[Federal Register Volume 59, Number 228 (Tuesday, November 29, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-29274]
[[Page Unknown]]
[Federal Register: November 29, 1994]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AG86
Chronic Fatigue Syndrome
AGENCY: Department of Veterans Affairs.
ACTION: Interim rule with request for comments.
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SUMMARY: This document amends the Department of Veterans Affairs (VA)
Schedule for Rating Disabilities by adding a diagnostic code and
evaluation criteria for chronic fatigue syndrome. The intended effect
of this amendment is to ensure that veterans diagnosed with this
condition meet uniform criteria and receive consistent evaluations.
DATES: Comments must be received on or before January 30, 1995. This
amendment is effective November 29, 1994.
ADDRESSES: Mail written comments to: Director, Office of Regulations
Management (02D), Department of Veterans Affairs, 810 Vermont Ave., NW,
Washington, DC 20420 or hand deliver written comments to: Office of
Regulations Management, Room 1176, 801 Eye Street, NW, Washington, DC
20001. Comments should indicate that they are submitted in response to
``RIN 2900-AG86.'' All written comments received will be available for
public inspection in the Office of Regulations Management, Room 1176,
801 Eye Street, NW, Washington, DC 20001 between the hours of 8:00 a.m.
and 4:30 p.m., Monday through Friday (except holidays).
FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,
Regulations Staff, Compensation and Pension Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW,
Washington DC 20420, (202) 273-7210.
SUPPLEMENTARY INFORMATION: Chronic fatigue syndrome (CFS), while
similar to syndromes described in the last century, such as
neurasthenia, is a syndrome in which there has been renewed interest in
recent years. This document establishes a diagnostic code and criteria
for its evaluation. While this condition is of unknown etiology, we
have included it with systemic diseases, now designated Sec. 4.88b,
because it often involves many body systems, and may be of infectious
or immune origin, similar to other diseases in this section.
CFS is a condition characterized by non-specific symptoms. Because
it has been ill-defined and sometimes confused with other conditions,
we have provided required diagnostic criteria for VA purposes in
Sec. 4.88a. These criteria are based on diagnostic criteria for CFS
provided in a pamphlet entitled ``Chronic Fatigue Syndrome--A Pamphlet
for Physicians'' published in May, 1992 by the U.S. Department of
Health and Human Services, Public Health Service, National Institutes
of Health (NIH Publication No. 92-484).
The diagnosis of CFS, according to the NIH pamphlet, requires the
presence of two major criteria: (1) The new onset of persistent or
relapsing debilitating fatigue or easy fatigability in a person who has
no previous history of similar symptoms, that does not resolve with
bedrest, and that is severe enough to reduce or impair average daily
activity below 50% of the patient's premorbid activity level for a
period of at least six months, and (2) other clinical conditions that
may produce similar symptoms must be excluded by thorough evaluation,
based on history, physical examination, and appropriate laboratory
findings. In addition to these major criteria, there must be either at
least six of eleven specified symptoms plus at least two of three
physical criteria, or at least eight of the specified eleven symptoms.
These criteria are set forth in the final rule in a simplified form
that is not intended to be materially different from that contained in
the NIH pamphlet.
We have established three criteria for diagnosis: (1) The new onset
of debilitating fatigue that is severe enough to reduce daily activity
below 50 percent of the usual level for at least six months, (2) the
exclusion by history, examination and laboratory tests of other
clinical conditions that may produce similar symptoms, and (3) the
presence of six or more of the following: acute onset of the condition,
low grade fever, nonexudative pharyngitis, palpable or tender cervical
or axillary lymph nodes, generalized muscle aches or weakness, fatigue
lasting 24 hours or longer after exercise, headaches (of a type,
severity, or pattern that is different from headaches in the pre-morbid
state), migratory joint pains, neuropsychologic symptoms, sleep
disturbance.
Following the initial six-month period of illness required to
establish the diagnosis, some people function well at home and work,
while others are partially or totally disabled by the debilitating
fatigue and other symptoms, which often wax and wane. We will evaluate
the condition based either on symptoms of the syndrome as they affect
routine daily activities or on the periods of incapacitation which
result. While a reduction in daily activities of 50 percent for six
months is required to establish the diagnosis, thereafter CFS may be
manifested at other levels of severity. We have thus provided
evaluation levels of 10, 20, 40, 60 and 100 percent; the 10% evaluation
will be assigned for the condition when symptoms are controlled by
continuous medication. We have also included a note defining
incapacitation, a term used in the criteria, as a requirement for bed
rest and treatment by a physician.
