[Federal Register Volume 84, Number 24 (Tuesday, February 5, 2019)]
[Proposed Rules]
[Pages 1678-1690]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-00636]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AQ43


Schedule for Rating Disabilities: Infectious Diseases, Immune 
Disorders, and Nutritional Deficiencies

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
section of the VA Schedule for Rating Disabilities (VASRD or Rating 
Schedule) that addresses infectious diseases and immune disorders. The 
purpose of these changes is to incorporate medical advances since the 
last revision, update medical terminology, and clarify evaluation 
criteria. The proposed rule considers comments from experts and the 
public during a forum held from January 31 to February 1, 2011, on 
revising this section of the VASRD.

DATES: Comments must be received by VA on or before April 8, 2019.

ADDRESSES: Written comments may be submitted through 
www.regulations.gov; by mail or hand-delivery to Director, Regulation 
Policy and Management (00REG), Department of Veterans Affairs, 810 
Vermont Ave. NW, Room 1063B, Washington, DC 20420; or by fax to (202) 
273-9026. (This is not a toll free number.) Comments should indicate 
that they are submitted in response to ``RIN 2900-AQ43--Schedule for 
Rating Disabilities: Infectious Diseases, Immune Disorders, and 
Nutritional Deficiencies.'' Copies of comments received will be 
available for public inspection in the Office of Regulation Policy and 
Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., 
Monday through Friday (except holidays). Please call (202) 461-4902 for 
an appointment. (This is not a toll free number.) In addition, during 
the comment period, comments may be viewed online through the Federal 
Docket Management System (FDMS) at www.Regulations.gov.

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: As part of its ongoing revision of the 
VASRD, VA proposes changes to 38 CFR 4.88a, which pertains to chronic 
fatigue syndrome (CFS), and 38 CFR 4.88b, which pertains to the 
schedule of ratings for infectious diseases and immune disorders (we 
note that the proposed changes for Sec.  4.88b exclude the schedule of 
ratings for nutritional deficiencies--diagnostic codes (DC) 6313, 6314, 
and 6315). VA last updated the schedule of ratings in Sec.  4.88b on 
July 31, 1996 (see 61 FR 39875) and updated Sec.  4.88a on July 19, 
1995 (see 60 FR 37012).
    VA proposes to: (1) Update the medical terminology and definition 
of certain infectious diseases and immune disorders; (2) add medical 
conditions not currently in the Rating Schedule; (3) refine evaluation 
criteria based on medical advances that have occurred since the last 
revision; and (4) incorporate current understanding of functional 
changes associated with or resulting from disease (pathophysiology).
    A panel of independent experts convened by the Institute of 
Medicine (IOM) in February 2015 proposed an updated set of diagnostic 
criteria for infectious disease and immune disorders. This updated 
revision also included changing the name of CFS to ``Systemic Exertion 
Intolerance Disease (SEID)/Chronic fatigue Syndrome (CFS).''
    VA has clear authority to make this regulatory change because of 
its broad authority to ``prescribe all rules and regulations which are 
necessary or appropriate to carry out the laws administered by [VA] and 
are consistent with those laws.'' 38 U.S.C. 501(a); see also 38 U.S.C. 
1155 (VA's authority to adopt and apply schedule for rating 
disabilities).

Sec.  4.88a Chronic Fatigue Syndrome

    Currently, Sec.  4.88a specifies older diagnostic criteria for the 
diagnosis of CFS and uses outdated terminology to refer to this complex 
disease. VA proposes to update the nomenclature for this disease, which 
is also known as systemic exertion intolerance disease (SEID) or 
myalgic encephalomyelitis (ME), by changing the diagnostic code name to 
``Systemic Exertion Intolerance Disease (SEID)/Chronic Fatigue Syndrome 
(CFS).'' This new name captures a central characteristic of the disease 
that reflects negative effects of any exertion (physical, cognitive, or 
emotional) on patients' many organ systems. IOM (Institute of 
Medicine), Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: 
Redefining an Illness (2015), http://www.nationalacademies.org/hmd/~/
media/Files/Report%20Files/2015/

[[Page 1679]]

