable
to evaluate the actual residuals rather than provide a minimum
evaluation, and we have made no change based on this comment.
We proposed to eliminate the fixed one-year period of convalescence
evaluation following surgical correction of an aortic aneurysm (DC
7110) in favor of a 100-percent evaluation for an indefinite period
from the date of admission for surgical correction, with a mandatory VA
examination six months following discharge, and with any change in
evaluation subject to the notice and effective date provisions of
[[Page 65216]]
Sec. 3.105(e). One commenter urged that we retain the one-year
convalescence evaluation, but gave no specific reasons. We also
proposed an indefinite total evaluation following repair of an aneurysm
of a large artery (DC 7111) although the previous schedule had provided
no post-surgical total evaluation. One commenter suggested that a one-
year period of convalescence evaluation would be appropriate following
repair of an aneurysm of a large artery because, as after aortic
aneurysm repair, these patients lead a tenuous and sedentary existence
after surgery.
The period of total evaluation following surgery under DCs 7110 and
7111 will continue indefinitely under the revised schedule, and an
examination six months following the date of admission for surgical
correction will determine whether a change in evaluation is warranted,
based on actual residuals documented at that time. Since any change
will be implemented under the notice and effective date provisions of
Sec. 3.105 (e), the veteran will have the opportunity to present
medical evidence if he or she disagrees with the proposed change in
evaluation. These provisions assure an evaluation that reflects the
actual disability as documented by medical examination, and we have
made no change based on these comments.
The previous schedule assigned a 10-percent evaluation for aneurysm
of any small artery (DC 7112); we proposed that such an aneurysm be
assigned a zero-percent evaluation. One commenter stated that the
proposed change is based on empirical, as opposed to statistical,
evidence and that evaluations that have stood the test of time should
not be routinely reduced or discontinued.
Small artery aneurysms may produce symptoms such as headaches or
visual abnormalities due to local pressure effects, and an aneurysm
that ruptures may result in a wide variety of symptoms. However, small
artery aneurysms that are asymptomatic are found in about five percent
of the population (Cecil, 2165). Because of the wide range of possible
disabling effects, it is appropriate to rate each one on the actual
findings rather than provide a 10-percent evaluation in all cases. In
our judgment, an asymptomatic aneurysm of a small artery has no
disabling effects and does not warrant a compensable evaluation.
Another commenter asked where and how to rate cerebral aneurysms.
Aneurysms of cerebral arteries are evaluated under DC 7112, as are all
other aneurysms of small arteries. We have made no change in response
to this comment.
The previous schedule specified a minimum evaluation of 60 percent
for traumatic arteriovenous aneurysm (DC 7113) when there is cardiac
involvement, and we proposed no change. One commenter, noting that
designating a minimum evaluation implied that a higher one could be
assigned, asked what findings would warrant an evaluation higher than
60 percent, since 60 percent was also the highest evaluation under DC
7113.
The most serious potential consequence of arteriovenous aneurysm is
congestive heart failure due to high output, which would warrant a 100-
percent evaluation. We have, therefore, added a 100-percent evaluation,
to be assigned if there is high output heart failure.
In response to the request for more objective criteria, we have
revised the criteria for a 60-percent evaluation under DC 7113 to
require an enlarged heart, wide pulse pressure, and tachycardia rather
than the ambiguous term ``cardiac involvement'' that we had proposed.
We have revised the criteria for the 50-percent level for lower
extremity involvement or the 40-percent level for upper extremity
involvement, which were proposed as ``without cardiac involvement with
marked vascular symptoms,'' to require edema, stasis dermatitis, and
either ulceration or cellulitis. We have revised the criteria for the
30-percent level for lower extremity involvement or the 20-percent
level for upper extremity involvement, which were proposed as ``with
definite vascular symptoms,'' to require edema or stasis dermatitis.
These are not substantive changes, but more specific designations of
the cardiac and vascular signs that warrant these evaluations. We have
also revised the title of DC 7113 from ``arteriovenous aneurysm,
traumatic'' to ``arteriovenous fistula, traumatic,'' the currently
accepted term for the condition, which is a direct communication
between an artery and a vein.
One commenter requested that we add a paragraph under
arteriosclerosis obliterans (DC 7114) addressing the evaluation of
aorto-femoral bypass grafts.
To assure consistent evaluations of the residuals of aortic and
large arterial bypass surgery, we have added a note under DC 7114
stating that the residuals of aortic and large arterial bypass surgery
or arterial grafts are to be rated under that code. Since the most
common residuals of bypass surgery are signs and symptoms of arterial
insufficiency, it is appropriate to evaluate them under the criteria
for arteriosclerosis obliterans.
Two commenters suggested we provide a specific period of
convalescence evaluation following bypass surgery for aortoiliac and
femoral-popliteal artery disease.
