[Federal Register Volume 65, Number 152 (Monday, August 7, 2000)]
[Proposed Rules]
[Pages 48205-48210]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-19761]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AK12


Schedule for Rating Disabilities: Disabilities of the Liver

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: This document proposes to amend the Department of Veterans 
Affairs (VA) Schedule for Rating Disabilities by revising the portion 
of the Digestive System that addresses disabilities of the liver. The 
intended effect of this action is to update this 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.

DATES: Comments must be received by VA on or before October 6, 2000.

ADDRESSES: Mail or hand-deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Ave., NW, Room 1154, Washington, DC 20420; or fax comments to 
(202) 273-9289; or e-mail comments to ``[email protected]''. 
Comments should indicate that they are submitted in response to ``RIN 
2900-AK12.'' All comments received will be available for public 
inspection in the Office of Regulations Management, Room 1158, 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, 
Policy and Regulations Staff (211A), Compensation and Pension Service, 
Veterans Benefits Administration, Department of Veterans Affairs, 810 
Vermont Ave., NW, Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: This document proposes to amend the 
Department of Veterans Affairs (VA) Schedule for Rating Disabilities by 
revising that portion of the Digestive System that addresses 
disabilities of the liver. VA published an advance notice of proposed 
rulemaking in the Federal Register on May 2, 1991 (56 FR 20168), 
advising the public that it was preparing to revise and update the 
schedule for rating disabilities of the digestive system. This 
regulation proposes to amend only 38 CFR 4.112 and certain diagnostic 
codes in 38 CFR 4.114, in order to address hepatitis C and its 
sequelae, and to update evaluation criteria for other liver 
disabilities. Extensive new medical information has recently become 
available about hepatitis C, a liver disease that occurs frequently in 
veterans and at a prevalence rate which is likely higher than in the 
civilian population. To address hepatitis C and related liver 
disabilities adequately requires that we update the entire portion of 
the digestive system that pertains to liver disease.
    In response to the advance notice of proposed rulemaking, we 
received comments from the American Legion and from several VA 
employees. One commenter addressed liver disabilities, suggesting, 
among other things, that we add hepatitis A, B, and C, and chronic 
inflammation of the liver and its residuals, to the rating schedule. 
The same commenter also suggested that other residuals need to be 
addressed and that cirrhosis is not the only residual of chronic 
hepatitis. Another commenter suggested that we address liver 
transplants in the revised schedule. We propose to address each of 
these suggestions from commenters in this revision, as discussed below.
    In addition to publishing an advance notice, VA contracted with an 
outside consultant to recommend changes to the digestive system 
sections of the rating schedule to ensure that the schedule uses 
current medical terminology and unambiguous criteria, and that it 
reflects medical advances that have occurred since the last review. The 
consultant convened a panel of non-VA specialists to review that 
portion of the rating schedule dealing with the digestive system and to 
make recommendations for changes. The comments of the consultants on 
liver disabilities are incorporated into the discussions below.
    Current Sec. 4.112, ``Weight loss,'' addresses in general terms the 
issues of when weight loss is significant or important, how it is 
determined, and what is meant by inability to gain weight. Upon the 
advice of our contract consultants, we propose to make this information 
more specific, and therefore more useful for evaluation purposes, by 
stating that the term ``substantial weight loss,'' for purposes of 
evaluating conditions in Sec. 4.114, means a loss of greater than 20 
percent of the individual's baseline weight, sustained for three months 
or longer; that the term ``minor weight loss'' means a loss of 10 to 20 
percent of the individual's baseline weight, sustained for three months 
or longer; and that the term ``inability to gain weight'' means 
``substantial'' (rather than the current term ``significant'') weight 
loss with inability to regain it despite appropriate therapy. In view 
of these changes, we

