[Federal Register Volume 82, Number 211 (Thursday, November 2, 2017)]
[Rules and Regulations]
[Pages 50802-50807]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-23044]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AO44


Schedule for Rating Disabilities; The Endocrine System

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: This document amends the Department of Veterans Affairs (VA) 
Schedule for Rating Disabilities (VASRD) by revising the portion of the 
Schedule that addresses endocrine conditions and disorders of the 
endocrine system. The effect of this action is to ensure that the VASRD 
uses current medical terminology and to provide detailed and updated 
criteria for evaluation of endocrine disorders.

DATES: This rule is effective on December 10, 2017.

FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, Medical Officer, 
Part 4 VASRD Regulations Staff (211C), Compensation Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Avenue NW., Washington, DC 20420, [email protected], (202) 461-
9700 (this is not a toll-free telephone number).

SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal 
Register at 80 FR 39011 on July 8, 2015, to amend the portion of the 
VASRD dealing with endocrine disorders. VA provided a 60-day public 
comment period, and interested persons were invited to submit written 
comments, suggestions, or objections on or before September 8, 2015. VA 
received comments from four individuals. In addition, VA received a 
comment from a veterans service organization. Unless otherwise 
indicated below, VA adopts the changes set forth in the proposed rule.

Public Comments

    One commenter asked whether VA would recognize polycystic ovarian 
syndrome (PCOS) under the VA rating schedule. VA has a mechanism in 
place to address PCOS under 38 CFR 4.116. Specifically, the rating 
schedule for Gynecological Conditions and Disorders of the Breast 
addresses various ovarian conditions under Diagnostic Code (DC) 7615, 
``Ovary, disease, injury, or adhesions of'' and allows VA to rate based 
on whether symptoms are controlled by or require continuous treatment. 
In exceptional cases where the schedular evaluation is inadequate, 38 
CFR 3.321 allows for extraschedular evaluation. Therefore, VA makes no 
changes based on this comment.
    Two commenters proposed additional modifications to DC 7913, 
``Diabetes mellitus.'' One commenter suggested adding a note to address 
the issue of regulation of activities. Another commenter suggested not 
changing the insulin requirements within DC 7913 without considering 
the other requirements in the DC such as regulation of activities. The 
same commenter suggested removing the insulin requirement for a 20-
percent rating and the regulation of activities requirement at all 
disability ratings under the DC. The commenter stated that the 
functional impairment caused by required use of insulin is greater than 
impairment caused by ingestion of oral medication to control diabetes. 
As stated in the proposed rule, VA is not proposing any change to the 
evaluation criteria for DC 7913 at this time other than requiring ``one 
or more daily injection'' of insulin for a 20-, 40- or 60-percent 
rating and instead intends to establish a work group to specifically 
address this condition. Therefore, these comments are beyond the scope 
of this rulemaking. However, VA will take these comments into 
consideration in connection with a possible future rulemaking.
    One commenter suggested changing the terminology for a 100-percent 
rating under DC 7903, ``Hypothyroidism'' from ``myxedema'' to 
``myxedema coma or crisis'' because myxedema can be present without 
causing the requisite level of symptoms for a 100-percent rating. 
Myxedema is a term used to denote severe hypothyroidism, and myxedema 
coma or myxedema crisis is a medical emergency and represents a 
specific rare life-threatening clinical condition. Because the clinical 
picture of myxedema appears in the most extreme cases of 
hypothyroidism, we believe that this manifestation of the disability 
warrants a 100-percent rating (See Greenspan's Basic & Clinical 
Endocrinology (D.G. Gardner et al. eds., 9th ed. 2011) available at 
http://accessmedicine.mhmedical.com/content.aspx?bookid=380§ionid=39744047#8401831). Therefore, VA 
makes no changes based on this comment.
    The same commenter proposed that VA retain a 10-percent minimum 
evaluation in the DCs for endocrine disabilities because of the need 
for continuous medication to control the symptoms of these 
disabilities. VA disagrees. In the absence of symptoms, medical 
management of chronic endocrine disorders does not present a 
significant lifestyle adjustment, and it does not result in impairment 
of earning capacity (see 38 U.S.C. 1155). Therefore, VA makes no 
changes based on this comment.
    The same commenter noted a typographical error in the text of 
proposed DC 7911. The word ``adrenocortical'' was misspelled as 
``adrenalcortical.'' VA has changed the spelling of the term based on 
this comment.
    One commenter was supportive of the overall changes and additions 
to this section of the VASRD, such as additional DCs, clarification of 
notes on residuals affecting other body systems, instructions to rate 
some residuals separately, accounting for additional symptoms, and 
formation of a new work group for diabetes mellitus. The