The evaluation criteria for serious complications that might result
from bypass surgery and, therefore, be service-connected under the
provisions of 38 CFR 3.310(a), such as myocardial infarction, have
their own periods of convalescence evaluation. For the milder
complications, or the uncomplicated cases, the standard periods of
convalescence evaluation authorized under Sec. 4.30 of this part are
adequate, and we have made no change based on these comments.
The criterion for the 40-percent evaluation for arteriosclerosis
obliterans (DC 7114) in the previous schedule was ``well-established
cases with intermittent claudication or recurrent episodes of
superficial phlebitis;'' we proposed to revise this criterion to
``well-established cases of intermittent claudication with associated
physical findings (hair loss, skin changes).'' We proposed for the 100-
percent level: ``severe, with marked physical signs producing total
incapacity''; for the 60-percent level: ``claudication on minimal
walking (less than three miles per hour on a level grade) with
persistent coldness of the extremity''; and for the 20-percent level:
``minimal circulatory impairment, with paresthesias, temperature
changes and occasional claudication.'' One commenter noted that the
phrase ``well-established cases'' is one of the vague, indefinite, and
arbitrary elements in the schedule.
In response to both that comment and the requests for more
objective criteria, we have revised the criteria under this diagnostic
code: To specify at each evaluation level the distance that can be
covered before claudication occurs; and to base evaluations on
objective physical findings, such as peripheral pulses, trophic
changes, persistent coldness, and deep ischemic ulcers. We have also
added an objective alternative criterion, the ankle/brachial index, at
each level, and a note explaining that this index is obtained by
dividing the systolic blood pressure at the ankle by the systolic blood
pressure in the arm. The ratio is normally one or greater; but because
arterial occlusive disease obstructs the blood flow in the legs, the
ratio in patients with that condition is less than one. A ratio of less
than 0.5 is consistent with severe ischemia (Harrison, 1019). The
ankle/brachial index thus allows a noninvasive
[[Page 65217]]
objective assessment of the severity of peripheral vascular disease.
We proposed to evaluate Raynaud's syndrome (DC 7117) as 100-
percent, 60-percent, 40-percent, or 20-percent disabling, using
measures such as ``marked'' circulatory changes, ``multiple'' ulcerated
areas, ``frequent'' vasomotor disturbances, and ``occasional'' attacks
of blanching or flushing. One commenter suggested that we replace
subjective terms with more objective requirements.
Simply replacing the indefinite words would not result in truly
objective criteria. We have, therefore, defined ``characteristic
attacks'' of Raynaud's disease for VA purposes as consisting of
sequential color changes of the digits lasting minutes to hours,
sometimes with pain and paresthesias, and precipitated by exposure to
cold or by emotional upsets. We have revised the evaluation criteria
based on the frequency of characteristic attacks, the number of digital
ulcers, and whether autoamputation in one or more digits has occurred.
While we proposed no change in the former 20-percent level, which
required ``occasional attacks of blanching or flushing,'' under the
more objective criteria we have provided both a 20- and a 10-percent
level, with 20-percent requiring characteristic attacks four to six
times a week, and 10-percent requiring characteristic attacks one to
three times a week. This will ensure more consistent evaluations in
milder cases of Raynaud's, where, in the former schedule, the
assignment of zero percent or 20 percent depended on an individual
rater's interpretation of ``occasional.''
One commenter suggested that we include neurologic symptoms
associated with exposure to low or subfreezing temperatures under the
evaluation criteria for DC 7117.
In response to this comment, we have included pain and
paresthesias, which are neurologic symptoms, among the possible
manifestations of the characteristic attacks of Raynaud's syndrome.
We proposed to assign 40-percent, 20-percent, and zero-percent
evaluations for angioneurotic edema (DC 7118), based generally on the
frequency, severity, and duration of attacks. One commenter recommended
that we add a 10-percent evaluation; another recommended that we
replace language such as ``frequent'' and ``infrequent'' with more
definite terms.
Angioneurotic edema is a condition that is ordinarily self-limited,
with attacks subsiding in one to seven days (Merck, 333), but at times
palliative treatment is used. There are also unusual types that are
more persistent and resistant to therapy. We have established more
objective criteria based on the typical duration of attacks, their
frequency, and on whether there is laryngeal involvement. We have added
a 10-percent evaluation, to be assigned if attacks without laryngeal
involvement occur two to four times a year. These criteria will foster
more consistent evaluations for angioneurotic edema, since different
raters will not be required to interpret subjective terms such as
``mild,'' ``moderate,'' ``frequent,'' and ``infrequent.''
One commenter suggested that when angioneurotic edema affects the
larynx even briefly, a 10-percent evaluation is warranted.
In our judgment, angioneurotic edema affecting the larynx does
warrant separate consideration in the evaluation criteria because
laryngeal edema commonly causes respiratory distress due to airway
obstruction and requires emergency treatment. This situation is serious
enough that if it occurs once or twice a year, it warrants a 20-percent
evaluation; if it occurs more than twice a year, it warrants a 40-
percent evaluation.