[[Page 48206]]

propose to remove the current reference to standard age, height, and 
weight tables, since it is more accurate to compare weight after onset 
of the illness with the individual's own usual, baseline, or premorbid 
weight, rather than with the ``predicted average weight for height and 
age,'' which may never have applied to that individual.
    Injury of the liver (diagnostic code 7311) is currently evaluated 
under the criteria for adhesions of the peritoneum (diagnostic code 
7301). However, our specialist consultants noted that injury to the 
liver may result in abnormalities other than adhesions, such as damage 
to the liver parenchyma. We, therefore, propose to add the option of 
evaluating as cirrhosis of the liver (diagnostic code 7312) or chronic 
liver disease without cirrhosis (diagnostic code 7345) (see discussion 
below), depending on the specific residuals. These criteria would 
better encompass the possible residuals of liver injury. Our 
consultants also suggested that we add the phrase ``including surgery'' 
to the title of this diagnostic code. However, the current title is not 
restrictive as to what types of injury are included, and we, therefore, 
do not propose to adopt the suggested change.
    Diagnostic code 7312 is currently titled ``liver, cirrhosis of.'' 
We propose to broaden the scope of this code to include primary biliary 
cirrhosis and the cirrhotic phase of sclerosing cholangitis, two 
conditions that are not included in the current rating schedule but 
that are related to cirrhosis of the liver and have similar disabling 
effects. We propose to revise the title accordingly to ``Cirrhosis of 
the liver, primary biliary cirrhosis, or cirrhotic phase of sclerosing 
cholangitis.'' Cirrhosis of the liver is currently evaluated at 100, 
70, 50, or 30 percent, based on ascites, recurrent hemorrhage from 
esophageal varices, enlargement of the liver, muscle wasting, loss of 
strength, dilated abdominal veins, dyspepsia, weight loss, and 
impairment of health. The evaluation criteria rely on subjective terms, 
such as ``pronounced,'' ``severe,'' ``moderately severe,'' and 
``moderate,'' and on the frequency of ``tapping'' (an outdated term) 
for ascites. We propose to delete the subjective and outdated terms, 
but to retain the same evaluation levels, add a 10 percent evaluation 
level, and base the evaluation on similar, but updated, criteria. We 
propose to base evaluation under diagnostic code 7312 on the presence 
or history of ascites (an accumulation of fluid in the abdominal 
cavity), hemorrhage from varices (enlarged, tortuous veins at the lower 
end of the esophagus) or portal gastropathy (erosive gastritis), 
hepatic encephalopathy, portal hypertension, splenomegaly (enlarged 
spleen), jaundice, and emaciation (or lesser degrees of weight loss), 
as well as on symptoms of generalized weakness, anorexia (lack of 
appetite), abdominal pain, and malaise (a vague feeling of bodily 
discomfort). These are all signs and symptoms of cirrhosis that occur 
at different stages of the disease. Ascites, hemorrhage, and hepatic 
encephalopathy are all major complications that usually occur only in 
advanced stages of cirrhosis, when there is portal hypertension 
(elevated blood pressure in the veins of the portal system, which may 
occur with severe liver disease) (``The Merck Manual,'' 374, 17th ed., 
1999). We propose to assign a 100-percent evaluation if ascites, 
hepatic encephalopathy, or hemorrhage from varices or portal 
gastropathy is present and refractory (not readily yielding to 
treatment or unresponsive) to treatment, or if there is persistent 
jaundice, generalized weakness, and significant weight loss. We propose 
to assign a 70-percent evaluation if there is a history of two or more 
episodes of ascites, hepatic encephalopathy, or hemorrhage from varices 
or portal gastropathy, but with periods of remission between attacks, 
and a 50-percent evaluation if there is a history of one episode of 
ascites, hepatic encephalopathy, or hemorrhage from varices or portal 
gastropathy. We propose to assign a 30-percent evaluation if there is 
portal hypertension and splenomegaly, with weakness, anorexia, 
abdominal pain, malaise, and at least minor weight loss. We also 
propose to add a 10-percent evaluation level, to be assigned if there 
is weakness, anorexia, abdominal pain, and malaise. This would provide 
an appropriate evaluation level for individuals who have symptoms due 
to cirrhosis but do not meet the criteria for a 30-percent evaluation, 
as might occur in the early stages of the disease. These criteria are 
similar to those suggested by our consultants, except that we propose 
to exclude subjective terms such as ``pronounced'' and ``mild.'' We 
also propose, to assure consistency in application of these criteria, 
to add a note stating that evaluation under this diagnostic code 
requires documentation of cirrhosis (by biopsy or imaging) and abnormal 
liver function tests, which are much more accurate methods for 
diagnosing cirrhosis. The proposed criteria are expressed in current 
medical terminology, are objective enough to assure consistent 
evaluations, and provide a broad range of evaluation percentages.
    Residuals of liver abscess, diagnostic code 7313, are currently 
evaluated at 20 or 30 percent, based on whether there are ``moderate'' 
or ``severe'' symptoms. We propose to delete diagnostic code 7313 
because our consultants advised us that abscesses of the liver now 
resolve without residual disability through the use of modern 
antibiotics and drainage techniques.
    Diagnostic code 7343 is currently titled ``new growths, malignant, 
exclusive of skin growths.'' We propose to change ``new growths, 
malignant'' to ``malignant neoplasms,'' because that is current medical 
terminology, and to add ``of the digestive system'' to the title, 
because this would more clearly indicate that this code refers only to 
malignant neoplasms of this system. Under current diagnostic code 7343, 
a 100-percent evaluation is assigned, and then continued for one year 
following cessation of surgical, X-ray or antineoplastic chemotherapy. 
Rating is made on residuals at that time if there has been no local 
recurrence or metastases. In order to assure that an evaluation will be 
based on actual medical findings rather than on a regulatory assumption 
that there has been improvement, we are proposing to continue the total 
evaluation under this code indefinitely after treatment is 
discontinued, and to examine the veteran six months after treatment 
ends. If the results of this or any subsequent examination warrant a 
reduction in evaluation, the reduction would be implemented under the 
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. The proposed revision would not only 
require a current examination to assure that all residuals are 
documented, but also offer the veteran more contemporaneous notice of 
any proposed action and expand the veteran's opportunity to present 
evidence showing that the proposed action should not be taken. If local 
recurrence or metastasis is not present, evaluation would be made on 
residuals. This change would provide criteria similar to those used in 
the evaluation of malignant neoplasms in other sections of the rating 
schedule that have recently been revised. (See, for example, diagnostic 
code 7528, malignant neoplasms of the genitourinary system, in 38 CFR 
4.115b, and diagnostic code 7627, malignant neoplasms of gynecological 
system or breast, in 38 CFR 4.116.)