[[Page 50803]]

commenter also commented that proposed DCs 7900 (Hyperthyroidism), 7903 
(Hypothyroidism), and 7905 (Hypoparathyroidism) do not adequately 
account for disability due to uncontrolled thyroid hormone or calcium 
imbalance because proposed DCs 7900 and 7903 only provide a 30-percent 
rating for symptoms existing for up to six months after diagnosis and 
proposed DC 7905 provides a 100-percent rating for symptoms occurring 
for up to three months after diagnosis; thereafter, residual effects 
are rated under the body system affected by the endocrine disability. 
The commenter stated that endocrine function may still be disturbed 
while the correct dosage of medication is being determined and that 
some patients may not have received treatment.
    We first point out that the ratings under DC 7900 and 7903 are for 
``six months after initial diagnosis'' and the rating under DC 7905 is 
for ``three months after initial diagnosis.'' Thus, the claimants are 
likely receiving treatment. In addition, as VA explained in the notice 
of proposed rulemaking, most symptoms of hyperthyroidism and 
hypothyroidism are alleviated within six months of treatment (see 80 FR 
39011, 39013 (Jul. 8, 2015)).
    With regard to residual symptoms, the primary effect of chronic 
hyperthyroidism, hypothyroidism, and hypoparathyroidism is on body 
systems regulated by the thyroid. Therefore, in cases where veterans 
still have symptoms after six months for hyperthyroidism or 
hypothyroidism or after three months for hypoparathyroidism, VA 
addresses residual symptoms by rating all residuals based on the 
specific disability presented under the most appropriate DCs within the 
appropriate body system(s).
    The residuals of endocrine disorders such as uncontrolled thyroid 
hormone or calcium imbalance produce measurable disability including 
muscle damage, blood-clotting issues, nerve and kidney damage, 
depression, and many others. Therefore, VA makes no changes based on 
this comment.
    The commenter also stated that VA has not provided a reasoned 
argument for eliminating a 10-percent evaluation when continued 
medication is required under DCs 7900 and 7903. Ratings under the 
schedule are ``based, as far as practicable, upon the average 
impairments of earning capacity resulting from [specific] injuries'' or 
combination of injuries (see 38 U.S.C. 1155). As detailed above, VA 
explained in the notice of proposed rulemaking that symptoms of 
hyperthyroidism and hypothyroidism generally resolve completely within 
six months after diagnosis and that symptoms of hypoparathyroidism are 
generally eliminated following treatment with calcium and vitamin D 
supplementation (see 80 FR 39011, 39012-14 (Jul. 8, 2015)). Because 
symptoms are generally eliminated or minimal once a patient receives 
appropriate medication, there is no impairment of earning capacity and 
therefore no need to retain the 10-percent rating under DCs 7900, 7903, 
and 7905. As explained above, any disabling residuals may be rated 
under the most appropriate rating code. Further, if medication is 
discontinued and symptoms reappear, the disability could again be rated 
under the schedule for rating disabilities of the endocrine system.
    The same commenter suggested that proposed DC 7912 should account 
for residuals of common treatment procedures such as the Whipple 
procedure, which is also used for the treatment of pancreatic cancer. 
VA regulations allow for secondary service connection for disabilities 
that are proximately due to or the result of a service-connected 
disease or injury (see 38 CFR 3.310(a)). Disabilities that are 
secondarily service connected and have distinguishable symptoms, to 
include disabilities that arise from the treatment of a service-
connected disability, are rated separately under the VA rating 
schedule. Therefore, VA makes no changes based on this comment.
    The same commenter proposed that VA amend DCs 7901 and 7902 to 
account for the specific characteristics of disfigurement due to 
thyroid enlargement rather than rating such disfigurement under DC 7800 
because the criteria in DC 7800 do not match the features of thyroid 
enlargement. The commenter provided two examples of this alleged 
inconsistency, cystic thyroid nodules requiring draining and soft 
swelling of the neck. If disfigurement related to thyroid enlargement 
does not satisfy the criteria in DC 7800, the disfigurement does not 
result in impairment of earning capacity and is not compensable (see 38 
U.S.C. 1155). Therefore, VA makes no changes based on these comments.
    VA appreciates the comments submitted in response to the proposed 
rule. Based on the rationale stated in the proposed rule and in this 
document, the proposed rule is adopted with the change noted.
    We are additionally adding updates to 38 CFR part 4, Appendices A, 
B, and C, to reflect changes to the endocrine system rating criteria 
made by this rulemaking. The appendices are tools for users of the 
VASRD and do not contain substantive content regarding evaluation of 
disabilities. As such, we believe it is appropriate to include these 
updates in this final rule.