MECFS/MECFScliniciansguide.pdf (last accessed August 30, 2018).
    VA is also proposing to revise the current diagnostic criteria for 
SEID/CFS to adhere to evidence-based criteria which were adopted by the 
Centers for Disease Control and Prevention (CDC). IOM Report on ME/CFS 
(2015) (updated July 3, 2017), https://www.cdc.gov/me-cfs/symptoms-diagnosis/diagnosis.html (last accessed July 17, 2018). According to 
the 2015 IOM Report, up to 2.5 million Americans suffer from this 
disease which is characterized by profound fatigue, cognitive 
dysfunction, sleep abnormalities, pain, autoimmune manifestations, and 
a variety of other symptoms that are made worse by exertion of any 
sort. New diagnostic criteria will take into consideration whether this 
severe chronic fatigue significantly interferes with daily activities 
and work, if the affected individual concurrently has four or more of 
the eight symptoms as outlined in CDC evidence-based criteria and 
whether these symptoms first appeared before the fatigue, have 
persisted or recurred during six or more consecutive months of illness, 
and were due to ongoing exertion or other medical conditions associated 
with fatigue.
    The CDC mandates a thorough medical history, physical examination, 
mental status examination, and laboratory tests to identify underlying 
or contributing conditions that require treatment. CDC recognizes and 
identifies several conditions that do not exclude a diagnosis of SEID/
CFS. Currently, Sec.  4.88b lists 19 DCs encompassing infectious 
diseases and immune disorders. VA proposes to revise these codes to 
reflect current terminology, advances in medical knowledge, 
recommendations from the 2015 IOM Report on ME/CFS and a 2007 IOM 
Report on evaluating veterans for disability benefits, IOM, A 21st 
Century System For Evaluating Veterans for Disability Benefits (2007), 
https://www.nap.edu/read/11885/chapter/1 (last accessed July 17, 2018).

Schedule of Ratings--Infectious Diseases, Immune Disorders, and 
Nutritional Deficiencies

Proposed General Rating Formula for Sec.  4.88b

    Currently, each infectious disease listed under Sec.  4.88b has its 
own prescribed rating criteria. In most cases, each specific infectious 
disease warrants a 100 percent evaluation during an active period of 
the disease. Thereafter, any residual functional impairment from the 
infectious disease determines the level of disability. These evaluation 
principles are generally consistent with the clinical presentation of 
infectious diseases.
    VA proposes one General Rating Formula for Sec.  4.88b. This 
approach is based on the association between clinical resolution or 
stabilization of an infectious disease and elimination or complete 
suppression of the causative infectious agent. Regardless of whether 
resolution occurs spontaneously or because of treatment, long-term 
disability in such situations results from residual functional 
impairment of the body systems affected by the infectious disease, 
rather than the infection itself. Sheila Davey, World Health 
Organization, World Health Organization Report on Infectious Diseases: 
Removing Obstacles to Healthy Development (1999).
    Therefore, VA's proposal to use a General Rating Formula does not 
substantively change the current evaluation criteria so much as their 
organization. This rulemaking proposes to restructure rating criteria 
by creating one General Rating Formula applicable to multiple 
infectious diseases, regardless of etiology. A General Rating Formula 
for infectious diseases would ensure consistency in rating these 
conditions and be similar to the use of a General Rating Formula in 
other sections of the VASRD, such as in Sec. Sec.  4.97, 4.116, 4.130, 
and others. This formula would be a familiar concept for Veterans 
Benefits Administration (VBA) employees and minimize the risk for error 
by providing one criterion applicable to multiple diagnostic codes. 
Although each specific infectious disease has a different etiology and 
natural history, once the active disease phase is over, disability 
would be rated on residuals. VA would assign a 100 percent disability 
rating during the variable length of each specific disease's active 
phase. For most infectious diseases manifesting acutely, the length of 
the active disease phase (i.e., the time between disease onset and 
resolution or stabilization) is at most usually six to eight weeks. VA 
proposes to assign a 100 percent evaluation during the active disease 
phase. VA recognizes that some infectious diseases, such as 
tuberculosis, may have a longer than average active disease phase. 
Therefore, VA proposes that the General Rating Formula apply only in 
those cases where specific rating criteria are not otherwise provided. 
Diagnostic codes in Sec.  4.88b that would not follow the General 
Rating Formula would be 6301, 6302, 6310, 6311, 6312, 6313, 6314, 6315, 
6325, 6326, 6351, and 6354.
    After the disease becomes inactive, VA proposes to assign a 0 
percent evaluation. However, even though advancements in antimicrobial 
therapy have significantly lessened the occurrence of residuals of 
infectious diseases, they continue to occur. Therefore, VA generally 
proposes to append each diagnostic code with a note describing the most 
common residuals associated with a given infection. See below for 
additional details. As a list of every residual would be impractical, 
these notes would clearly indicate that they are not exhaustive. Where 
ascertainable residuals exist, VA proposes to assign evaluations for 
those residuals under the appropriate body system(s).
    Certain infectious conditions are prone to relapse and require 
laboratory evaluation for confirmation. L. Joseph Wheat et al., 
Clinical Practice Guidelines for the Management of Patients with 
Histoplasmosis: 2007 Update by the Infectious Diseases Society of 
America, 45 Clinical Infectious Diseases 807, 807-25 (2007). 
Oftentimes, non-specific constitutional symptoms (weakness, tiredness, 
insomnia, weight loss, etc.) occur following the active phase of an 
infectious disease. However, such symptoms may be due to other causes 
than the infection. Therefore, to ensure VA assigns the most 
appropriate evaluations for relapsing infections, VA proposes to 
include a note in the rule requiring that relapses be confirmed by 
pathogen-specific testing using appropriate microbiologic, serologic, 
biochemical (e.g., nucleic acid detection)histopathologic methods.
    Finally, although VA proposes using a General Rating Formula for 
most infectious diseases, VA notes that each infectious disease has a 
different long-term impact. For those that have longer active phases 
and/or are commonly associated with relapse and residuals, VA proposes 
to require VA examination once the disease is no longer active so that 
a medical professional can evaluate the individual's condition. In 
these cases, VA also proposes to apply the provisions of Sec.  3.105(e) 
that require VA to send beneficiaries notice of any proposed reduction 
in evaluation and provide an opportunity to respond before it becomes 
effective.