[[Page 48207]]

    We also propose to change the title of DC 7344 from ``new growths, 
benign'' to ``benign neoplasms,'' in accordance with current medical 
usage, and to revise the instructions to make clear that this condition 
is to be evaluated under a diagnostic code which reflects the resulting 
predominant disability or residual.
    Diagnostic code 7345 is currently titled ``infectious hepatitis.'' 
This is the former name for hepatitis A, the first type of viral 
hepatitis that was identified. Hepatitis A is a type of acute 
infectious disease that plays no role in the production of chronic 
hepatitis or cirrhosis (Merck, 377). For that reason, hepatitis A is so 
unlikely to present as chronic liver infection warranting service 
connection in veterans that it does not warrant a specific diagnostic 
code. We, therefore, propose to remove the title ``infectious 
hepatitis.'' There are, however, a number of other conditions that may 
result in chronic liver disease without cirrhosis that are not included 
in the current schedule, including chronic viral hepatitis B and C, 
chronic active hepatitis, autoimmune hepatitis, hemochromatosis, and 
drug-induced hepatitis. These conditions have manifestations that are 
similar enough to allow their evaluation under a single set of 
criteria. We, therefore, propose to retitle diagnostic code 7345 
``chronic liver disease without cirrhosis (including hepatitis B, 
chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug 
induced hepatitis, etc., but excluding bile duct disorders and 
hepatitis C).'' We are proposing to exclude bile duct disorders from 
this category, although they are sometimes closely related to liver 
disorders, because they are addressed under other diagnostic codes in 
Sec. 4.114. We propose to include hepatitis B infection (formerly 
called serum hepatitis), another type of viral hepatitis, in this group 
of conditions because, unlike hepatitis A infection, which we propose 
to exclude from the group, it does result in chronic liver infection in 
up to ten percent of cases.
    A separate diagnostic code, 7354, is being proposed for hepatitis 
C, a type of viral hepatitis that was not identified until 1989, which 
can also result in chronic liver infection, cirrhosis, and malignancy 
of the liver. We are proposing to provide a separate diagnostic code 
for hepatitis C because there are still many unanswered questions about 
the disease, and public health epidemiologic concerns make it desirable 
for us to be able to track cases for statistical purposes. However, we 
propose to provide evaluation criteria for diagnostic code 7354 which 
are identical to those we are proposing for diagnostic code 7345, since 
the effects are similar. Until the hepatitis C virus was identified, 
hepatitis C infection was often categorized as ``non-A, non-B 
hepatitis,'' a term used for any type of hepatitis that could not be 
identified as one of the known types (A or B). For that reason, we 
propose to add non-A, non-B hepatitis to the title, as a condition to 
be evaluated under diagnostic code 7354. We also propose to require 
that there be serologic evidence of hepatitis C infection and that the 
signs and symptoms listed in the criteria be due to hepatitis C 
infection (because some are nonspecific findings that could be from a 
variety of causes).
    Evaluations under diagnostic code 7345 are currently based on the 
extent of liver damage, the severity of gastrointestinal symptoms, the 
frequency and duration of disabling episodes of symptoms, whether there 
are symptoms of fatigue, mental depression, or anxiety, and whether 
dietary restriction, rest therapy, or other therapeutic measures are 
required. We propose to base the evaluation for diagnostic codes 7345 
and 7354 in part on the total duration of incapacitating episodes 
resulting from the manifestations and symptoms of these conditions, and 