Benefits Costs

    The change to the proposed rule will not alter the estimated costs 
provided in the previous Notice of Proposed Rulemaking.

Effective Date of Final Rule

    Veterans Benefits Administration (VBA) personnel utilize the 
Veterans Benefit Management System for Rating (VBMS-R) to process 
disability compensation claims that involve disability evaluations made 
under the VASRD. In order to ensure that there is no delay in 
processing veterans' claims, VA must coordinate the effective date of 
this final rule with corresponding VBMS-R system updates. As such, this 
final rule will apply effective December 10, 2017, the date VBMS-R 
system updates related to this final rule will be complete.

Executive Orders 12866 and 13563

    Executive Orders 13563 and 12866 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action,'' requiring review by the Office of 
Management and Budget (OMB), unless OMB waives such review, as ``any 
regulatory action that is likely to result in a rule that may: (1) Have 
an annual effect on the economy of $100 million or more or adversely 
affect in a material way the economy, a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or State, local, or tribal governments or communities; (2) 
Create a serious inconsistency or otherwise interfere with an action 
taken or planned by another agency; (3) Materially alter the budgetary 
impact of entitlements, grants, user fees, or loan programs or the 
rights and obligations of recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or

[[Page 50804]]

the principles set forth in this Executive Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this final rule have been examined, and have been 
determined not to be a significant regulatory action under Executive 
Order 12866. VA's impact analysis can be found as a supporting document 
at http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of this 
rulemaking and its impact analysis are available on VA's Web site at 
http://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''

Regulatory Flexibility Act

    The Secretary hereby certifies that this final rule will not have a 
significant economic impact on a substantial number of small entities 
as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
612. This final rule will not directly affect any small entities. Only 
certain VA beneficiaries could be directly affected. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of sections 603 
and 604.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in the expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any one year. This final rule will have no such effect on 
State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

    This final rule contains no provisions constituting a collection of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521).

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance program numbers and 
titles for this rule are 64.009, Veterans Medical Care Benefits; 
64.104, Pension for Non-Service-Connected Disability for Veterans; 
64.109, Veterans Compensation for Service-Connected Disability; and 
64.110, Veterans Dependency and Indemnity Compensation for Service-
Connected Death.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on April 19, 2017, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Approved: April 19, 2017.
Jeffrey Martin,
Office Program Manager, Office of Regulation Policy & Management, 
Office of the Secretary, Department of Veterans Affairs

    Editor's Note:  This document was received for publication at 
the Office of the Federal Register on October 19, 2017.

