[Federal Register Volume 60, Number 77 (Friday, April 21, 1995)]
[Rules and Regulations]
[Pages 19851-19856]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-9714]



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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AE72


Schedule for Rating Disabilities; Gynecological Conditions and 
Disorders of the Breast

AGENCY: Department of Veterans Affairs.

ACTION: Final regulation.

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SUMMARY: This document amends the section of the Department of Veterans 
Affairs (VA) Schedule for Rating Disabilities on Gynecological 
Conditions and Disorders of the Breast. This amendment is based on a 
General Accounting Office (GAO) study noting that there has been no 
comprehensive review of the rating schedule since 1945, and 
recommending that such a review be conducted. The intended effect of 
this action is to update the gynecological and breast disorders section 
of the rating schedule to ensure that it uses current medical 
terminology, unambiguous criteria, and that it reflects medical 
advances which have occurred since the last review.

EFFECTIVE DATE: This amendment is effective May 22, 1995.

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: In December 1988, the General Accounting 
Office (GAO) recommended that VA prepare a plan for a comprehensive 
review of the rating schedule and, based on the results, revise the 
medical criteria accordingly. As part of the process to implement these 
recommendations, VA published in the Federal Register of March 26, 1992 
(57 FR 10450-53) a proposal to amend 38 CFR 4.116 and 4.116a. 
Interested persons were invited to submit written comments, 
suggestions, or objections on or before April 27, 1992. We received 
comments from Disabled American Veterans, Veterans of Foreign Wars, 
Paralyzed Veterans of America, and from several VA employees.
    Two commenters suggested that we revise the proposed criteria for 
rating endometriosis under diagnostic code (DC) 7629, placing the 
emphasis on pain and abnormal bleeding rather than on headaches.
    Upon further review, VA concurs that symptoms such as headaches and 
muscle cramps are not the most appropriate criteria for evaluating 
endometriosis, and we have therefore modified the proposed criteria. At 
the 50 percent level, the proposed criteria specified endometriomas 
larger than 2 x 2 cm., ovary or tubes bound down or obstructed by 
adhesions, or obliteration of the cul-de-sac. These criteria have been 
modified to call for lesions involving the bladder or bowel confirmed 
by laparoscopy, pelvic pain or heavy or irregular bleeding not 
controlled by treatment, and bowel or bladder symptoms. The proposed 30 
percent level called for several lesions or minimal adhesions with side 
effects such as headaches, muscle cramps, or edema despite treatment; 
but the schedule has been revised to require pelvic pain or heavy or 
irregular bleeding not controlled by treatment.
    One commenter suggested that we include 10 percent and 100 percent 
levels for evaluation of endometriosis.
    Upon further consideration we have added a 10 percent level for 
those cases in which pain or bleeding requires continuous treatment. 
However, endometriosis does not in our judgment reach the level of 
total disability. Some women have incapacitating symptoms, but on a 
cyclic basis related to their menstrual periods. Others have milder 
symptoms on a constant basis. Providing a 50 percent level recognizes 
the substantial level of disability that women may experience because 
of endometriosis, but we believe that, in general, the highest level of 
disability assigned for a condition should not exceed the evaluation 
for absence of the organ involved. In this case, 50 percent for removal 
of the uterus and both ovaries is the highest post-surgical evaluation.
    One individual suggested that a convalescent period of six months 
at 100 percent should be provided for endometriosis following surgery 
or other corrective procedure. [[Page 19852]] 
    VA does not concur. The most extensive surgery that is likely to be 
needed for endometriosis is a hysterectomy and bilateral salpingo-
oophorectomy. Healing, convalescence, and residuals are likely to be 
similar to those after such surgery for other conditions. We have 
established a convalescent period for this type of surgery of three 
months, which is discussed in more detail below. More conservative 
surgery is often indicated, including some done on an outpatient basis. 
Recovery would be even more rapid in such cases and, in our judgment, 