A second commenter objected that the proposed changes to DC 7118
were based on empirical, as opposed to statistical, information.
As noted under the response to comments about DC 7122, 38 U.S.C.
1155 gives the Secretary the authority to revise the rating schedule
periodically in accordance with experience. The revisions of these
criteria are based on the usual effects of the disease, which is
consistent with the basis of revisions throughout the current
comprehensive revision of the rating schedule. They are medically,
rather than statistically, based, and no statistical studies were done
in conjunction with the revision.
Under the previous schedule, there were a variety of methods used
to evaluate vascular diseases affecting the extremities, particularly
when more than one extremity was affected. For example, the criteria
for thrombophlebitis (DC 7121) applied to a single extremity, and if
other extremities were affected, they were separately evaluated. For
varicose veins (DC 7120), the criteria for a 10-percent evaluation
applied to either unilateral or bilateral involvement; but at other
evaluation levels, different percentages were assigned for unilateral
and bilateral involvement, with no direction for evaluation if one
extremity were more severely affected than the other. The criteria for
intermittent claudication (DC 7116) applied to a single extremity;
determining the evaluation for multiple extremities required
application of a complex set of rules (contained in a note following DC
7117) that sometimes produced an evaluation for involvement of multiple
extremities no higher than that for involvement of a single extremity.
We proposed no substantive change in either the methods of evaluating
these conditions or in the percentage levels.
One commenter questioned why the percentage evaluations and the
method of determining the evaluation when more than one extremity is
affected differ for arterial and venous diseases. He suggested that we
use 20-, 40,-and 60-percent levels for both peripheral arterial
diseases (DCs 7114 through 7117), and venous diseases (DCs 7120 and
7121) instead of the variety of levels proposed, and that we adopt a
uniform and simple method of determining evaluations when more than one
extremity is involved, such as adding ten percent for each additional
extremity involved.
We proposed evaluations levels of 20, 40, 60, and 100 percent for
DCs 7114, 7115, and 7117, and we have kept those levels in this rule,
with the addition of a 10-percent level for DC 7117. (We removed DC
7116, ``intermittent claudication,'' which was in the previous
schedule, because it was a symptom of disease rather than a disease.)
In response to the comment, we have further revised DCs 7120 (varicose
veins) and 7121 (post-phlebitic syndrome of any etiology) to provide
percentage evaluation levels of 10, 20, 40, 60, and 100 percent. In
addition, we have revised the method of evaluating DCs 7114
(arteriosclerosis obliterans), 7115 (thromboangiitis obliterans), and
7120 (varicose veins) so that the criteria apply to a single extremity,
as the criteria for DC 7121 do. If the paired extremity is also
affected, the evaluation for each extremity will be separately
determined and combined using the combined ratings table (see 38 CFR
4.25) and the bilateral factor (see 38 CFR 4.26) when applicable.
Section 4.26 also provides instructions on applying the bilateral
factor when there is involvement of upper and lower extremities. While
we have made the percentage levels similar, the signs, symptoms, and
effects of venous and arterial diseases differ greatly and, therefore,
require different evaluation criteria.
In order to adopt the more consistent method of separately
evaluating each extremity affected by vascular disease and to assure
that venous conditions with similar findings receive consistent
evaluations, further revisions of the evaluation criteria for varicose
veins
[[Page 65218]]
(DC 7120) and post-phlebitic syndrome of any etiology (DC 7121) were
required.
Varicose veins are ordinarily asymptomatic or mildly symptomatic,
but may produce prolonged venous insufficiency and progress to
thrombophlebitis and postphlebitic syndrome. Signs of venous
insufficiency, such as edema, stasis pigmentation, ulceration, eczema,
and induration, and symptoms such as aching and fatigue, are the major
disabling effects of varicose veins. The size, location, extent, etc.,
of varicose veins do not correlate with symptoms (Merck, 590), and we
have removed those criteria as factors in evaluation. The presence or
absence of impairment of the deep circulation is more an indicator of
the feasibility of surgical repair than of functional impairment, and
we have, therefore, removed references to the deep circulation from the
evaluation criteria. We have replaced these criteria with criteria
based on symptoms (such as aching and fatigue after prolonged standing
or walking) or objective physical findings (such as edema, stasis
pigmentation, eczema, or ulceration).
The effects of chronic venous insufficiency are the same, whether
from varicosities, thrombophlebitis, or some other cause. The
postphlebitic syndrome may itself lead to the development of
varicosities because of chronic venous insufficiency (Cecil, 363-7).
Therefore, the possible manifestations and disabling effects of
varicose veins and postphlebitic syndrome are very similar, and we have
used the same criteria to evaluate both conditions, with evaluation
levels of 0, 10, 20, 40, 60, and 100 percent for involvement of a
single extremity, and the same method of evaluation for multiple
extremity involvement as that used in arterial vascular disease of the
extremities.