    For the reasons set out in the preamble, the Department of Veterans 
Affairs amends 38 CFR part 4 as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

0
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

0
2. Amend Sec.  4.104 by revising the entry for 7008 to read as follows:


Sec.  4.104  Schedule of ratings-cardiovascular system.

                          Diseases of the Heart
------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
 
                                * * * * *
7008 Hyperthyroid heart disease.
  Rate under the appropriate cardiovascular diagnostic code,
   depending on particular findings.
 
                                * * * * *
------------------------------------------------------------------------


0
3. Amend Sec.  4.119 by:
0
a. Revising the entries for 7900 through 7905;
0
b. Adding in numerical order an entry for 7906; and
0
c. Revising the entries for 7907 through 7909, 7911 through 7913, and 
7915 through 7919.
    The revisions and addition read as follows:


Sec.  4.119  Schedule of ratings--endocrine system.

------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
7900 Hyperthyroidism, including, but not limited to, Graves'
 disease:
    For six months after initial diagnosis...................         30
    Thereafter, rate residuals of disease or complications of
     medical treatment within the appropriate diagnostic
     code(s) within the appropriate body system.
    Note (1): If hyperthyroid cardiovascular or cardiac
     disease is present, separately evaluate under DC 7008
     (hyperthyroid heart disease).
    Note (2): Separately evaluate eye involvement occurring
     as a manifestation of Graves' Disease as diplopia (DC
     6090); impairment of central visual acuity (DCs 6061-
     6066); or under the most appropriate DCs in Sec.   4.79.
7901 Thyroid enlargement, toxic:
    Note (1): Evaluate symptoms of hyperthyroidism under DC
     7900, hyperthyroidism, including, but not limited to,
     Graves' disease.
    Note (2): If disfigurement of the neck is present due to
     thyroid disease or enlargement, separately evaluate
     under DC 7800 (burn scar(s) of the head, face, or neck;
     scar(s) of the head, face, or neck due to other causes;
     or other disfigurement of the head, face, or neck).
7902 Thyroid enlargement, nontoxic:
    Note (1): Evaluate symptoms due to pressure on adjacent
     organs (such as the trachea, larynx, or esophagus) under
     the appropriate diagnostic code(s) within the
     appropriate body system.
    Note (2): If disfigurement of the neck is present due to
     thyroid disease or enlargement, separately evaluate
     under DC 7800 (burn scar(s) of the head, face, or neck;
     scar(s) of the head, face, or neck due to other causes;
     or other disfigurement of the head, face, or neck).
7903 Hypothyroidism:

[[Page 50805]]