Proposed Changes to Existing Diagnostic Codes

    As discussed above, VA proposes to apply a General Rating Formula 
for infectious diseases unless otherwise noted. Additionally, VA 
proposes to provide notes identifying common residuals associated with 
particular diseases and instructions to rating personnel regarding the 
level of medical

[[Page 1680]]

review necessary following cessation of treatment and infection. These 
specific proposed changes are discussed below.

Diagnostic Code 6300

    Currently, DC 6300 is titled ``Cholera, Asiatic'' referring only to 
infection with toxigenic strains of Vibrio cholerae; it does not 
reflect infections due to other species within the genus Vibrio. Non-
cholera Vibrio species cause diarrheal diseases, as well as wound 
infections and septicemia. To reflect the total array of diseases 
caused by Vibrio species, VA proposes to rename this DC ``Vibriosis 
(cholera, non-cholera), to encompass conditions caused by V. cholerae 
and by non-cholera Vibrio organisms.
    Cholera due to V. cholerae and gastroenteritis due to other Vibrio 
species are associated with severe diarrhea of relatively short 
duration. Hoi Ho et al., Vibrio Infections, Medscape.com (July 24, 
2018), http://emedicine.medscape.com/article/232038-overview. Including 
the incubation period, cholera usually lasts 7 to 10 days and results 
in total remission, or, in 5 to 10 percent of cases, death if left 
untreated. Therefore, the proposed General Rating Formula would be 
appropriate for both cholera and non-cholera gastroenteritis due to 
other Vibrio species, and VA would remove the existing provision for a 
separate three-month convalescence period as it would no longer be 
necessary.
    VA proposes to use a note to provide information about common 
residual disability of cholera and non-cholera Vibrio infection, 
including renal failure, skin, and musculoskeletal conditions, such as 
necrotizing fasciitis. VA proposes no changes to the evaluation 
criterion for this DC except eliminating the three-month convalescence 
and adding a note to address rating of residual disability.

