[Federal Register Volume 83, Number 68 (Monday, April 9, 2018)]
[Rules and Regulations]
[Pages 15068-15074]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-07081]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP13


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

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 
rating schedule that addresses gynecological conditions and disorders 
of the breast. The effect of this action is to ensure that this portion 
of the rating schedule uses current medical terminology and to provide 
detailed and updated criteria for evaluation of gynecological 
conditions and disorders of the breast.

DATES: Effective Date: This rule is effective on May 13, 2018.

FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, M.D., M.B.A., 
Medical Officer, Part 4 VASRD Regulations Staff (211C), Compensation 
Service, Veterans Benefits Administration, Department of Veterans 
Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (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 10637 on February 27, 2015, to amend 38 CFR 4.116, 
the portion of the VASRD dealing with gynecological conditions and 
disorders of the breast. VA provided a 60-day public comment period and 
interested persons were invited to submit written comments on or before 
April 28, 2015. VA received 13 comments.
    Several commenters expressed their support for the proposed rule 
and thanked VA for promoting gender equality in the rating schedule.
    One commenter demanded compensation for his multiple debilitating 
health issues, which he attributed to exposure to toxic substances at 
Fort McClellan. He also urged VA to pass the Fort McClellan Health 
Registry Act, H.R. 411, 113th Cong. (2013). Several commenters stated 
their belief that their multiple medical conditions are due to exposure 
to toxic substances at Fort McClellan and asked to be considered for 
service connection. Another commenter provided information about his 
medical conditions, which he stated he developed after his reservist's 
training at Fort McClellan that involved chemical agent training. These 
comments focus on issues of service connection, rather than the 
appropriate rating for already service-connected disabilities, and 
individual claims for VA benefits, which are beyond the scope of this 
rulemaking. Regarding the commenter's request that VA ``pass'' the Fort 
McClellan Health Registry Act, VA notes that this act is a 
Congressional act and not before VA. This comment is also beyond the 
scope of this rulemaking. Therefore, VA makes no changes to the 
proposed rule based on these comments.
    One commenter had a question about the proposed note to diagnostic 
code 7615 ``Ovary, disease, injury, or adhesions of'' asking if the 
note would create a narrow category for disability evaluation by 
identifying dysmenorrhea and secondary amenorrhea. The commenter's 
concern is not entirely clear. To the extent the commenter is asking 
whether VA considers dysmenorrhea and secondary amenorrhea disabilities 
for rating purposes, the note to diagnostic code 7615 provides that 
dysmenorrhea and secondary amenorrhea shall be rated under that 
diagnostic code. To the extent the commenter is asking whether 
identification of dysmenorrhea and secondary amenorrhea in the note 
limits the application of diagnostic code 7615 to those diseases, it 
does not. Dysmenorrhea and secondary amenorrhea are only examples of 
diseases that would be rated under diagnostic code 7615. Other 
impairments associated with disease, injury, or adhesions of the 
ovaries will continue to be rated under diagnostic code 7615. 
Therefore, VA makes no changes based on this comment.
    One commenter wanted to include premature hysterectomy secondary to 
menorrhagia as an additional gynecological disability in the rating 
schedule. VA evaluates service-connected hysterectomy under diagnostic 
codes 7617 and 7618. The cause of the hysterectomy may be a factor in 
determining service connection, but is not important in evaluating the 
condition. Therefore, VA makes no changes based on this comment.
    One commenter suggested adding a new diagnostic code or adjusting 
an existing code for infertility due to the loss or loss of use of 
other organs besides the uterus and ovaries, specifically fallopian 
tubes. The commenter asserted that, with respect to the uterus and 
ovaries, the minimum rating for a condition that causes infertility is 
20 percent and that this rating does not take into account symptoms, 
only whether the organs are able to function reproductively. Therefore, 
the commenter asserts that any damage to any part of the female 
reproductive system that causes infertility should result in at least a 
20 percent evaluation.
    While tubal damage may be associated with infertility, infertility 
is not in itself a disability for VA rating purposes. It does not 
result in the loss of average earning capacity. See 38 CFR 4.1 (stating 
that the purpose of the rating schedule is to represent the average 
impairment in earning capacity resulting from diseases and injuries in 
civil occupations). Diagnostic code 7614, Fallopian tube, disease, 
injury, or adhesions of, provides disability ratings for functional 
impairment due to symptoms associated with fallopian tube damage. If 
loss or loss of use of a creative organ due to service-connected 
fallopian tube damage is present, VA will consider special monthly 
compensation under the provisions of 38 CFR 3.350(a). VA makes no 
changes based on this comment.
    The same commenter proposes to add the diagnosis of repeated 
miscarriages to the list of presumptive conditions for female veterans 
who have been exposed to radiation, herbicides, or other environmental 
factors that could negatively impact the ability of a fetus to properly 
develop and carry to full term. The commenter also suggested VA provide 
for an award of special monthly compensation under the provisions of 
Sec.  3.350(a) for repeated miscarriages of an unknown etiology while 
on active duty. Miscarriages themselves are not