According to the Centers for Disease Control (CDC) , approximately
50 percent of individuals suspected of having CFS show signs of
psychiatric illness before the onset of CFS symptoms (``Chronic Fatigue
Syndrome'', Disease Directory Document #362100, CDC FAX Information
Service, November 18, 1993). It is also possible that there may be a
secondary mental disorder in some cases that encompasses some or all of
the neuropsychologic symptoms used to establish the diagnosis of CFS.
This would not, however, negate the diagnosis of CFS.
It is necessary to make this rule effective upon publication.
Unlisted conditions are rated under the schedules for closely related
conditions. However, because of the variety of analogous conditions to
be considered with chronic fatigue syndrome, it is necessary to
establish a final rule immediately in order to avoid inconsistency in
evaluations. Comments have been solicited for 60 days after publication
of this document. VA may modify the rule in response to comments, if
appropriate.
Because no notice of proposed rulemaking was required in connection
with the adoption of this interim final rule, no regulatory flexibility
analysis is required under the Regulatory Flexibility Act (5 U.S.C. 601
et seq.). Further, this amendment would not directly affect any small
entities since it would affect only individuals.
This rule has been reviewed as a ``significant regulatory action''
under E.O. 12866 by the Office of Management and Budget.
The Catalog of Federal Domestic Assistance program numbers are
64.104 and 64.109.
List of Subjects in 38 CFR Part 4
Individuals with disability, Pensions, Veterans.
Approved: August 1, 1994.
Jesse Brown,
Secretary of Department 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
Subpart B--Disability Ratings
1. The authority citation for part 4 is revised to read as follows:
Authority: 38 U.S.C. 1155.
Sec. 4.88a [Redesignated as Sec. 4.88b]
Sec. 4.88b [Redesignated as Sec. 4.88c]
2. Sections 4.88a and 4.88b are redesignated 4.88b and 4.88c
respectively.
3. Section 4.88a is added to read as follows:
Sec. 4.88a Chronic fatigue syndrome.
(a) For VA purposes, the diagnosis of chronic fatigue syndrome
requires:
(1) new onset of debilitating fatigue severe enough to reduce daily
activity to less than 50 percent of the usual level for at least six
months; and
(2) the exclusion, by history, physical examination, and laboratory
tests, of all other clinical conditions that may produce similar
symptoms; and
(3) six or more of the following:
(i) acute onset of the condition,
(ii) low grade fever,
(iii) nonexudative pharyngitis,
(iv) palpable or tender cervical or axillary lymph nodes,
(v) generalized muscle aches or weakness,
(vi) fatigue lasting 24 hours or longer after exercise,
(vii) headaches (of a type, severity, or pattern that is different
from headaches in the pre-morbid state),
(viii) migratory joint pains,
(ix) neuropsychologic symptoms,
(x) sleep disturbance.
(b) [Reserved]
4. Newly redesignated section 4.88b is amended by adding diagnostic
code 6354 following diagnostic code 6351, to read as follows:
Sec. 4.88b Schedule of ratings--systemic diseases.
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Rating
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6354Chronic Fatigue Syndrome (CFS):
Debilitating fatigue, cognitive impairments (such as
inability to concentrate, forgetfulness, confusion), or a
combination of other signs and symptoms:
Which are nearly constant and so severe as to restrict
routine daily activities almost completely and which may
occasionally preclude self-care........................... 100
Which are nearly constant and restrict routine daily
activities to less than 50 percent of the pre-illness
level; or which wax and wane, resulting in periods of
incapacitation of at least six weeks total duration per
year...................................................... 60
Which are nearly constant and restrict routine daily
activities to 50 to 75 percent of the pre-illness level;
or which wax and wane, resulting in periods of
incapacitation of at least four but less than six weeks
total duration per year................................... 40
Which are nearly constant and restrict routine daily
activities by less than 25 percent of the pre-illness
level; or which wax and wane, resulting in periods of
incapacitation of at least two but less than four weeks
total duration per year................................... 20
Which wax and wane but result in periods of incapacitation
of at least one but less than two weeks total duration per
year; or symptoms controlled by continuous medication..... 10
Note: For the purpose of evaluating this disability, the
condition will be considered incapacitating only while it
requires bed rest and treatment by a physician.
*****
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[FR Doc. 94-29274 Filed 11-28-94; 8:45 am]
BILLING CODE 8320-01-P