We added under DC 7120: ``With the following findings attributed to
the effects of varicose veins,'' and under DC 7121: ``With the
following findings attributed to venous disease'' in order to assure
that the examiner has determined that the abnormal findings are
attributed to venous disease.
One commenter suggested that we clarify how to assign bilateral
evaluations for frozen feet (DC 7122) and varicose veins (DC 7120) when
one extremity is more severely affected than the other.
The changes described above that we have made in the evaluation
criteria, evaluation percentages, and method of determining an
evaluation for multiple extremity involvement will allow accurate and
consistent evaluations when more than one extremity is affected by
varicose veins, but to different degrees. We have made similar changes
in the method of evaluating cold injury, DC 7122, in order to assure
accurate and consistent evaluations when there is multiple extremity
involvement, and this is further discussed below.
We proposed no change in the previous evaluation criteria for
frozen feet (DC 7122). One commenter suggested that we expand the
criteria to include cold injuries to the hands, face, and ears; another
suggested that higher ratings may be warranted for loss of use of
multiple fingers or one or both hands.
We have revised the title of DC 7122 from ``frozen feet, residuals
of'' to ``cold injury, residuals of'' to indicate that it may be used
to evaluate any cold injury. Because cold injury produces similar
tissue changes wherever it occurs, a single diagnostic code and set of
evaluation criteria are adequate; we have, however, revised the
criteria to more accurately reflect the range of effects that cold
injury may produce, such as arthralgia, tissue loss, nail
abnormalities, and color changes. We have also deleted the bilateral
evaluations contained in the prior schedule in favor of evaluating each
affected part separately and combining them for the overall evaluation
for cold injury, a change which is similar to changes we have made in
the method of evaluating peripheral arterial and venous diseases of the
extremities. In the case of paired extremities, the evaluations will be
combined, if appropriate, in accordance with Secs. 4.25 and 4.26 (as
described in Note (2), added following DC 7122).
The proposed note following DC 7122 directed that higher ratings
could be assigned, if warranted, because of loss of toes, by reference
to amputation ratings. We have edited this Note (1) for clarity and
added a statement about the evaluation of complications such as
peripheral neuropathy or squamous cell carcinoma of the skin at the
site of a scar.
One commenter requested that we include neurologic symptoms
associated with exposure to low or subfreezing temperatures in the
evaluation criteria for DC 7122, cold injuries.
In response to this suggestion, we have added numbness or locally
impaired sensation, which are neurologic symptoms, to the evaluation
criteria.
One individual suggested that cold injuries of the hands are
generally more disabling than those of the lower extremities.
The severity of cold injuries to various parts of the body depends
on such factors as the extent and duration of exposure, more than on
the particular part affected. We have provided evaluation criteria
that, applied with the notes regarding amputations and complications,
are flexible enough to cover a broad range of severity and allow
evaluation of any extent of tissue damage from cold injury to any body
part, so we have not adopted any changes based on this comment.
The current schedule provides six months of convalescence
evaluation for soft tissue sarcoma of vascular origin (DC 7123). We
proposed that a total evaluation be assigned indefinitely, with a
mandatory VA examination to be conducted six months following the
completion of therapy. One commenter recommended that we allow one year
of convalescence evaluation.
We believe that an examination six months following the cessation
of treatment affords sufficient time for convalescence and
stabilization of residuals, particularly since the rule requires only
an examination, not a reduction, at that time. In our judgment, this
method of determining the length of the total evaluation is both fairer
and more accurate than assigning a total evaluation for a specified
length of time, since the evaluation will be based on actual residual
disability as documented by the examination, and the veteran will
receive advance notice of any change and have the opportunity to submit
additional evidence showing that the change is not warranted.
Two commenters requested that VA provide a zero-percent evaluation
for all diagnostic codes.
On October 6, 1993, VA revised its regulation addressing the issue
zero-percent evaluations (38 CFR 4.31) to authorize assignment of a
zero-percent evaluation for any disability in the rating schedule when
minimum requirements for a compensable evaluation are not met. In
general, that regulatory provision precludes the need for zero-percent
evaluation criteria.
On further review, we have revised the title of DC 7121 from
``phlebitis or thrombophlebitis'' to ``post-phlebitic syndrome of any
etiology'' because both superficial and deep acute thrombophlebitis are
transient conditions, but it is the chronic form of thrombophlebitis
with venous insufficiency, known as ``postphlebitic leg,''
``postphlebitic sequelae of chronic venous insufficiency,''
``postphlebitic syndrome,'' or ``stasis syndrome,'' that may follow
thrombophlebitis. This is not a substantive change.