[[Page 15069]]

disabilities for VA rating purposes, as they do not result in 
impairment of earning capacity. See 38 CFR 4.1. The proposed rating 
criteria provide for adequate ratings based on impairment in earning 
capacity due to service-connected damage to reproductive organs, which 
may include chronic residuals of medical or surgical complications of 
pregnancy incurred during service. Additionally, special monthly 
compensation may be warranted for loss or loss of use of a creative 
organ due to service-connected disability. See 38 CFR 3.350(a)(1). 
Updating the list of presumptive conditions for veterans who have been 
exposed to radiation, herbicides, or other environmental factors is 
beyond the scope of this rulemaking, which is about the rating of 
conditions which have been service connected, not about which diseases 
should be subject to presumptive service connection. Therefore, VA 
makes no changes based on these comments.
    The same commenter asked how powerful a diagnosis of female sexual 
arousal disorder would be as supporting evidence for military sexual 
trauma (MST). This rulemaking concerns the rating schedule in part 4, 
specifically 38 CFR 4.116, and the evaluations that VA assigns for 
physiological impairment due to disorders of the gynecological system 
and disorders of the breasts. The evidentiary criteria for 
posttraumatic stress disorder are listed in 38 CFR 3.304(f). Further, 
mental disabilities due to MST are evaluated under the rating schedule 
for mental disorders in Sec.  4.130. This comment is beyond the scope 
of this rulemaking. Therefore, VA makes no changes based on this 
comment.
    One commenter was supportive of the overall changes and additions 
to this section of the rating schedule. However, the commenter 
expressed concern that the proposed rating criteria for diagnostic code 
7621 do not adequately measure disability affecting multiple body 
systems. Specifically, the commenter stated that the proposed rule was 
unclear as to whether a veteran would obtain evaluations under other 
body systems for the complications of pelvic organ prolapse, or whether 
the mild, moderate, or severe rating under proposed amended diagnostic 
code 7621 is meant to encompass all symptoms due to one or multiple 
pelvic organ prolapses. The commenter stated that, if these 
manifestations in different body systems are meant to be compensated 
under diagnostic code 7621, there is great potential for 
undercompensating the veteran, as separate ratings under the 
genitourinary and digestive system may afford a higher combined 
evaluation. The commenter further questioned whether rating the 
manifestations separately would constitute ``pyramiding'' under 38 CFR 
4.14.
    The same commenter also indicated that the Pelvic Organ Prolapse 
Quantification (POP-Q) scoring system upon which proposed diagnostic 
code 7621 was based does not correlate with the severity of symptoms 
affecting multiple body systems. In addition, the same commenter 
suggested that VA add a note to diagnostic code 7621 to clarify that 
functional impairment of other body systems, including the urinary and 
the digestive systems, as a result of pelvic organ prolapse, shall be 
evaluated under the appropriate diagnostic codes.
    Evaluations under proposed diagnostic code 7621 were intended to 
represent the average severity of symptoms, including gynecological, 
urinary, and digestive symptoms, and level of impairment as 
contemplated by the POP-Q system. Therefore, assigning separate ratings 
under proposed diagnostic code 7621 and the genitourinary or digestive 
systems would have violated pyramiding principles under 38 CFR 4.14 by 
allowing evaluations for urinary and/or digestive symptoms twice. See 
Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). VA acknowledges, 
however, that the average may not apply to all women and that two women 
with the same degree of prolapse (as measured by POP-Q) may experience 
different disabling effects based on their anatomical size. Therefore, 
in order to more accurately evaluate functional impairment and to 
ensure that the severity of the symptoms affecting multiple body 
systems are fully captured, VA amends the proposed rating criteria and 
the note under diagnostic code 7621 to include guidance on how to rate 
the residuals and complications of pelvic organ prolapse.
    First, VA amends diagnostic code 7621 to provide a 10 percent 
disability rating in all cases of complete or incomplete pelvic organ 
prolapse due to injury, disease, or surgical complications of 
pregnancy. This minimum level of compensation recognizes the disabling 
effects of the alteration to a woman's normal anatomy, such as a 
feeling of vaginal fullness or heaviness or pressure in the pelvis, 
that are not generally included in the compensable levels of disability 
in other body systems. The higher disability ratings in originally 
proposed diagnostic code 7621 took into consideration genitourinary, 
digestive, and skin symptoms, which will now be evaluated separately as 
described in the revised note to diagnostic code 7621.
    Second, VA agrees with the commenter that information should be 
added to the proposed note under diagnostic code 7621 to clarify how 
rating personnel should evaluate urinary and digestive symptoms 
associated with pelvic organ prolapse. Specifically, VA is adding 
information to the note under diagnostic code 7621 to clarify that 
rating personnel should separately evaluate any genitourinary, 
digestive, or skin symptoms under the appropriate diagnostic code(s) 
and combine all evaluations with the 10 percent evaluation under 
diagnostic code 7621. With this clarification, VA ensures that women 
with pelvic organ prolapse will receive adequate levels of compensation 
based on the functional impairment associated with their prolapse, 
regardless of any anatomical differences. The discussion by the 
commenter identified another potential approach of considering the 
greater evaluation under either proposed diagnostic code 7621 or the 
appropriate system. Under that approach, however, a veteran whose 
evaluation was based on a diagnostic code under a different body system 
would not be compensated for the disabling effects of prolapse specific 
to the gynecological system. The revised rule ensures that the 
disabling effects associated with multiple body systems are fully 
captured.
    The same commenter also suggested VA amend VA Form 21-0960K-2, 
Gynecological Conditions Disability Benefits Questionnaire (DBQ) to add 
questions regarding the effects of any diagnosed gynecological 
condition on the digestive system and consideration of whether the 
veteran has loss of use of a creative organ. The commenter noted that 
the DBQ already asks the examiner to comment on whether the 
gynecological conditions impact the genitourinary system. Currently, VA 
Form 21-0960K-2 asks an examiner to report any complications resulting 
from obstetrical or gynecological conditions or procedures. 
Additionally, VA Form 21-0960K-2 asks the examiner if the veteran has 
any other pertinent findings, complications, conditions, signs and/or 
symptoms related to any conditions listed in the diagnosis section of 
the form. Therefore, VA has an adequate mechanism to capture each and 
every condition related to the effects of any diagnosed gynecological 
condition, including the digestive system and loss of use of a creative 
organ. VA also notes that all affected DBQs will be updated upon 
issuance of this final rule and will