six months of convalescence cannot be justified.
    One commenter noted that 30-40 percent of patients with 
endometriosis become infertile and that 10-15 percent of infertile 
women have endometriosis.
    While endometriosis may be associated with infertility, infertility 
is not itself a disability for VA rating purposes. It does not result 
in impairment of average earning capacity. If loss or loss of use of a 
creative organ is established as due to endometriosis, special monthly 
compensation under the provisions of 38 CFR 3.350(a) may be considered.
    One commenter suggested a language change under the criteria for 
evaluation of prolapse of the uterus, DC 7621, from ``complete--through 
vulva'' to ``complete--through vagina and introitus.''
    The language suggested by the commenter is more technically 
accurate and we have revised the language as suggested.
    Four commenters expressed concern about a lack of clarity in the 
criteria for evaluating residuals of breast surgery under DC 7626. One 
said that the phrase ``following mastectomy or lumpectomy without 
significant alteration of size or form'' at the 0 percent level is 
confusing because literally ``mastectomy'' will result in significant 
alteration of size or form and that therefore ``biopsy'' should be 
substituted for ``mastectomy.'' Another said that it is impossible to 
remove the breast (i.e., perform a mastectomy) without significant 
alteration of size or form, and that therefore ``mastectomy'' should be 
replaced by ``lumpectomy.'' One felt that the phrase ``significant 
alteration of size or form'' is too subjective to be useful, and also 
that a mastectomy or lumpectomy which requires removal of some breast 
tissue together with supporting tissues will change the size and form 
of the breast and should be compensated at a 10 percent level.
    In response to these comments, VA has simplified the criteria for 
evaluating breast surgery residuals and has clarified them by adding a 
note defining the terms used for the various types of breast surgery 
specified at each level of evaluation. At the 0 percent level, we have 
replaced the words ``mastectomy or lumpectomy'' with ``wide local 
excision,'' a term that we also define for VA purposes in the note. 
Since the commenters did not offer alternative language for us to 
consider, however, we have retained the phrase ``significant alteration 
of size or form.'' We believe the term is objective enough to be useful 
since it requires a substantial, as opposed to a subtle or minimal, 
alteration in the normal size or form of the breast. Furthermore, a 
mastectomy or lumpectomy or any other wide local excision that 
significantly alters the size or form of the breast will be 
compensated, not at 10 percent, but at 30 percent. For degrees of 
alteration that are not significant, a 10 percent evaluation is not 
warranted because there is no industrial impairment and little or no 
cosmetic deformity.
    Two commenters suggested that there be major and minor evaluations 
for breast surgery under DC 7626, comparable to muscle loss under DC 
5302, extrinsic muscles of shoulder girdle.
    VA does not concur. Muscle loss is not the only disability that 
results from a radical mastectomy. There are two additional disabling 
aspects: removal of the breast and removal of lymphatic tissue. The 
residuals of removal of a breast include pain and deformity, each of 
variable extent, and a 30 percent level of disability has been 
established for removal of one breast without involvement of muscle or 
lymphatic tissue. Disability of the pectoral muscle under DC 5302 is 
assessed solely on loss of function, and complete removal warrants an 
evaluation of 30 percent or 40 percent, depending on whether it is on 
the major or minor side. Residuals from the removal of lymphatic tissue 
during a radical mastectomy may be as mild in degree as minimal 
deformity or pain or as severe as massive lymphedema of an arm. Thus 
the residual disability from each of the three elements has a range of 
severity, and it is the combination of the three that we have taken 
into account in assigning a level of disability following breast 
surgery. Considering all of these facets of disability, we do not 
believe that the difference between muscle loss on the major and on the 
minor side significantly influences the overall disability from a 
radical mastectomy. Fifty percent was the assigned level of impairment 
for a unilateral radical mastectomy in the 1945 rating schedule. In our 
judgment this is a reasonable assessment, and we have retained it in 
this revision. In other than radical breast surgery there is no muscle 