 
    Hypothyroidism manifesting as myxedema (cold intolerance,        100
     muscular weakness, cardiovascular involvement
     (including, but not limited to hypotension, bradycardia,
     and pericardial effusion), and mental disturbance
     (including, but not limited to dementia, slowing of
     thought and depression))................................
    Note (1): This evaluation shall continue for six months
     beyond the date that an examining physician has
     determined crisis stabilization. Thereafter, the
     residual effects of hypothyroidism shall be rated under
     the appropriate diagnostic code(s) within the
     appropriate body system(s) (e.g., eye, digestive, and
     mental disorders).
    Hypothyroidism without myxedema..........................         30
    Note (2): This evaluation shall continue for six months
     after initial diagnosis. Thereafter, rate residuals of
     disease or medical treatment under the most appropriate
     diagnostic code(s) under the appropriate body system
     (e.g., eye, digestive, mental disorders).
    Note (3): If eye involvement, such as exophthalmos,
     corneal ulcer, blurred vision, or diplopia, is also
     present due to thyroid disease, also separately evaluate
     under the appropriate diagnostic code(s) in Sec.   4.79,
     Schedule of Ratings--Eye (such as diplopia (DC 6090) or
     impairment of central visual acuity (DCs 6061-6066)).
7904 Hyperparathyroidism:
    For six months from date of discharge following surgery..        100
    Note (1): After six months, rate on residuals under the
     appropriate diagnostic code(s) within the appropriate
     body system(s) based on a VA examination.
    Hypercalcemia (indicated by at least one of the                   60
     following: Total Ca greater than 12 mg/dL (3-3.5 mmol/
     L), Ionized Ca greater than 5.6 mg/dL (2-2.5 mmol/L),
     creatinine clearance less than 60 mL/min, bone mineral
     density T-score less than 2.5 SD (below mean) at any
     site or previous fragility fracture)....................
    Note (2): Where surgical intervention is indicated, this
     evaluation shall continue until the day of surgery, at
     which time the provisions pertaining to a 100-percent
     evaluation shall apply.
    Note (3): Where surgical intervention is not indicated,
     this evaluation shall continue for six months after
     pharmacologic treatment begins. After six months, rate
     on residuals under the appropriate diagnostic code(s)
     within the appropriate body system(s) based on a VA
     examination.
    Symptoms such as fatigue, anorexia, nausea, or                    10
     constipation that occur despite surgery; or in
     individuals who are not candidates for surgery but
     require continuous medication for control...............
    Asymptomatic.............................................          0
    Note (4): Following surgery or other treatment, evaluate
     chronic residuals, such as nephrolithiasis (kidney
     stones), decreased renal function, fractures, vision
     problems, and cardiovascular complications, under the
     appropriate diagnostic codes.
7905 Hypoparathyroidism:
    For three months after initial diagnosis.................        100
    Thereafter, evaluate chronic residuals, such as
     nephrolithiasis (kidney stones), cataracts, decreased
     renal function, and congestive heart failure under the
     appropriate diagnostic codes.
7906 Thyroiditis:
    With normal thyroid function (euthyroid).................          0
    Note: Manifesting as hyperthyroidism, evaluate as
     hyperthyroidism, including, but not limited to, Graves'
     disease (DC 7900); manifesting as hypothyroidism,
     evaluate as hypothyroidism (DC 7903).
7907 Cushing's syndrome:
    As active, progressive disease, including areas of               100
     osteoporosis, hypertension, and proximal upper and lower
     extremity muscle wasting that results in inability to
     rise from squatting position, climb stairs, rise from a
     deep chair without assistance, or raise arms............
    Proximal upper or lower extremity muscle wasting that             60
     results in inability to rise from squatting position,
     climb stairs, rise from a deep chair without assistance,
     or raise arms...........................................
    With striae, obesity, moon face, glucose intolerance, and         30
     vascular fragility......................................
    Note: The evaluations specifically indicated under this
     diagnostic code shall continue for six months following
     initial diagnosis. After six months, rate on residuals
     under the appropriate diagnostic code(s) within the
     appropriate body system(s).
7908 Acromegaly:
    Evidence of increased intracranial pressure (such as             100
     visual field defect), arthropathy, glucose intolerance,
     and either hypertension or cardiomegaly.................
    Arthropathy, glucose intolerance, and hypertension.......         60
    Enlargement of acral parts or overgrowth of long bones...         30
7909 Diabetes insipidus:
    For three months after initial diagnosis.................         30
    Note: Thereafter, if diabetes insipidus has subsided,
     rate residuals under the appropriate diagnostic code(s)
     within the appropriate body system.
    With persistent polyuria or requiring continuous hormonal         10
     therapy.................................................
7911 Addison's disease (adrenocortical insufficiency):
    Four or more crises during the past year.................         60
    Three crises during the past year, or; five or more               40
     episodes during the past year...........................
    One or two crises during the past year, or; two to four           20
     episodes during the past year, or; weakness and
     fatigability, or; corticosteroid therapy required for
     control.................................................
    Note (1): An Addisonian ``crisis'' consists of the rapid
     onset of peripheral vascular collapse (with acute
     hypotension and shock), with findings that may include:
     anorexia; nausea; vomiting; dehydration; profound
     weakness; pain in abdomen, legs, and back; fever;
     apathy, and depressed mentation with possible
     progression to coma, renal shutdown, and death.
    Note (2): An Addisonian ``episode,'' for VA purposes, is
     a less acute and less severe event than an Addisonian
     crisis and may consist of anorexia, nausea, vomiting,
     diarrhea, dehydration, weakness, malaise, orthostatic
     hypotension, or hypoglycemia, but no peripheral vascular
     collapse.
    Note (3): Tuberculous Addison's disease will be evaluated
     as active or inactive tuberculosis. If inactive, these
     evaluations are not to be combined with the graduated
     ratings of 50 percent or 30 percent for non-pulmonary
     tuberculosis specified under Sec.   4.88b. Assign the
     higher rating.
7912 Polyglandular syndrome (multiple endocrine neoplasia,
 autoimmune polyglandular syndrome):