Diagnostic Code 6301

    VA evaluates DC 6301, visceral leishmaniasis, at 100 percent for 
six months following cessation of treatment, after which a VA 
examination helps determine residual disability. VA proposes only minor 
changes to this rating criteria, but proposes to change the note 
regarding rating residual disability. VA would generally identify those 
residuals commonly associated with post-infection or post-treatment 
residuals that may warrant evaluation. Currently, DC 6301 lists 
lymphadenopathy as one such residual disability. However, 
lymphadenopathy follows numerous diseases and is a frequent physical 
finding which, even when permanent, is otherwise without symptoms or 
disability that would warrant evaluation. Robert Ferrer, 
Lymphadenopathy: Differential Diagnosis and Evaluation, 58 a.m. Fam. 
Physician 1313, 1313-20 (Oct. 15, 1998). In many cases, it may 
constitute a normal physical finding. Vikramjit S. Kanwar, 
Lymphadenopathy, Medscape.com (Feb. 1, 2018), http://emedicine.medscape.com/article/956340-overview.
    As lymphadenopathy is often associated with other diseases and, 
regardless of origin, commonly presents without symptoms or disability 
warranting evaluation, VA proposes to remove it from the note in DC 
6301. VA notes that the list of possible residuals in proposed DC 6301 
would not be exhaustive. Thus, if a veteran presents with 
lymphadenopathy as a residual of visceral leishmaniasis that results in 
chronic, functional impairment, VA would consider an evaluation under 
the appropriate system.
    In addition to the above revision, VA proposes to amend the 
existing Note 1 to inform that the residual effects of infection 
include bone marrow diseases. Parasites--Leishmaniasis, CDC (Jan. 10, 
2013), https://www.cdc.gov/parasites/leishmaniasis/index.html. This 
note would also refer to the residuals listed in 38 CFR 3.317(d), 
``Long-term health effects potentially associated with infectious 
diseases.''
    Finally, VA proposes to add a new Note 2 to address the use of 
culture, histopathology, and other diagnostic testing to confirm 
relapses. Clinicians rely on such diagnostic testing, which has 
increased steadily in accuracy and availability, to determine whether 
symptoms are due to leishmaniasis or some other disease. Shyam Sundar & 
M. Rai, ``Laboratory Diagnosis of Visceral Leishmaniasis,'' 9 Clinical 
and Diagnostic Laboratory Immunology 951, 951-58 (2002). VA also 
proposes to retitle the existing note as Note 1 to account for the 
addition of this second note.

Diagnostic Code 6302

    VA would not change the rating criteria for leprosy (Hansen's 
disease), but proposes to amend the current Note under DC 6302 by 
adding amputations as a residual in the proposed Note. The neurologic 
impairment in leprosy involves sensory and motor deficits/loss in the 
extremities that may lead to auto-amputation. Preenon Bagchi et al., 
Bacterio-Informatics: Identifying the Cause of Hansen's Disease and 
Establish [sic] a Remedy for the Same, 2 Int'l J. of Bioinformatics 
Res. and Applications 15, 15-19 (2010).

Diagnostic Code 6304

    VA proposes to evaluate DC 6304, malaria, using the General Rating 
Formula because it is an acute, debilitating disease with predictable 
clinical presentation.
    VA proposes to amend an existing note and to add one new notes. 
Note 1 would explicitly state that VA requires diagnostic confirmation 
for both the initial diagnosis and any relapse. To reflect advances in 
malarial testing, VA also proposes to refer to other specific 
diagnostic tests such as antigen detection, immunologic 
(immunochromatographic) tests, and molecular testing, such as 
polymerase chain reaction tests. Malaria Diagnosis (United States), CDC 
(Nov. 19, 2015), https://www.cdc.gov/malaria/diagnosis_treatment/diagnosis.html.
    Note 2 would recognize potential nervous system residuals because 
severe forms of malaria affect the brain as an encephalopathy. Pralay 
Sarkar et al., ``Critical care aspects of malaria,'' 25 J. of Intensive 
Care Med. 93, 93-103 (2010). In addition, this note would also refer to 
the residuals listed in Sec.  3.317(d).