impairment at all, so the comment on major and minor evaluations is not 
applicable.
    One commenter, stating that there is no industrial impairment 
following mastectomy with significant alteration of size or form but 
without removal of axillary lymph nodes unless there are painful scars, 
suggested that the proposed evaluation of 50 percent for both and 30 
percent for one should be lower.
    VA does not agree with the commenter. Residuals of mastectomy may 
include pain, deformity, and sense of loss with psychological distress. 
Any of these may have an effect on an individual's functioning and can 
occur regardless of whether or not the external appearance of the 
clothed individual is altered. We are retaining the current evaluations 
because the residuals remain essentially the same as they have been for 
many years, and, in our judgment, result in residual disability 
consistent with the levels currently assigned.
    We proposed to retain Sec. 4.116 of the 1945 rating schedule intact 
with only minor changes, but one commenter criticized that section as 
ambiguous and confusing, particularly the part which indicates that 
removal of uterus, ovaries, etc., is considered disabling, but only 
prior to the natural menopause.
    VA agrees that the implied distinction of surgery before or after 
the natural menopause is not warranted. The rating schedule spells out, 
without qualification or restriction, the evaluations to be assigned 
following the removal of female reproductive organs once the 
convalescent period has ended. The surgical residuals from the anatomic 
removal of an organ or organs do not differ depending on whether or not 
natural, surgical, or any other type of menopause has occurred. The 
last sentence of Sec. 4.116 has therefore been deleted.
    We have also removed the sentences addressing congenital 
malformations and new growths. They are redundant since they state 
principles stated elsewhere, specifically in Sec. 4.9, covering 
congenital or developmental defects as applied to the entire rating 
schedule, in Sec. 4.10, covering functional impairment in general, and 
in the criteria under DC's 7627 and 7628, covering evaluation of 
neoplasms.
    Finally, the first two sentences of Sec. 4.116, ``[i]n rating 
disability from gynecological conditions the following will not be 
considered as ratable conditions: (a) The natural menopause, (b) 
amenorrhea, when this is based upon [[Page 19853]] developmental defect 
or abnormality, and (c) pregnancy and childbirth and their incidents, 
except surgical complications under certain circumstances'' and ``The 
surgical complications of pregnancy will not be held the result of 
service except when additional disability resulted from treatment 
therein or they are otherwise attributable to unusual circumstances of 
service,'' have been changed. The second sentence contains unclear 
remarks about the surgical complications of pregnancy, seemingly 
restricting service connection for many of them. Chronic disabilities 
resulting from pregnancy, whether medical or surgical, are subject to 
service connection if incurred during service, as with other chronic 
disabilities. Since this sentence is not only ambiguous but offers no 
specific information that would aid in evaluation of disabilities, it 
has been deleted.
    The first sentence has been shortened and the type of amenorrhea 
that is not considered a ratable condition clarified as ``primary'' 
amenorrhea. This remaining sentence would serve better as a note, and 
we have deleted Sec. 4.116 in its entirety and retained this sentence 
as part of Note (1) at the beginning of this portion of the rating 
schedule. We have also added a sentence to the note stating that 
chronic residuals of medical or surgical complications of pregnancy may 
be disabilities for rating purposes. Since Sec. 4.116 has been deleted, 
Sec. 4.116a has been redesignated as Sec. 4.116.
    One commenter felt that the rating schedule should include rating 
criteria for cervical dysplasia.
    VA does not concur. Cervical dysplasia is neither disease nor 
injury, but a cellular abnormality of the cervix revealed by a Pap 
smear. It may resolve without residuals or it may represent a 
premalignant condition which is a forerunner of carcinoma or carcinoma 
in situ of the cervix. If carcinoma develops in service, whether or not 
preceded by cervical dysplasia, it will be service-connected. If 
carcinoma develops after service, the diagnosis of cervical dysplasia 
in service may or may not be a factor in establishing service 