[[Page 65219]]
For the sake of clarity, we have made nonsubstantive changes in the
notes under ventricular arrhythmias (DC 7011), heart valve replacement
(DC 7016), cardiac transplantation (DC 7019), aortic aneurysm (DC
7110), aneurysm, any large artery (DC 7111), and soft tissue sarcoma
(DC 7123).
VA appreciates the comments submitted in response to the proposed
rule, which is now adopted with the amendments noted above.
The Secretary hereby certifies that this regulatory amendment will
not have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act (RFA), 5
U.S.C. 601-612. The reason for this certification is that this
amendment would not directly affect any small entities. Only VA
beneficiaries could be directly affected. Therefore, pursuant to 5
U.S.C. 605(b), this amendment is exempt from the initial and final
regulatory flexibility analysis requirements of sections 603 and 604.
This regulatory amendment has been reviewed by the Office of
Management and Budget under the provisions of Executive Order 12866,
Regulatory Planning and Review, dated September 30, 1993.
The Catalog of Federal Domestic Assistance program numbers are
64.104 and 64.109.
List of Subjects in 38 CFR Part 4
Disability benefits, Individuals with disabilities, Pensions,
Veterans.
Approved: August 7, 1997.
Hershel W. Gober,
Acting Secretary of Veterans Affairs.
For the reasons set out in the preamble, 38 CFR part 4, subpart B,
is amended as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
Subpart B--Disability Ratings
Secs. 4.100 through 4.102 [Removed and Reserved]
2. Sections 4.100, 4.101, 4.102 are removed and reserved.
3. Section 4.104 is revised to read as follows:
Sec. 4.104 Schedule of ratings--cardiovascular system.
Diseases of the Heart
Note (1): Evaluate cor pulmonale, which is a form of secondary heart
disease, as part of the pulmonary condition that causes it.
Note (2): One MET (metabolic equivalent) is the energy cost of
standing quietly at rest and represents an oxygen uptake of 3.5
milliliters per kilogram of body weight per minute. When the level
of METs at which dyspnea, fatigue, angina, dizziness, or syncope
develops is required for evaluation, and a laboratory determination
of METs by exercise testing cannot be done for medical reasons, an
estimation by a medical examiner of the level of activity (expressed
in METs and supported by specific examples, such as slow stair
climbing or shoveling snow) that results in dyspnea, fatigue,
angina, dizziness, or syncope may be used.
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
7000 Valvular heart disease (including rheumatic heart
disease):
During active infection with valvular heart damage and
for three months following cessation of therapy for
the active infection.................................. 100
Thereafter, with valvular heart disease (documented by
findings on physical examination and either
echocardiogram, Doppler echocardiogram, or cardiac
catheterization) resulting in:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electro-cardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7001 Endocarditis:
For three months following cessation of therapy for
active infection with cardiac involvement............. 100
Thereafter, with endocarditis (documented by findings
on physical examination and either echocardiogram,
Doppler echocardiogram, or cardiac catheterization)
resulting in:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7002 Pericarditis:
For three months following cessation of therapy for
active infection with cardiac involvement............. 100
Thereafter, with documented pericarditis resulting in:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electro-cardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
[[Page 65220]]
7003 Pericardial adhesions:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electro-cardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7004 Syphilitic heart disease:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
Note: Evaluate syphilitic aortic aneurysms under DC 7110
(aortic aneurysm).
7005 Arteriosclerotic heart disease (Coronary artery
disease):
With documented coronary artery disease resulting in:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
Note: If nonservice-connected arteriosclerotic heart
disease is superimposed on service-connected valvular or
other non-arteriosclerotic heart disease, request a
medical opinion as to which condition is causing the
current signs and symptoms.
7006 Myocardial infarction:
During and for three months following myocardial
infarction, documented by laboratory tests............ 100
Thereafter:
With history of documented myocardial infarction,
resulting in:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7007 Hypertensive heart disease:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7008 Hyperthyroid heart disease:
Include as part of the overall evaluation for
hyperthyroidism under DC 7900. However, when atrial
fibrillation is present, hyperthyroidism may be
evaluated either under DC 7900 or under DC 7010
(supraventricular arrhythmia), whichever results in a
higher evaluation.
7010 Supraventricular arrhythmias:
Paroxysmal atrial fibrillation or other
supraventricular tachycardia, with more than four
episodes per year documented by ECG or Holter monitor. 30
Permanent atrial fibrillation (lone atrial
fibrillation), or; one to four episodes per year of
paroxysmal atrial fibrillation or other
supraventricular tachycardia documented by ECG or
Holter monitor........................................ 10
7011 Ventricular arrhythmias (sustained):
For indefinite period from date of hospital admission
for initial evaluation and medical therapy for a
sustained ventricular arrhythmia, or; for indefinite
period from date of hospital admission for ventricular
aneurysmectomy, or; with an automatic implantable
Cardioverter-Defibrillator (AICD) in place............ 100
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
[[Page 65221]]
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
Note: A rating of 100 percent shall be assigned from the
date of hospital admission for initial evaluation and
medical therapy for a sustained ventricular arrhythmia or
for ventricular aneurysmectomy. Six months following
discharge, the appropriate disability rating shall be
determined by mandatory VA examination. Any change in
evaluation based upon that or any subsequent examination
shall be subject to the provisions of Sec. 3.105(e) of
this chapter.