Diagnostic Code 6305

    VA proposes to amend the title of this DC, currently ``Lymphatic 
filariasis,'' to include the term elephantiasis, which is another name 
commonly associated with the chronic form of this condition. Lymphatic 
Filariasis Fact Sheet No. 102, World Health Organization (May 11, 
2018), http://www.who.int/mediacentre/factsheets/fs102/en/.
    The new General Rating Formula would provide 100 percent evaluation 
for the acute phase of active infection for lymphatic filariasis. The 
proposed General Rating Formula would be appropriate for use in this 
acute infection. However, no actual changes in the evaluation criteria 
would result from this organizational change intended to help rating 
personnel easily apply the VASRD.
    VA proposes to add information to more adequately address the range 
of potential residuals, which include lymphedema (permanent swelling) 
and lymphatic obstruction. Parasites--Lymphatic Filariasis, CDC (June 
14, 2013), http://www.cdc.gov/parasites/lymphaticfilariasis/disease.html. VA proposes a new Note to instruct rating personnel to 
evaluate under the appropriate body system residuals such as 
epididymitis, lymphangitis, lymphatic obstruction, or lymphedema 
affecting extremities, genitals, and/or breasts.

[[Page 1681]]

Diagnostic Code 6306

    Bartonellosis, currently evaluated under DC 6306, generally 
resolves within two months with appropriate treatment. Kassem A. 
Hammoud et al., Bartonellosis, Medscape.com (Oct. 17, 2012), http://emedicine.medscape.com/article/213169-overview. Therefore, VA proposes 
to rate active bartonellosis under the General Rating Formula at 100 
percent, and VA would remove the existing provision for a separate 
three-month convalescence period as it would no longer be necessary.
    VA also proposes to update the residual disability to include 
endocarditis, which occurs when the bloodstream may carry this 
bacterium to the heart valves. John L. Brusch et al., Infective 
Endocarditis--Pathophysiology, Medscape.com (Dec. 17, 2013), http://emedicine.medscape.com/article/216650-overview#a0104.

Diagnostic Code 6307

    VA proposes to evaluate DC 6307, plague, which is an acute, 
debilitating disease of short duration, using the General Rating 
Formula.
    Use of modern antibiotics renders residual disability from the 
infection itself extremely rare. Therefore, VA proposes to delete the 
existing note regarding specific residuals and replace it with a note 
stating that VA would rate any residual disability under the 
appropriate body system. Again, lymphadenopathy is a frequent physical 
finding following numerous diseases, often permanent and without 
disabling symptoms. Robert Ferrer, Lymphadenopathy: Differential 
Diagnosis and Evaluation, 58 Am.Fam. Physician at 1313-20. VA proposes 
removing lymphadenopathy as a residual because it may be a normal 
physical finding. Vikramjit S. Kanwar, Lymphasdenopathy, Medscape.com 
(July 10, 2015), http://emedicine.medscape.com/article/956340-overview); Plague, CDC (Nov. 28, 2012), http://www.cdc.gov/plague/.

Diagnostic Code 6308

    VA proposes to evaluate DC 6308, relapsing fever, which is an 
acute, debilitating disease of short duration, using the General Rating 
Formula.
    Modern treatment helps most patients recover from this disease 
within a few days, with little incidence of splenic damage. Long-term 
sequelae of relapsing fever are rare, but include iritis, uveitis, 
cranial nerve, and other neuropathies. Tick-borne Relapsing Fever 
(TBRF), CDC (Jan. 8, 2016), http://www.cdc.gov/relapsing-fever/clinicians/. Therefore, VA proposes a new Note adding iritis and 
uveitis as residual disabilities and retaining the remainder of the 
existing information without substantive change.
    VA does not propose any changes to the evaluation criteria for this 
DC.

Diagnostic Code 6309

    VA proposes to evaluate DC 6309, rheumatic fever, which is an 
acute, febrile disease typically lasting less than a month, using the 
General Rating Formula. The existing note regarding residuals would 
remain substantively unchanged.

Diagnostic Code 6310

    VA does not propose substantive change to the criteria under 
diagnostic code 6310 for syphilis and other treponemal infections. 
However, for consistency with the remainder of this section, VA 
proposes to replace the term ``complications'' with the term ``residual 
disability,'' which VA would rate under the appropriate body system.
    Additionally, VA proposes to remove specific references to the 
names associated with each DC identified in this note because future 
revisions of the rating schedule would retitle several of them.