[[Page 15070]]

adhere to the same principles of recording pertinent findings. 
Therefore, VA makes no changes based on these comments.
    Lastly, the same commenter suggested VA add a separate diagnostic 
code in Sec.  4.116 for loss of coital function due to removal of the 
vagina by colpectomy and a note to consider special monthly 
compensation under 38 CFR 3.350(a) to increase rating consistency. VA 
appreciates this comment, but notes that the VASRD, in accordance with 
38 CFR 4.1, is ``a guide in the evaluation of disability'' in terms of 
occupational impairment and is not an exhaustive list of all potential 
diseases or conditions. This is further reinforced by 38 CFR 4.20, 
which specifically provides for analogous evaluations for unlisted 
conditions according to closely related diseases or injuries based on 
function affected, anatomical location, and symptomatology.
    Colpectomy, also known as vaginectomy, is a surgical procedure that 
obliterates the vaginal canal in order to alleviate the symptoms of 
advanced pelvic organ prolapse or to treat gynecological malignancies. 
Such obliterative procedure is reserved for women who are not 
candidates for more extensive surgery or do not plan future vaginal 
intercourse. Colpectomy is generally deemed appropriate for elderly 
patients with medical comorbidities or for patients with previous 
failed prolapse surgery or pessary trials who are not sexually active. 
Evans, J., Karram, M., ``Step by step: Obliterating the vaginal canal 
to correct pelvic organ prolapse,'' OBG Manag. 2012 February;24(2):30-
41 https://www.mdedge.com/sites/default/files/Document/September-2017/0212_OBGM_Karram.pdf. Colpectomy in younger patients is performed to 
treat advanced vaginal and/or uterine cancer. In cases of uterine 
cancer, colpectomy is used exclusively in conjunction with total 
abdominal hysterectomy. In cases of vaginal cancer, vaginectomy may be 
partial, subtotal, or total, depending on the extent of the disease. 
Vaginal reconstruction is offered in order to preserve coital function. 
Bardavil, T. et al., ``Vaginal Cancer'' (updated Jan. 11, 2015), 
Medscape, https://emedicine.medscape.com/article/269188-overview#a23 
(last accessed March 8, 2018). Partial vaginectomy is not associated 
with the loss of coital function.
    Accordingly, the vast majority of colpectomy procedures involve 
associated partial or complete hysterectomy, currently addressed in 
diagnostic code 7618 and a new, separate diagnostic code for colpectomy 
is unnecessary; functional impairment due to the colpectomy/total 
vaginectomy is adequately addressed under diagnostic code 7618 for 
partial and/or total hysterectomy. In rare cases, colpectomy is 
performed without any form of hysterectomy; VA will evaluate these 
circumstances analogously to diagnostic code 7618, and, in the absence 
of functional impairment or other findings, apply the provisions of 38 
CFR 4.31 to establish service connection at a noncompensable rate. This 
approach provides VA with adequate criteria to evaluate functional 
impairment associated with colpectomy, with or without hysterectomy, 
and to establish service connection for a disability for purposes of an 
award of special monthly compensation under 38 CFR 3.350(a). We note 
that while vaginal damage due to colpectomy may be associated with loss 
of coital function, coital function is not in itself a disability for 
VA rating purposes. It does not result in the loss of earning capacity. 
See 38 CFR 4.1.
    Entitlement to special monthly compensation for anatomical loss or 
loss of use of a creative organ may not be awarded more than once per 
creative organ. In the case of colpectomy with loss of coital function, 
the presence or absence of partial/total hysterectomy does not entitle 
a female veteran to additional awards of special monthly compensation 
based on further anatomical loss of a creative organ; in either 
scenario the veteran has met the statutory criteria for anatomical loss 
or loss of use of the female creative organ with varying degrees of 
functional disability associated with the loss/loss of use. 
Accordingly, establishing a separate diagnostic code for colpectomy 
would not create entitlement to additional special monthly compensation 
under 38 CFR 3.350. For these reasons, VA makes no changes based on 
these comments at this time.
    One commenter was supportive of the proposed addition of the new 
diagnostic code 7632, Female sexual arousal disorder (FSAD). The 
commenter noted that the title used, ``Female sexual arousal 
disorder,'' is not the current medical term used in The Diagnostic and 
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In DSM-
5, gender-specific sexual dysfunctions have been added, and, for 
females, sexual desire and arousal disorders have been combined into 
one disorder: Female Sexual Interest/Arousal Disorder.
    VA's proposed diagnostic code 7632 differs from the DSM-5 diagnosis 
because it only addresses the physiologic form of FSAD, which is caused 
in part by decreased blood flow to the genital area and peripheral 
nerve damage due to micro trauma or disease process. This form of FSAD 
does not include the psychological features of Female Sexual Interest/
Arousal Disorder outlined in DSM-5 such as lack of, or significantly 
reduced, sexual interest or desire. If an individual is diagnosed with 
Female Sexual Interest/Arousal Disorder as outlined in DSM-5 that is 
service connected, she will be rated under the appropriate diagnostic 
code under 38 CFR 4.130, which pertains to mental disorders. 
Furthermore, if her disability picture includes FSAD, defined as the 
continual or recurrent inability to accomplish or maintain an ample 
lubrication-swelling reaction during sexual intercourse, then separate 
compensation under diagnostic code 7632 would be appropriate. 
Therefore, VA makes no changes based on this comment.
    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 as a final rule with the changes 
noted above. Additionally, VA notes that it is making a technical 
correction to its proposed changes to Appendix B to Part 4--Numerical 
Index of Disabilities. Specifically, VA inadvertently left out 
instructions to delete references to diagnostic codes 7622 and 7623 
which, as discussed in the proposed rule, are being removed.