7015 Atrioventricular block:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication or a pacemaker
required.............................................. 10
Note: Unusual cases of arrhythmia such as atrioventricular
block associated with a supraventricular arrhythmia or
pathological bradycardia should be submitted to the
Director, Compensation and Pension Service. Simple delayed
P-R conduction time, in the absence of other evidence of
cardiac disease, is not a disability.
7016 Heart valve replacement (prosthesis):
For indefinite period following date of hospital
admission for valve replacement....................... 100
Thereafter:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
Note: A rating of 100 percent shall be assigned as of the
date of hospital admission for valve replacement. Six
months following discharge, the appropriate disability
rating shall be determined by mandatory VA examination.
Any change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of Sec.
3.105(e) of this chapter.
7017 Coronary bypass surgery:
For three months following hospital admission for
surgery............................................... 100
Thereafter:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
7018 Implantable cardiac pacemakers:
For two months following hospital admission for
implantation or reimplantation........................ 100
Thereafter:
Evaluate as supraventricular arrhythmias (DC 7010),
ventricular arrhythmias (DC 7011), or atrioventricular
block (DC 7015). Minimum.............................. 10
Note: Evaluate implantable Cardioverter-Defibrillators
(AICD's) under DC 7011.
7019 Cardiac transplantation:
For an indefinite period from date of hospital
admission for cardiac transplantation................. 100
Thereafter:
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Minimum............................................ 30
Note: A rating of 100 percent shall be assigned as of the
date of hospital admission for cardiac transplantation.
One year following discharge, the appropriate disability
rating shall be determined by mandatory VA examination.
Any change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of Sec.
3.105(e) of this chapter.
7020 Cardiomyopathy:
[[Page 65222]]
Chronic congestive heart failure, or; workload of 3
METs or less results in dyspnea, fatigue, angina,
dizziness, or syncope, or; left ventricular
dysfunction with an ejection fraction of less than 30
percent............................................... 100
More than one episode of acute congestive heart failure
in the past year, or; workload of greater than 3 METs
but not greater than 5 METs results in dyspnea,
fatigue, angina, dizziness, or syncope, or; left
ventricular dysfunction with an ejection fraction of
30 to 50 percent...................................... 60
Workload of greater than 5 METs but not greater than 7
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; evidence of cardiac hypertrophy or
dilatation on electrocardiogram, echocardiogram, or X-
ray................................................... 30
Workload of greater than 7 METs but not greater than 10
METs results in dyspnea, fatigue, angina, dizziness,
or syncope, or; continuous medication required........ 10
Diseases of the Arteries and Veins
7101 Hypertensive vascular disease (hypertension and
isolated systolic hypertension):
Diastolic pressure predominantly 130 or more........... 60
Diastolic pressure predominantly 120 or more........... 40
Diastolic pressure predominantly 110 or more, or;
systolic pressure predominantly 200 or more........... 20
Diastolic pressure predominantly 100 or more, or;
systolic pressure predominantly 160 or more, or;
minimum evaluation for an individual with a history of
diastolic pressure predominantly 100 or more who
requires continuous medication for control............ 10
Note (1): Hypertension or isolated systolic hypertension
must be confirmed by readings taken two or more times on
at least three different days. For purposes of this
section, the term hypertension means that the diastolic
blood pressure is predominantly 90mm. or greater, and
isolated systolic hypertension means that the systolic
blood pressure is predominantly 160mm. or greater with a
diastolic blood pressure of less than 90mm.
Note (2): Evaluate hypertension due to aortic insufficiency
or hyperthyroidism, which is usually the isolated systolic
type, as part of the condition causing it rather than by a
separate evaluation.
7110 Aortic aneurysm:
If five centimeters or larger in diameter, or; if
symptomatic, or; for indefinite period from date of
hospital admission for surgical correction (including
any type of graft insertion).......................... 100
Precluding exertion.................................... 60
Evaluate residuals of surgical correction according to
organ systems affected.
Note: A rating of 100 percent shall be assigned as of the
date of admission for surgical correction. Six months
following discharge, the appropriate disability rating
shall be determined by mandatory VA examination. Any
change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of Sec.
3.105(e) of this chapter.