to define an incapacitating episode in notes under diagnostic codes 
7345 and 7354 as a period of acute signs and symptoms severe enough to 
require bed rest and treatment by a physician. This is the same 
definition we provided in a notice of proposed rulemaking published in 
the Federal Register on February 24, 1997 (62 FR 8204) that would 
revise the evaluation criteria for intervertebral disc syndrome 
(diagnostic code 5293), another condition that would be evaluated on 
the basis of the total duration of incapacitating episodes. We propose 
to change the evaluation levels under 7345 from 100, 60, 30, 10, and 
zero percent to 100, 60, 40, 20, 10, and zero percent, the same levels 
that we proposed for the evaluation of intervertebral disc syndrome 
(except that we did not propose a zero-percent level for intervertebral 
disc syndrome), in order to maintain internal consistency in the rating 
schedule for conditions evaluated on the basis of the total duration of 
incapacitating episodes.
    A zero-percent evaluation is currently assigned under diagnostic 
code 7345 if hepatitis is ``healed, nonsymptomatic.'' We propose to 
retain the zero-percent level under diagnostic code 7345 and add it 
under diagnostic code 7354 for nonsymptomatic disease, but to remove 
the term ``healed,'' because chronic liver disease may in some cases be 
nonsymptomatic even when not healed, and would still warrant no more 
than a zero-percent evaluation. Retaining a zero-percent evaluation 
level for chronic liver disease without cirrhosis would assure an 
appropriate evaluation of the condition in the absence of symptoms. Ten 
percent of those who are infected with the hepatitis B virus go on to 
develop chronic liver infection, and 75-85 percent of those infected 
with the hepatitis C virus develop chronic liver infection. However, 
tests to determine whether chronic liver infection is present when 
there is evidence of a past history of viral hepatitis are not routine 
and standardized. We are, therefore, proposing that a zero-percent 
evaluation be assigned to all nonsymptomatic veterans who have 
serologic evidence of having had a hepatitis B or C virus infection in 
order to assure appropriate handling of later-developing sequelae of 
hepatitis B and C.
    According to our consultants, the most common symptom of chronic 
liver disease is fatigue. We, therefore, propose to list fatigue, 
malaise, nausea, vomiting, anorexia, arthralgia, and right upper 
quadrant pain as symptoms of chronic liver disease that might 
characterize an incapacitating episode. These are all symptoms of 
chronic liver disease (Merck, 354-385) and are more explicit than the 
indefinite language, such as ``gastrointestinal disturbance'' and 
``marked symptoms,'' that our consultants suggested. We propose to 
assign a 100-percent evaluation if there are near-constant 
incapacitating symptoms (such as fatigue, malaise (a vague feeling of 
bodily discomfort), nausea, vomiting, anorexia (lack of appetite), 
arthralgia (joint pain), and right upper quadrant pain); a 60-percent 
evaluation if there are incapacitating episodes having a total duration 
at least six weeks during the past 12-month period, but not occurring 
constantly, or there is daily fatigue, malaise, and anorexia, with 
substantial weight loss (or other indication of malnutrition), and 
hepatomegaly (enlarged liver); a 40-percent evaluation if there are 
incapacitating episodes having a total duration of at least four weeks, 
but less than six weeks, during the past 12-month period, or there is 
daily fatigue, malaise, and anorexia, with minor weight loss and 
hepatomegaly; a 20-percent evaluation if there are incapacitating 
episodes having a total duration of at least two weeks, but less than 
four weeks, during the past 12-month period, or there is daily fatigue, 
malaise, and anorexia, but without