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 May 13, 2018, the date VBMS-R system 
updates related to this final rule will be complete.

Executive Orders 12866, 13563, and 13771

    Executive Orders 12866 and 13563 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).

[[Page 15071]]

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,'' which requires review by the Office of Management 
and Budget (OMB), 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 the principles set forth in 
this Executive Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this regulatory action have been examined and it has 
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 the rulemaking and its impact analysis are available on VA's website 
at http://www.va.gov/orpm by following the link for VA Regulations 
Published from FY 2004 through FYTD. This rule is not an E.O. 13771 
regulatory action because this rule is not significant under E.O. 
12866.

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 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 provisions constituting a collection of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521). Specifically, this final rule is associated with information 
collections related to the filing of disability benefits claims (VA 
Form 21-526EZ) as well as Disability Benefits Questionnaires (DBQs) 
which enable a claimant to gather the necessary information from his or 
her treating physician as to the current symptoms and severity of a 
disability (VA Forms 21-0960K-1, Breast Conditions and Disorders DBQ, 
and 21-0960K-2, Gynecological Conditions DBQ). Both information 
collections are currently approved by the Office of Management and 
Budget (OMB) and have been assigned OMB control numbers 2900-0747 and 
2900-0778, respectively. VA has reviewed the impact of this final rule 
on these information collections and determined that the information 
collection burden is de minimis.

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.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

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. Jacquelyn 
Hayes-Byrd, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on April 3, 2018, for publication.

    Dated: April 3, 2018.
Jeffrey M. Martin,
Impact Analyst, Office of Regulation Policy & Management, Office of the 
Secretary, Department of Veterans Affairs.
    For the reasons set out in the preamble, VA amends 38 CFR part 4 as 
follows:

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.  4.116 as follows:
0
a. Revise the entry for diagnostic code 7610;
0
b. Add a note at the end of the entries for diagnostic codes 7615 and 
7619;
0
c. Revise the entry for diagnostic code 7621;
0
d. Remove the entries for diagnostic codes 7622 and 7623;
0
e. Revise the entries for diagnostic codes 7627 and 7628;
0
f. Add entries for diagnostic codes 7630 through 7632 in numerical 
order; and
0
g. Add an authority citation at the end of the section.
    The revisions and additions read as follows:


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

------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
 
                              * * * * * * *
7610 Vulva or clitoris, disease or injury of (including
 vulvovaginitis)
 
                              * * * * * * *
7615 * * *

[[Page 15072]]

 
    Note: For the purpose of VA disability evaluation, a  ..............
     disease, injury, or adhesions of the ovaries
     resulting in ovarian dysfunction affecting the
     menstrual cycle, such as dysmenorrhea and secondary
     amenorrhea, shall be rated under diagnostic code
     7615
 
                              * * * * * * *
7619 * * *
    Note: In cases of the removal of one ovary as the
     result of a service-connected injury or disease,
     with the absence or nonfunctioning of a second
     ovary unrelated to service, an evaluation of 30
     percent will be assigned for the service-connected
     ovarian loss
 
                              * * * * * * *
7621 Complete or incomplete pelvic organ prolapse due to              10
 injury, disease, or surgical complications of pregnancy
    Note: Pelvic organ prolapse occurs when a pelvic
     organ such as bladder, urethra, uterus, vagina,
     small bowel, or rectum drops (prolapse) from its
     normal place in the abdomen. Conditions associated
     with pelvic organ prolapse include: uterine or
     vaginal vault prolapse, cystocele, urethrocele,
     rectocele, enterocele, or any combination thereof.
     Evaluate pelvic organ prolapse under DC 7621.
     Evaluate separately any genitourinary, digestive,
     or skin symptoms under the appropriate diagnostic
     code(s) and combine all evaluations with the 10
     percent evaluation under DC 7621
 
                              * * * * * * *
7627 Malignant neoplasms of gynecological system........             100
    Note: A rating of 100 percent shall continue beyond
     the cessation of any surgical, radiation,
     antineoplastic chemotherapy or other therapeutic
     procedures. 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. Rate
     chronic residuals to include scars, lymphedema,
     disfigurement, and/or other impairment of function
     under the appropriate diagnostic code(s) within the
     appropriate body system
7628 Benign neoplasms of gynecological system. Rate
 chronic residuals to include scars, lymphedema,
 disfigurement, and/or other impairment of function
 under the appropriate diagnostic code(s) within the
 appropriate body system
 
                              * * * * * * *
7630 Malignant neoplasms of the breast..................             100
    Note: A rating of 100 percent shall continue beyond
     the cessation of any surgical, radiation,
     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. Rate
     chronic residuals according to impairment of
     function due to scars, lymphedema, or disfigurement
     (e.g., limitation of arm, shoulder, and wrist
     motion, or loss of grip strength, or loss of
     sensation, or residuals from harvesting of muscles
     for reconstructive purposes), and/or under
     diagnostic code 7626
7631 Benign neoplasms of the breast and other injuries
 of the breast. Rate chronic residuals according to
 impairment of function due to scars, lymphedema, or
 disfigurement (e.g., limitation of arm, shoulder, and
 wrist motion, or loss of grip strength, or loss of
 sensation, or residuals from harvesting of muscles for
 reconstructive purposes), and/or under diagnostic code
 7626
7632 Female sexual arousal disorder (FSAD)..............           \1\ 0
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation under Sec.
  3.350 of this chapter.


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


0
3. Amend appendix A to part 4 by:
0
a. Revising the entries for diagnostic codes 7610, 7615, 7619, 7621, 
7622, 7623, 7627, and 7628; and
0
b. Adding, in numerical order, entries for diagnostic codes 7630 
through 7632.
    The revisions and additions read as follows:

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

------------------------------------------------------------------------
                            Diagnostic
          Sec.               code No.
------------------------------------------------------------------------
 
                              * * * * * * *
                                    7610  Criterion May 22, 1995; title
                                           May 13, 2018.
 
                              * * * * * * *
                                    7615  Criterion May 22, 1995; note
                                           May 13, 2018.
 