7111 Aneurysm, any large artery:
If symptomatic, or; for indefinite period from date of
hospital admission for surgical correction............ 100
Following surgery:
Ischemic limb pain at rest, and; either deep ischemic
ulcers or ankle/brachial index of 0.4 or less......... 100
Claudication on walking less than 25 yards on a level
grade at 2 miles per hour, and; persistent coldness of
the extremity, one or more deep ischemic ulcers, or
ankle/brachial index of 0.5 or less................... 60
Claudication on walking between 25 and 100 yards on a
level grade at 2 miles per hour, and; trophic changes
(thin skin, absence of hair, dystrophic nails) or
ankle/brachial index of 0.7 or less................... 40
Claudication on walking more than 100 yards, and;
diminished peripheral pulses or ankle/brachial index
of 0.9 or less........................................ 20
Note (1): The ankle/brachial index is the ratio of the
systolic blood pressure at the ankle (determined by
Doppler study) divided by the simultaneous brachial artery
systolic blood pressure. The normal index is 1.0 or
greater.
Note (2): These evaluations are for involvement of a single
extremity. If more than one extremity is affected,
evaluate each extremity separately and combine (under Sec.
4.25), using the bilateral factor, if applicable.
Note (3): A rating of 100 percent shall be assigned as of
the date of hospital admission for surgical correction.
Six months following discharge, the appropriate disability
rating shall be determined by mandatory VA examination.
Any change in evaluation based upon that or any subsequent
examination shall be subject to the provisions of Sec.
3.105(e) of this chapter.
7112 Aneurysm, any small artery:
Asymptomatic........................................... 0
Note: If symptomatic, evaluate according to body system
affected. Following surgery, evaluate residuals under the
body system affected.
7113 Arteriovenous fistula, traumatic:
With high output heart failure......................... 100
Without heart failure but with enlarged heart, wide
pulse pressure, and tachycardia....................... 60
Without cardiac involvement but with edema, stasis
dermatitis, and either ulceration or cellulitis:
Lower extremity.................................... 50
Upper extremity.................................... 40
With edema or stasis dermatitis:
Lower extremity.................................... 30
Upper extremity.................................... 20
7114 Arteriosclerosis obliterans:
Ischemic limb pain at rest, and; either deep ischemic
ulcers or ankle/brachial index of 0.4 or less......... 100
Claudication on walking less than 25 yards on a level
grade at 2 miles per hour, and; either persistent
coldness of the extremity or ankle/brachial index of
0.5 or less........................................... 60
Claudication on walking between 25 and 100 yards on a
level grade at 2 miles per hour, and; trophic changes
(thin skin, absence of hair, dystrophic nails) or
ankle/brachial index of 0.7 or less................... 40
Claudication on walking more than 100 yards, and;
diminished peripheral pulses or ankle/brachial index
of 0.9 or less........................................ 20
Note (1): The ankle/brachial index is the ratio of the
systolic blood pressure at the ankle (determined by
Doppler study) divided by the simultaneous brachial artery
systolic blood pressure. The normal index is 1.0 or
greater.
Note (2): Evaluate residuals of aortic and large arterial
bypass surgery or arterial graft as arteriosclerosis
obliterans.
Note (3): These evaluations are for involvement of a single
extremity. If more than one extremity is affected,
evaluate each extremity separately and combine (under Sec.
4.25), using the bilateral factor (Sec. 4.26), if
applicable.
[[Page 65223]]
7115 Thrombo-angiitis obliterans (Buerger's Disease):
Ischemic limb pain at rest, and; either deep ischemic
ulcers or ankle/brachial index of 0.4 or less......... 100
Claudication on walking less than 25 yards on a level
grade at 2 miles per hour, and; either persistent
coldness of the extremity or ankle/brachial index of
0.5 or less........................................... 60
Claudication on walking between 25 and 100 yards on a
level grade at 2 miles per hour, and; trophic changes
(thin skin, absence of hair, dystrophic nails) or
ankle/brachial index of 0.7 or less................... 40
Claudication on walking more than 100 yards, and;
diminished peripheral pulses or ankle/brachial index
of 0.9 or less........................................ 20
Note (1): The ankle/brachial index is the ratio of the
systolic blood pressure at the ankle (determined by
Doppler study) divided by the simultaneous brachial artery
systolic blood pressure. The normal index is 1.0 or
greater.
Note (2): These evaluations are for involvement of a single
extremity. If more than one extremity is affected,
evaluate each extremity separately and combine (under Sec.
4.25), using the bilateral factor (Sec. 4.26), if
applicable.
7117 Raynaud's syndrome:
With two or more digital ulcers plus autoamputation of
one or more digits and history of characteristic
attacks............................................... 100
With two or more digital ulcers and history of
characteristic attacks................................ 60
Characteristic attacks occurring at least daily........ 40
Characteristic attacks occurring four to six times a
week.................................................. 20
Characteristic attacks occurring one to three times a
week.................................................. 10
Note: For purposes of this section, characteristic attacks
consist of sequential color changes of the digits of one
or more extremities lasting minutes to hours, sometimes
with pain and paresthesias, and precipitated by exposure
to cold or by emotional upsets. These evaluations are for
the disease as a whole, regardless of the number of
extremities involved or whether the nose and ears are
involved.