[[Page 48208]]

weight loss or hepatomegaly; a 10-percent evaluation if there are 
incapacitating episodes having a total duration of at least one week, 
but less than two weeks, during the past 12-month period, or there is 
intermittent fatigue, malaise, and anorexia; and a zero-percent 
evaluation if the condition is nonsymptomatic. These criteria encompass 
the usual disabling effects of this group of diseases and are in 
keeping with current medical information. In addition, they are more 
objective than the current criteria (which include such subjective 
terms as ``minimal,'' ``moderate,'' ``marked,'' and ``mild'') and would 
thus help assure consistency of evaluations.
    Although our consultants did not suggest that we remove 
``depression'' and ``anxiety'' as criteria under diagnostic code 7345, 
we propose to do so. They are not prominent symptoms of chronic liver 
disease. If a mental disorder is medically determined to be secondary 
to liver disease, it would be separately evaluated under the mental 
disorders portion of the rating schedule.
    In order to clarify the method of evaluation of the major sequelae 
of chronic liver disease, we propose to add a note under diagnostic 
codes 7345 and 7354 directing that sequelae of these conditions, such 
as cirrhosis or malignancy of the liver, be evaluated under an 
appropriate diagnostic code, as long as the same signs and symptoms are 
not used as the basis for evaluation under both 7354 and under another 
diagnostic code. (See 38 CFR 4.14.) We propose to add a second note 
under diagnostic codes 7345 and 7354 defining an incapacitating 
episode, as discussed above, and a third note under diagnostic code 
7345 stating that hepatitis B infection must be confirmed by serologic 
testing in order to evaluate it under diagnostic code 7345. The 
criteria for the evaluation of hepatitis C under diagnostic code 7354 
similarly require that there be serologic evidence of hepatitis C 
infection for evaluation under that code. This will enable VA to 
accurately determine which type of hepatitis a veteran has.
    The ability to perform liver transplants is a significant medical 
advance that is not reflected in the current rating schedule. We, 
therefore, propose to add diagnostic code 7351 for liver transplants 
and to provide a 100-percent evaluation for an indefinite period from 
the date of hospital admission for transplant surgery, with a mandatory 
VA examination one year following hospital discharge. This would allow 
a reasonable period of time to assess whether rejection of the 
transplant or infection will occur, and for recovery from the surgery. 
We propose to provide instructions that the appropriate disability 
rating shall then be determined based on the examination, and subject 
to the provisions of 38 CFR 3.105(e). 38 CFR 3.105(e) requires a 60-day 
notice before VA reduces an evaluation and an additional 60-day notice 
before the reduced evaluation takes effect. The revision would not only 
require a current examination to assure that all residuals are 
documented, but also offer the veteran more contemporaneous notice of 
any proposed action and expand the veteran's opportunity to present 
evidence showing that the proposed action should not be taken. We 
propose to require a minimum evaluation of 30 percent following 
transplant, because of the need for long-term immunosuppressive 
medication and its associated problems. The proposed evaluation 
criteria are similar to those provided in 38 CFR 4.115b for evaluation 
following kidney transplant and in 38 CFR 4.104 for evaluation 
following cardiac transplant.
    The Secretary hereby certifies that the adoption of the proposed 
rule would not have a significant economic impact on a substantial 
number of small entities as they are defined in the Regulatory 
Flexibility Act (RFA), 5 U.S.C. 601-612. This action would not directly 
affect any small entities. Only VA beneficiaries could be directly 
affected. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule is 
exempt from the initial and final regulatory flexibility analysis 
requirements of sections 603 and 604.
    This proposed rule has been reviewed by the Office of Management 
and Budget under the provisions of Executive Order 12866.
    The Unfunded Mandates Reform Act requires (in section 202) that 
agencies prepare an assessment of anticipated costs and benefits before 
developing any rule that may result in an expenditure by State, local, 
or tribal governments, in the aggregate, or by the private sector of 
$100 million or more in any given year. This rule would have no 
consequential effect on State, local, or tribal governments.