connection, which will be determined under either presumptive 
provisions of 38 CFR 3.309(a) or the general principles relating to 
service connection in 38 CFR 3.303 et seq. Since cervical dysplasia is 
not itself a disability, it does not in our judgment warrant inclusion 
in the rating schedule.
    One commenter objected to the retention of separate sections for 
genitourinary conditions and gynecological conditions, calling this a 
remnant of antiquated prejudices.
    VA does not concur. In fact, the separation of these disciplines is 
standard throughout modern medicine, with separate specialists, 
textbooks, medical school and hospital departments, etc. Urology has 
developed as a specialty that includes both the urinary tract and the 
male genital tract because these two systems share some common anatomy. 
This is not the case in females, however, where the genital tract is 
independent of the urinary tract and is the focus of the separate 
specialty of gynecology. Combining these systems would be contrary to a 
major focus of the current revision, which is to bring the rating 
schedule in line with current medical practice, and would be of no 
discernible advantage to veterans or to those using the rating 
schedule.
    The same commenter asserted that conditions of the gynecological 
system, especially the loss of procreative organs, do not cause 
impairment of earning capacity and should therefore not be compensated. 
A second commenter suggested that our proposed method of evaluating 
disabilities of the gynecological system based on the need for or 
response to treatment is inappropriate because it is not based on 
impairment of earning capacity as required by 38 U.S.C. 1155. A third 
related comment was an objection that the proposed evaluations covering 
disease, injury, or adhesions of the female reproductive organs (DC 
7610-7615) were based on optimum success in overcoming the effects of 
disease and the results of surgery rather than the resultant average 
impairment.
    VA disagrees with the three commenters. The conditions in this 
system may cause pain, abnormal bleeding, incontinence, etc., and such 
symptoms undoubtedly cause women to lose time from work, which affects 
the ability to obtain and retain employment, and thus affects income. 
In addition, loss of procreative organs may affect endocrine function, 
renal function, psychological function, etc., any of which may affect 
the ability to work. How well a patient feels, which often relates to 
how well or how poorly a disease or injury has responded to treatment, 
is a significant factor in employment. A person who requires continuous 
treatment is more disabled than one who does not, and one who has 
symptoms despite continuous treatment is even more impaired. Since 
evaluation criteria for conditions in other body systems (e.g., malaria 
(DC 9304), leukemia (DC 7703), and hypo- and hyper-thyroidism (DC 7900 
and DC 7903)) take into account the need for treatment, the evaluation 
criteria which we proposed under DC's 7610 through 7615 are also 
consistent with other portions of the rating schedule. Our method of 
evaluating many of these conditions based on response to treatment is 
therefore appropriate because it assigns those who have symptoms 
despite treatment the highest level of evaluation because they are the 
ones who will suffer the most adverse effects on employment.
    One commenter suggested that we not compensate pelvic inflammatory 
disease, which he states is most often a sexually transmitted disease, 
because, short of tertiary complications of syphilis, male veterans are 
not compensated for sexually transmitted diseases. He stated that the 
proposed rule retains disparate ratings for the same type of disability 
affecting male and female veterans.
    VA again disagrees. The provisions of 38 CFR 3.301(c)(1) 
specifically permit consideration of service connection for residuals 
of venereal disease if the initial infection occurred during active 
service. The commenter's statement that males are not compensated for 
residuals of venereal disease is inaccurate. Urethral strictures, for 
example, which in some cases represent residuals of venereal disease, 
may be compensable disabilities. We would also point out that venereal 
disease presents differently, both acutely and chronically, in males 
and females, and that rating criteria and entitlement to compensation 
are based on disability, not on etiology. For these reasons, we find 
that the inclusion of pelvic inflammatory disease in the rating 
schedule does not represent disparate evaluations of similar 