7118 Angioneurotic edema:
Attacks without laryngeal involvement lasting one to
seven days or longer and occurring more than eight
times a year, or; attacks with laryngeal involvement
of any duration occurring more than twice a year...... 40
Attacks without laryngeal involvement lasting one to
seven days and occurring five to eight times a year,
or; attacks with laryngeal involvement of any duration
occurring once or twice a year........................ 20
Attacks without laryngeal involvement lasting one to
seven days and occurring two to four times a year..... 10
7119 Erythromelalgia:
Characteristic attacks that occur more than once a day,
last an average of more than two hours each, respond
poorly to treatment, and that restrict most routine
daily activities...................................... 100
Characteristic attacks that occur more than once a day,
last an average of more than two hours each, and
respond poorly to treatment, but that do not restrict
most routine daily activities......................... 60
Characteristic attacks that occur daily or more often
but that respond to treatment......................... 30
Characteristic attacks that occur less than daily but
at least three times a week and that respond to
treatment............................................. 10
Note: For purposes of this section, a characteristic attack
of erythromelalgia consists of burning pain in the hands,
feet, or both, usually bilateral and symmetrical, with
increased skin temperature and redness, occurring at warm
ambient temperatures. These evaluations are for the
disease as a whole, regardless of the number of
extremities involved.
7120 Varicose veins:
With the following findings attributed to the effects
of varicose veins: Massive board-like edema with
constant pain at rest................................. 100
Persistent edema or subcutaneous induration, stasis
pigmentation or eczema, and persistent ulceration..... 60
Persistent edema and stasis pigmentation or eczema,
with or without intermittent ulceration............... 40
Persistent edema, incompletely relieved by elevation of
extremity, with or without beginning stasis
pigmentation or eczema................................ 20
Intermittent edema of extremity or aching and fatigue
in leg after prolonged standing or walking, with
symptoms relieved by elevation of extremity or
compression hosiery................................... 10
Asymptomatic palpable or visible varicose veins........ 0
Note: These evaluations are for involvement of a single
extremity. If more than one extremity is involved,
evaluate each extremity separately and combine (under Sec.
4.25), using the bilateral factor (Sec. 4.26), if
applicable.
7121 Post-phlebitic syndrome of any etiology:
With the following findings attributed to venous
disease:
Massive board-like edema with constant pain at rest 100
Persistent edema or subcutaneous induration, stasis
pigmentation or eczema, and persistent ulceration. 60
Persistent edema and stasis pigmentation or eczema,
with or without intermittent ulceration........... 40
Persistent edema, incompletely relieved by
elevation of extremity, with or without beginning
stasis pigmentation or eczema..................... 20
Intermittent edema of extremity or aching and
fatigue in leg after prolonged standing or
walking, with symptoms relieved by elevation of
extremity or compression hosiery.................. 10
Asymptomatic palpable or visible varicose veins.... 0
Note: These evaluations are for involvement of a single
extremity. If more than one extremity is involved,
evaluate each extremity separately and combine (under Sec.
4.25), using the bilateral factor (Sec. 4.26), if
applicable.
7122 Cold injury residuals:
With pain, numbness, cold sensitivity, or arthralgia
plus two or more of the following: tissue loss, nail
abnormalities, color changes, locally impaired
sensation, hyperhidrosis, X-ray abnormalities
(osteoporosis, subarticular punched out lesions, or
osteoarthritis) of affected parts..................... 30
With pain, numbness, cold sensitivity, or arthralgia
plus tissue loss, nail abnormalities, color changes,
locally impaired sensation, hyperhidrosis, or X-ray
abnormalities (osteoporosis, subarticular punched out
lesions, or osteoarthritis) of affected parts......... 20
With pain, numbness, cold sensitivity, or arthralgia... 10
Note (1): Amputations of fingers or toes, and complications
such as squamous cell carcinoma at the site of a cold
injury scar or peripheral neuropathy should be separately
evaluated under other diagnostic codes.
Note (2): Evaluate each affected part (hand, foot, ear,
nose) separately and combine the ratings, if appropriate,
in accordance with Secs. 4.25 and 4.26.
[[Page 65224]]
7123 Soft tissue sarcoma (of vascular origin)............. 100
Note: A rating of 100 percent shall continue beyond the
cessation of any surgical, X-ray, antineoplastic
chemotherapy or other therapeutic procedure. Six months
after discontinuance of such treatment, the appropriate
disability rating shall be determined by mandatory VA
examination. Any change in evaluation based upon that or
any subsequent examination shall be subject to the
provisions of Sec. 3.105(e) of this chapter. If there has
been no local recurrence or metastasis, rate on residuals.
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(Authority: 38 U.S.C. 1155)
[FR Doc. 97-32413 Filed 12-10-97; 8:45 am]
BILLING CODE 8320-01-P