    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: April 13, 2000.
Togo D. West, Jr.,
Secretary of Veterans Affairs.
    For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
is proposed to be 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.

    2. Revise Sec. 4.112 to read as follows:


Sec. 4.112  Weight loss.

    For purposes of evaluating conditions in Sec. 4.114, the term 
``substantial weight loss'' means a loss of greater than 20 percent of 
the individual's baseline weight, sustained for three months or longer; 
and the term ``minor weight loss'' means a weight loss of 10 to 20 
percent of the individual's baseline weight, sustained for three months 
or longer. The term ``inability to gain weight'' means that there has 
been substantial weight loss with inability to regain it despite 
appropriate therapy.

(Authority: 38 U.S.C. 1155)

    3. Section 4.114 is amended by:
    A. Revising diagnostic codes 7311, 7312, 7343, 7344, and 7345.
    B. Adding diagnostic codes 7351 and 7354.
    C. Adding a new authority citation at the end of the section.
    The revisions and additions read as follows:


Sec. 4.114  Schedule of ratings--Digestive system.

* * * * *

------------------------------------------------------------------------
                                                                  Rating
------------------------------------------------------------------------
7311 Residuals of injury of the liver.
    Depending on the specific residuals, evaluate as adhesions
     of peritoneum (diagnostic code 7301), cirrhosis of liver
     (diagnostic code 7312), or chronic liver disease without
     cirrhosis (diagnostic code 7345).
7312 Cirrhosis of the liver, primary biliary cirrhosis, or
 cirrhotic phase of sclerosing cholangitis:
    With one of the following refractory to treatment: ascites,      100
     hepatic encephalopathy, or hemorrhage from varices or
     portal gastropathy (erosive gastritis), or; with
     persistent jaundice, generalized weakness, and substantial
     weight loss...............................................

[[Page 48209]]