[[Page 50806]]

 
    Evaluate according to major manifestations to include,
     but not limited to, Type I diabetes mellitus,
     hyperthyroidism, hypothyroidism, hypoparathyroidism, or
     Addison's disease.
7913 Diabetes mellitus:
    Requiring more than one daily injection of insulin,              100
     restricted diet, and regulation of activities (avoidance
     of strenuous occupational and recreational activities)
     with episodes of ketoacidosis or hypoglycemic reactions
     requiring at least three hospitalizations per year or
     weekly visits to a diabetic care provider, plus either
     progressive loss of weight and strength or complications
     that would be compensable if separately evaluated.......
    Requiring one or more daily injection of insulin,                 60
     restricted diet, and regulation of activities with
     episodes of ketoacidosis or hypoglycemic reactions
     requiring one or two hospitalizations per year or twice
     a month visits to a diabetic care provider, plus
     complications that would not be compensable if
     separately evaluated....................................
    Requiring one or more daily injection of insulin,                 40
     restricted diet, and regulation of activities...........
    Requiring one or more daily injection of insulin and              20
     restricted diet, or; oral hypoglycemic agent and
     restricted diet.........................................
    Manageable by restricted diet only.......................         10
    Note (1): Evaluate compensable complications of diabetes
     separately unless they are part of the criteria used to
     support a 100-percent evaluation. Noncompensable
     complications are considered part of the diabetic
     process under DC 7913.
    Note (2): When diabetes mellitus has been conclusively
     diagnosed, do not request a glucose tolerance test
     solely for rating purposes.
 
                              * * * * * * *
7915 Neoplasm, benign, any specified part of the endocrine
 system:
    Rate as residuals of endocrine dysfunction.
7916 Hyperpituitarism (prolactin secreting pituitary
 dysfunction):
    Note: Evaluate as malignant or benign neoplasm, as
     appropriate.
7917 Hyperaldosteronism (benign or malignant):
    Note: Evaluate as malignant or benign neoplasm, as
     appropriate.
7918 Pheochromocytoma (benign or malignant):
    Note: Evaluate as malignant or benign neoplasm as
     appropriate.
7919 C-cell hyperplasia of the thyroid:
    If antineoplastic therapy is required, evaluate as a
     malignant neoplasm under DC 7914. If a prophylactic
     thyroidectomy is performed (based upon genetic testing)
     and antineoplastic therapy is not required, evaluate as
     hypothyroidism under DC 7903.
 
                              * * * * * * *
------------------------------------------------------------------------


0
4. Amend the table in appendix A to part 4 in the entries for Sec. 
4.104 and Sec. 4.119 by:
0
a. Revising the entry for 7008;
0
b. Revising the entries for 7900 through 7905;
0
c. Adding in numerical order an entry for 7906; and
0
d. Revising the entries for 7907 through 7909, 7911 through 7913, and 
7915 through 7919.
    The revisions and addition read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 
1946

------------------------------------------------------------------------
                  Diagnostic
      Sec.         code No.
------------------------------------------------------------------------
 
                              * * * * * * *
                        7008  Evaluation January 12, 1998; criterion
                               December 10, 2017.
 