disabilities for males and females, and the commenter's statements do 
not, in our judgment, establish a rational basis for deleting this 
condition from the rating schedule.
    We proposed changing the convalescent periods for Ovary, removal of 
(DC 7619) and Uterus and both ovaries, removal of (DC 7617) from six 
months to three months, and two commenters objected. One stated that by 
reducing certain evaluations and periods of convalescence, VA was 
exceeding the GAO mandate to review the rating schedule to update 
medical terminology and evaluation criteria, and that a statistical 
study of impairment in earning capacity should be done. The other said 
that removal of both uterus and ovaries is a far more significant 
surgical procedure than the removal of the uterus alone or ovary alone 
and there is a basis for continuation of the six-month convalescent 
period.
    VA disagrees. A convalescent period of three months after removal 
of the [[Page 19854]] uterus and/or ovaries is regarded as adequate for 
most patients because of improvements in surgical techniques and in 
postoperative care, including the practice of early ambulation. The 
average convalescent period is actually shorter than three months, with 
most patients requiring no more than six to eight weeks to convalesce. 
VA's mandate to readjust the schedule does not derive from GAO but from 
38 U.S.C. 1155, which instructs the Secretary to revise the schedule 
``in accord with experience.'' A need for shorter periods of 
convalescence represents a significant medical advance since the last 
revision, and changes in the rating schedule to reflect this are 
appropriate.
    Three commenters objected to the proposal concerning the period of 
total evaluation following the completion of therapy for malignancy, 
citing the wide variety of possible side effects, the varying 
individual time requirements for convalescence, and the complexity of 
certain medical procedures.
    VA does not concur with the objections. The commenters appear to 
have misinterpreted the proposed rule to mean that a convalescent 
evaluation will be terminated six months after treatment has ceased. 
However, under the proposed change, there cannot be a reduction at the 
end of six months because the process of reevaluation does not begin 
until that time. First, there must be a VA examination six months after 
completion of treatment. Then, if the results of that or any subsequent 
examination warrant a reduction in evaluation, the reduction will be 
implemented under the provisions of 38 CFR 3.105(e), which require a 
60-day notice before VA can reduce an evaluation and an additional 60-
day notice before the reduced evaluation takes effect. The revision not 
only requires a current examination to assure that all residuals are 
documented, but also offers the veteran more contemporaneous notice of 
any proposed action and expands the veteran's opportunity to present 
evidence showing that the proposed action should not be taken. In our 
judgment this method will better ensure that actual side effects and 
recuperation times are taken into account because they will be noted on 
the required VA exam. Based on commenters' concerns, however, we have 
revised the note under this code so that it cannot be misinterpreted as 
requiring a reduction six months after treatment is terminated. We have 
also added to the note a direction to rate on residuals, if there has 
been no local recurrence or metastasis, in order to make these 
provisions consistent with those we provided for malignancies of the 
revised genitourinary system. This is not a substantive change, but has 
been made to provide further clarity, as well as internal consistency 
within the rating schedule.
    Two commenters urged us to retain a minimum evaluation of 10 
percent following surgery or the completion of therapy for malignancy.
    VA does not agree. Residuals following the medical or surgical 
treatment of malignancy are common, but vary widely in type and 
severity, and a specified arbitrary level of residual disability cannot 
be assumed to be present in every case. As previously discussed, we 
will be requiring a VA examination for each individual before adjusting 
the convalescent evaluation, and that examination will also ensure that 
actual residual disabilities will be documented and assigned an 
accurate evaluation, which may be more or less than 10 percent.
    Two commenters suggested that we retain the evaluation for removal 
of one ovary with or without partial removal of the other at 10 percent 
rather than changing it to 0 percent. Another stated that removal of 