                              * * * * * * *
                                    7619  Criterion May 22, 1995; note
                                           May 13, 2018.
 
                              * * * * * * *
                                    7621  Criterion May 22, 1995;
                                           evaluation May 13, 2018.
                                    7622  Removed May 13, 2018.
                                    7623  Removed May 13, 2018.
 
                              * * * * * * *
                                    7627  Criterion March 10, 1976;
                                           criterion May 22, 1995;
                                           title, note May 13, 2018.
                                    7628  Added May 22, 1995; title,
                                           criterion May 13, 2018.

[[Page 15073]]

 
 
                              * * * * * * *
                                    7630  Added May 13, 2018.
                                    7631  Added May 13, 2018.
                                    7632  Added May 13, 2018.
 
                              * * * * * * *
------------------------------------------------------------------------


0
4. Amend appendix B to part 4 by:
0
a. Revising the entries for diagnostic codes 7610 and 7621;
0
b. Removing the entries for diagnostic codes 7622 and 7623;
0
c. Revising the entries for diagnostic codes 7627 and 7628; and
0
d. Adding, in numerical order, entries for diagnostic codes 7630 
through 7632.
    The revisions and additions read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
     Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
          Gynecological Conditions and Disorders of the Breast
------------------------------------------------------------------------
7610........................  Vulva or clitoris, disease or injury of
                               (including vulvovaginitis).
 
                              * * * * * * *
7621........................  Complete or incomplete pelvic organ
                               prolapse due to injury or disease or
                               surgical complications of pregnancy.
 
                              * * * * * * *
7627........................  Malignant neoplasms of gynecological
                               system.
7628........................  Benign neoplasms of gynecological system.
 
                              * * * * * * *
7630........................  Malignant neoplasms of the breast.
7631........................  Benign neoplasms of the breast and other
                               injuries of the breast.
7632........................  Female sexual arousal disorder (FSAD).
 
                              * * * * * * *
------------------------------------------------------------------------


0
5. Amend appendix C to part 4 as follows:
0
a. Add in alphabetical order an entry for ``Complete or incomplete 
pelvic organ prolapse due to injury or disease or surgical 
complications of pregnancy, including uterine or vaginal vault 
prolapse, cystocele, urethrocele, rectocele, enterocele, or 
combination''.
0
b. Add in alphabetical order an entry for ``Female sexual arousal 
disorder (FSAD)''.
0
c. Under the heading ``Injury,'' add in alphabetical order an entry for 
``Breast''.
0
d. Under the heading ``Neoplasms: Benign:'':
0
i. Add in alphabetical order an entry for ``Breast''.
0
ii. Remove ``Gynecological or breast'' and in its place add 
``Gynecological''.
0
e. Under the heading ``Neoplasms: Malignant:'':
0
i. Add in alphabetical order an entry for ``Breast''.
0
ii. Remove ``Gynecological or breast'' and in its place add 
``Gynecological''.
0
f. Remove the entry ``Pregnancy, surgical complications''.
0
g. Under the heading ``Uterus,'' remove the entry ``Displacement''.
0
h. Remove ``Vulva disease or injury of'' and add in its place ``Vulva 
or clitoris, disease or injury of''.
    The additions and revisions read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Complete or incomplete pelvic organ prolapse due to                 7621
 injury or disease or surgical complications of
 pregnancy, including uterine or vaginal vault prolapse,
 cystocele, urethrocele, rectocele, enterocele, or
 combination............................................
 
                              * * * * * * *
Female sexual arousal disorder (FSAD)...................            7632
 
                              * * * * * * *
Injury:
 

[[Page 15074]]

 
                              * * * * * * *
    Breast..............................................            7631
 
                              * * * * * * *
Neoplasms:
    Benign:
        Breast..........................................            7631
 
                              * * * * * * *
    Malignant:
        Breast..........................................            7630
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2018-07081 Filed 4-6-18; 8:45 am]
 BILLING CODE 8320-01-P