                              * * * * * * *
4.119..........         7900  Criterion August 13, 1981; evaluation June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7901  Criterion August 13, 1981; evaluation June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7902  Evaluation August 13, 1981; criterion June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7903  Criterion August 13, 1981; evaluation June
                               9, 1996; evaluation December 10, 2017;
                               criterion December 10, 2017; note
                               December 10, 2017.
                        7904  Criterion August 13, 1981; evaluation June
                               9, 1996; evaluation December 10, 2017;
                               criterion December 10, 2017; note
                               December 10, 2017.
                        7905  Evaluation; August 13, 1981; evaluation
                               June 9, 1996; evaluation December 10,
                               2017; criterion December 10, 2017.
                        7906  Added December 10, 2017.
                        7907  Evaluation; August 13, 1981; evaluation
                               June 9, 1996; criterion December 10,
                               2017; note December 10, 2017.
                        7908  Criterion August 13, 1981; criterion June
                               9, 1996; criterion December 10, 2017.
                        7909  Evaluation August 13, 1981; criterion June
                               9, 1996; evaluation June 9, 1996;
                               criterion December 10, 2017; evaluation
                               December 10, 2017; note December 10,
                               2017.
                        7910  Removed June 9, 1996.
                        7911  Evaluation March 11, 1969; evaluation
                               August 13, 1981; criterion June 9, 1996;
                               title December 10, 2017; note December
                               10, 2017.
                        7912  Title December 10, 2017; criterion
                               December 10, 2017.
                        7913  Criterion September 9, 1975; criterion
                               August 13, 1981; criterion June 6, 1996;
                               evaluation June 9, 1996; criterion
                               December 10, 2017; note December 10,
                               2017.
 

[[Page 50807]]

 
                              * * * * * * *
                        7915  Criterion June 9, 1996; criterion December
                               10, 2017.
                        7916  Added June 9, 1996; note December 10,
                               2017.
                        7917  Added June 9, 1996; note December 10,
                               2017.
                        7918  Added June 9, 1996; note December 10,
                               2017.
                        7919  Added June 9, 1996; evaluation June 9,
                               1996; criterion December 10, 2017; note
                               December 10, 2017.
 
                              * * * * * * *
------------------------------------------------------------------------


0
5. Amend Appendix B to part 4 by:
0
a. Revising the entries for diagnostic codes 7900 through 7902;
0
b. Adding, in numerical order, an entry for diagnostic code 7906; and
0
c. Revising the entries for diagnostic codes 7911 and 7912.
    The revisions and addition read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
     Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                          THE ENDOCRINE SYSTEM
------------------------------------------------------------------------
7900.........................  Hyperthyroidism, including, but not
                                limited to, Graves' disease.
7901.........................  Thyroid enlargement, toxic.
7902.........................  Thyroid enlargement, nontoxic.
 
                              * * * * * * *
7906.........................  Thyroiditis.
 
                              * * * * * * *
7911.........................  Addison's disease (adrenocortical
                                insufficiency).
7912.........................  Polyglandular syndrome (multiple
                                endocrine neoplasia, autoimmune
                                polyglandular syndrome).
 
                              * * * * * * *
------------------------------------------------------------------------


0
6. Amend Appendix C to Part 4 as follows:
0
a. Add, in alphabetical order, entries for ``Graves' disease'' and 
``Polyglandular syndrome'';
0
b. Revise the entry for ``Thyroid gland''; and
0
c. Add, in alphabetical order, an entry for ``Thyroiditis''.
    The additions and revision read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
                                                              Diagnostic
                                                               code No.
------------------------------------------------------------------------
 
                                * * * * *
Graves' disease............................................         7900
 
                                * * * * *
Polyglandular syndrome.....................................         7912
 
                                * * * * *
Thyroid gland..............................................
  Nontoxic thyroid enlargement.............................         7902
  Toxic thyroid enlargement................................         7901
Thyroiditis................................................         7906
 
                                * * * * *
------------------------------------------------------------------------

[FR Doc. 2017-23044 Filed 11-1-17; 8:45 am]
 BILLING CODE 8320-01-P