one ovary is analogous to atrophy of both ovaries and should therefore 
be rated at 20 percent.
    VA does not concur. One ovary or even part of an ovary produces 
sufficient hormone to maintain normal reproductive and endocrine 
functions without hormonal replacement therapy. The ultimate test of 
ovarian hormonal function is the ability to support a pregnancy, and it 
is a well-established medical fact that one ovary is sufficient to 
support a pregnancy. This is significantly different from complete 
atrophy of both ovaries (DC 7620), where there would be no hormonal 
output, and replacement therapy would be necessary.
    Two commenters requested that we annotate certain diagnostic codes 
in this section to indicate entitlement to special monthly compensation 
(SMC) under 38 U.S.C. 1114(k) for loss of a creative organ. One 
suggested annotating DC's 7617, 7618, 7619, and 7626, and the other 
suggested annotations ``where appropriate.''
    Because the statutory requirements for SMC are very complicated and 
in some cases involve more than one body system, it is impractical to 
provide detailed information at every location in the rating schedule 
where the potential for entitlement to SMC might arise. Rating 
specialists must be aware of the need to refer to 38 CFR 3.350, the 
governing regulation, in every instance where the veteran has a 
condition which potentially establishes eligibility for SMC. To that 
end, we have added a note at the beginning of Sec. 4.116 requiring 
rating specialists to refer to Sec. 3.350 any time they evaluate a 
claim involving loss or loss of use of one or more creative organs. In 
view of the comments received, we have also placed footnotes after 
diagnostic codes 7617 (removal of uterus and both ovaries), 7618 
(removal of uterus), 7619 (removal of ovary), and 7620 (complete 
atrophy of both ovaries) instructing raters to review for entitlement 
to SMC. While the conditions we have annotated clearly call for review 
for entitlement to SMC, almost any condition in this section might, 
under certain circumstances, establish entitlement to SMC. The note at 
the beginning of Sec. 4.116 makes it clear that it is the 
responsibility of the rating specialist to recognize those 
circumstances and assign SMC when warranted. The lack of a footnote 
does not relieve rating specialists of that responsibility.
    Viewing the rating schedule as a whole, we are concerned that if 
there are footnotes only for obvious grants of SMC, individual veterans 
entitled to SMC in less obvious situations will be disadvantaged if 
rating specialists fail to recognize potential entitlement because they 
have not been prompted to do so by a footnote. We believe that the 
combination of the regulatory requirement in the note and the footnotes 
is the best method of making sure that potential entitlement to SMC is 
considered.
    On further review, we have made some additional changes to the 
proposed revisions for the sake of clarity and objectivity. The title 
of DC 7627 has been changed from ``Breast, removal of'' to ``Breast, 
surgery of,'' since surgery often stops short of removal of a breast.
    In order to eliminate the need to search in other sections of the 
rating schedule for criteria to evaluate DC 7625, Fistula, 
urethrovaginal, (which in the proposed rule was to be rated as voiding 
dysfunction under the genitourinary schedule), we have provided the 
criteria for voiding dysfunction (continual urine leakage, post 
surgical urinary diversion, urinary incontinence, or stress 
incontinence subset of criteria) under DC 7625. The only difference is 
that we changed the word urethroperineal to urethrovaginal, as being 
more specific to this system.
    Similarly, we proposed that Fistula, rectovaginal (DC 7624) be 
evaluated as DC 7332, rectum and anus, impairment of sphincter control 
(in the digestive system section of the rating schedule). In response 
to a general comment on the proposed rating schedule revisions of a 
number of body systems, which strongly [[Page 19855]] favored the 
elimination of subjectivity and urged its extension, we removed terms 
such as ``extensive leakage'' and ``fairly frequent'', which are part 
of the criteria for DC 7332, in favor of criteria that are more 
precise, but still based on the extent of fecal leakage and the 
necessity for wearing a pad.
    We made one additional minor technical change under DC 7628, Benign 
neoplasms of the gynecological system or breast. The word 
``genitourinary'' has been replaced by the word ``urinary'' as being 
more specific to this system.
    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