 
    History of two or more episodes of ascites, hepatic               70
     encephalopathy, or hemorrhage from varices or portal
     gastropathy (erosive gastritis), but with periods of
     remission between attacks.................................
    History of one episode of ascites, hepatic encephalopathy,        50
     or hemorrhage from varices or portal gastropathy (erosive
     gastritis)................................................
    Portal hypertension and splenomegaly, with weakness,              30
     anorexia, abdominal pain, malaise, and at least minor
     weight loss...............................................
    Symptoms such as weakness, anorexia, abdominal pain, and          10
     malaise...................................................
    Note: For evaluation under diagnostic code 7312,
     documentation of cirrhosis (by biopsy or imaging) and
     abnormal liver function tests must be present.
                  *        *        *        *        *
7343 Malignant neoplasms of the digestive system, exclusive of       100
 skin growths..................................................
    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.
7344 Benign neoplasms, exclusive of skin growths. Evaluate
 under an appropriate diagnostic code, depending on the
 predominant disability or the specific residuals after
 treatment.
7345 Chronic liver disease without cirrhosis (including
 hepatitis B, chronic active hepatitis, autoimmune hepatitis,
 hemochromatosis, drug-induced hepatitis, etc., but excluding
 bile duct disorders and hepatitis C).
    Near-constant incapacitating symptoms (such as fatigue,          100
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain)......................................
    Incapacitating episodes (with symptoms such as fatigue,           60
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     six weeks during the past 12-month period, but not
     occurring constantly, or; with daily fatigue, malaise, and
     anorexia, with substantial weight loss (or other
     indication of malnutrition), and hepatomegaly.............
    Incapacitating episodes (with symptoms such as fatigue,           40
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     four weeks, but less than six weeks, during the past 12-
     month period, or; with daily fatigue, malaise, and
     anorexia, with minor weight loss and hepatomegaly.........
    Incapacitating episodes (with symptoms such as fatigue,           20
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     two weeks, but less than four weeks, during the past 12-
     month period, or; with daily fatigue, malaise, and
     anorexia (without weight loss or hepatomegaly), requiring
     dietary restriction or continuous medication..............
    Incapacitating episodes (with symptoms such as fatigue,           10
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     one week, but less than two weeks, during the past 12-
     month period, or; intermittent fatigue, malaise, and
     anorexia..................................................
    Nonsymptomatic.............................................        0
    Note (1): Evaluate sequelae, such as cirrhosis or
     malignancy of the liver, under an appropriate diagnostic
     code, but do not use the same signs and symptoms as the
     basis for evaluation under DC 7354 and under a diagnostic
     code for sequelae. (See Sec.  4.14.).
    Note (2): For purposes of evaluating conditions under
     diagnostic code 7345, an incapacitating episode means a
     period of acute signs and symptoms severe enough to
     require bed rest and treatment by a physician.
    Note (3): Hepatitis B infection must be confirmed by
     serologic testing in order to evaluate it under diagnostic
     code 7345.
                  *        *        *        *        *
7351 Liver transplant.
    For an indefinite period from the date of hospital               100
     admission for transplant surgery..........................
    Minimum....................................................       30
    Note: A rating of 100 percent shall be assigned as of the
     date of hospital admission for transplant surgery and
     shall continue. 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.
7354 Hepatitis C (or non-A, non-B hepatitis).
    With serologic evidence of hepatitis C infection and the
     following signs and symptoms due to hepatitis C infection:
    Near-constant incapacitating symptoms (such as fatigue,          100
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain)......................................
    Incapacitating episodes (with symptoms such as fatigue,           60
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     six weeks during the past 12-month period, but not
     occurring constantly, or; with daily fatigue, malaise, and
     anorexia, with substantial weight loss (or other
     indication of malnutrition), and hepatomegaly.............

[[Page 48210]]

 
    Incapacitating episodes (with symptoms such as fatigue,           40
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     four weeks, but less than six weeks, during the past 12-
     month period, or; with daily fatigue, malaise, and
     anorexia, with minor weight loss and hepatomegaly.........
    Incapacitating episodes (with symptoms such as fatigue,           20
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     two weeks, but less than four weeks, during the past 12-
     month period, or; with daily fatigue, malaise, and
     anorexia (without weight loss or hepatomegaly), requiring
     dietary restriction or continuous medication..............
    Incapacitating episodes (with symptoms such as fatigue,           10
     malaise, nausea, vomiting, anorexia, arthralgia, and right
     upper quadrant pain) having a total duration of at least
     one week, but less than two weeks, during the past 12-
     month period, or; intermittent fatigue, malaise, and
     anorexia..................................................
    Nonsymptomatic.............................................        0
    Note (1): Evaluate sequelae, such as cirrhosis or
     malignancy of the liver, under an appropriate diagnostic
     code, but do not use the same signs and symptoms as the
     basis for evaluation under DC 7354 and under a diagnostic
     code for sequelae. (See Sec.  4.14.).
    Note (2): For purposes of evaluating conditions under
     diagnostic code 7354, an incapacitating episode means a
     period of acute signs and symptoms severe enough to
     require bed rest and treatment by a physician.
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(Authority: 38 U.S.C. 1155)

[FR Doc. 00-19761 Filed 8-4-00; 8:45 am]
BILLING CODE 8320-01-P