    Individuals with disability, Pensions, Veterans.

Approved: December 22, 1994.
Jesse Brown,
Secretary of Veterans Affairs.
    For the reasons set forth in the preamble, 38 CFR part 4, subpart 
B, is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

    1. The authority citation for part 4 is revised to read as follows:

    Authority: 38 U.S.C. 1155.

    2. The undesignated center heading appearing before Sec. 4.116 is 
revised to read as follows:

Gynecological Conditions and Disorders of the Breast

    3. Section 4.116 is removed.
    4. Section 4.116a is redesignated as Sec. 4.116 and its heading and 
text are revised to read as follows:


Sec. 4.116.  Schedule of ratingsgynecological conditions and disorders 
of the breast.

------------------------------------------------------------------------
                                                                  Rating
------------------------------------------------------------------------
    Note 1: Natural menopause, primary amenorrhea, and                  
     pregnancy and childbirth are not disabilities for rating           
     purposes. Chronic residuals of medical or surgical                 
     complications of pregnancy may be disabilities for rating          
     purposes.                                                          
    Note 2: When evaluating any claim involving loss or loss of         
     use of one or more creative organs, refer to Sec. 3.350 of         
     this chapter to determine whether the veteran may be               
     entitled to special monthly compensation. Footnotes in the         
     schedule indicate conditions which potentially establish           
     entitlement to special monthly compensation; however,              
     almost any condition in this section might, under certain          
     circumstances, establish entitlement to special monthly            
     compensation.                                                      
7610  Vulva, disease or injury of (including vulvovaginitis).           
7611  Vagina, disease or injury of.                                     
7612  Cervix, disease or injury of.                                     
7613  Uterus, disease, injury, or adhesions of.                         
7614  Fallopian tube, disease, injury, or adhesions of                  
 (including pelvic inflammatory disease (PID)).                         
7615  Ovary, disease, injury, or adhesions of.                          
General Rating Formula for Disease, Injury, or Adhesions of             
 Female Reproductive Organs (diagnostic codes 7610 through              
 7615):                                                                 
    Symptoms not controlled by continuous treatment............       30
    Symptoms that require continuous treatment.................       10
    Symptoms that do not require continuous treatment..........        0
7617  Uterus and both ovaries, removal of, complete:                    
    For three months after removal.............................   \1\100
    Thereafter.................................................    \1\50
7618  Uterus, removal of, including corpus:                             
    For three months after removal.............................   \1\100
    Thereafter.................................................    \1\30
7619  Ovary, removal of:                                                
    For three months after removal.............................   \1\100
    Thereafter:                                                         
        Complete removal of both ovaries.......................    \1\30
        Removal of one with or without partial removal of the           
         other.................................................     \1\0
7620  Ovaries, atrophy of both, complete.......................    \1\20
7621  Uterus, prolapse:                                                 
    Complete, through vagina and introitus.....................       50
    Incomplete.................................................       30
7622  Uterus, displacement of:                                          
    With marked displacement and frequent or continuous                 
     menstrual disturbances....................................       30
    With adhesions and irregular menstruation..................       10
7623  Pregnancy, surgical complications of:                             
    With rectocele or cystocele................................       50
    With relaxation of perineum................................       10
7624  Fistula, rectovaginal:                                            
    Vaginal fecal leakage at least once a day requiring wearing         
     of pad....................................................      100
    Vaginal fecal leakage four or more times per week, but less         
     than daily, requiring wearing of pad......................       60
    Vaginal fecal leakage one to three times per week requiring         
     wearing of pad............................................       30
    Vaginal fecal leakage less than once a week................       10
    Without leakage............................................        0
7625  Fistula, urethrovaginal:                                          
    Multiple urethrovaginal fistulae...........................      100
    Requiring the use of an appliance or the wearing of                 
     absorbent materials which must be changed more than four           
     times per day.............................................       60
    Requiring the wearing of absorbent materials which must be          
     changed two to four times per day.........................       40
    Requiring the wearing of absorbent materials which must be          
     changed less than two times per day.......................       20
7626  Breast, surgery of:                                               
    Following radical mastectomy:                                       
        Both...................................................       80
        One....................................................       50
    Following modified radical mastectomy:                              
        Both...................................................       60
        One....................................................       40
    Following simple mastectomy or wide local excision with             
     significant alteration of size or form:                            
        Both...................................................       50
        One....................................................       30
    Following wide local excision without significant                   
     alteration of size or form:                                        
        Both or one............................................        0
    Note: For VA purposes:                                              
        (1) Radical mastectomy means removal of the entire              
         breast, underlying pectoral muscles, and regional              
         lymph nodes up to the coracoclavicular ligament ......         
[[Page 19856]]                                                          
                                                                        
        (2) Modified radical mastectomy means removal of the            
         entire breast and axillary lymph nodes (in continuity          
         with the breast). Pectoral muscles are left intact....         
        (3) Simple (or total) mastectomy means removal of all           
         of the breast tissue, nipple, and a small portion of           
         the overlying skin, but lymph nodes and muscles are            
         left intact...........................................         
        (4) Wide local excision (including partial mastectomy,          
         lumpectomy, tylectomy, segmentectomy, and                      
         quadrantectomy) means removal of a portion of the              
         breast tissue.........................................         
7627  Malignant neoplasms of gynecological system or breast....      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.         
7628  Benign neoplasms of the gynecological system or breast.           
 Rate according to impairment in function of the urinary or             
 gynecological systems, or skin.                                        
7629  Endometriosis:                                                    
    Lesions involving bowel or bladder confirmed by                     
     laparoscopy, pelvic pain or heavy or irregular bleeding            
     not controlled by treatment, and bowel or bladder symptoms       50
    Pelvic pain or heavy or irregular bleeding not controlled           
     by treatment..............................................       30
    Pelvic pain or heavy or irregular bleeding requiring                
     continuous treatment for control..........................       10
    Note: Diagnosis of endometriosis must be substantiated by           
     laparoscopy.                                                       
------------------------------------------------------------------------
\1\Review for entitlement to special monthly compensation under Sec.    
  3.350 of this chapter.                                                

[FR Doc. 95-9714 Filed 4-20-95; 8:45 am]
BILLING CODE 8320-01-P