Diagnostic Code 6311

    Currently, DC 6311, miliary tuberculosis, provides a 100 percent 
evaluation during active infection. Under Sec.  4.88c, the 100 percent 
is continued for one year following the date of inactivity. Active 
infection may last for months to years, and, if undiagnosed or 
untreated, may result in death. The standard treatment for drug-
susceptible miliary tuberculosis is six to nine months with a 
combination of anti-tuberculosis drugs. If the meninges are involved, 
treatment will last for 9 to12 months, but may occasionally require 
longer a treatment duration. Nahid, P., et al., ``Executive Summary: 
Official American Thoracic Society/Centers for Disease Control and 
Prevention/Infectious Diseases Society of America Clinical Practice 
Guidelines: Treatment of Drug-Susceptible Tuberculosis,'' 63 Clinical 
Infectious Diseases 853, 853-867 (Oct. 2016), https://www.nidcd.nih.gov/health/balance/pages/meniere.aspx (last visited 
January 22, 2019). Relapses are common when medication is not taken for 
the full time prescribed and/or not taken in the appropriate 
combination. Generally, most relapses occur within the first 12 months 
of treatment completion. Tuberculosis (TB) Guidelines. CDC (May 4, 
2016), https://www.cdc.gov/tb/publications/guidelines/treatment.htm.
    To ensure that individuals are entitled to any resumption or 
continuation of the 100 percent evaluation after the initial active 
disease, VA proposes to add a Note requiring confirmation of relapse by 
culture, histopathology, or other diagnostic laboratory testing.
    VA also proposes Note 2 addressing residuals which may be found 
under Sec.  4.88c. Infection residuals include, but are not limited to, 
chronic diagnosed disabilities affecting such body systems as the skin 
and respiratory, central nervous, musculoskeletal, ocular, 
gastrointestinal, and genitourinary systems. VA would rate them under 
the appropriate body system. J.J. van der Harst & G.J. Luijckx, 
Treatment of Central Nervous System Tuberculosis Infections and 
Neurological Complications of Tuberculosis Treatment, 17 Current 
Pharmaceutical Design 2940, 2940-47 (2011).

Diagnostic Code 6316

    VA proposes to evaluate DC 6316, brucellosis, an acute, 
debilitating disease of short duration usually lasting several weeks or 
less, using the General Rating Formula. Brucellosis is easily treated 
with antibiotics, but, if untreated, brucellosis may become chronic and 
leave significant residuals. VA proposes no changes to the evaluation 
criteria.
    As the correct diagnosis is essential in determining if symptoms 
are due to brucellosis or some other disease entity, VA proposes to add 
a new Note 1 directing that culture, serologic testing, or both must 
confirm both the initial diagnosis and any relapse of active infection. 
Wafa Al-Nassir, Brucellosis, Medscape.com (June 16, 2017), http://emedicine.medscape.com/article/213430-overview.
    VA proposes to amend the existing note as Note 2 and expand the 
list of residuals in light of advances in medicine and early treatment. 
Note 2 would reflect the residuals most commonly associated with this 
infection, including meningitis, and liver, spleen, or musculoskeletal 
conditions. Brucellosis, CDC (Sept. 13, 2017) http://www.cdc.gov/brucellosis/index.html. As this condition is a presumptive disease 
related to Gulf War service, this note would also refer to the many 
specific residuals of brucellosis listed in Sec.  3.317(d).

Diagnostic Code 6317

    Currently, DC 6317 represents scrub typhus, an acute debilitating 
rickettsial disease lasting for several weeks or less. If untreated, a 
high mortality rate results. Antibiotic treatment rapidly eradicates 
the disease and significantly

[[Page 1682]]

reduces the chances of complications. Therefore, VA proposes to 
evaluate DC 6317 using the General Rating Formula. VA proposes to 
rename this DC to encompass all forms of rickettsial and similar 
erlichial and Anaplasma infections. These infections are not specific 
to the veteran population as they afflict travelers and field 
scientists as well. Renaming this DC would mean rating personnel need 
not further clarify the type of typhus infecting a veteran.
    VA is not proposing any changes to the evaluation criteria except 
to use the General Rating Formula. VA would also remove the existing 
provision for a separate three-month convalescence period as it would 
no longer be necessary.
    VA proposes to update the existing note to include such residuals 
frequently associated with DC 6317 as involvement of bone marrow and 
the central nervous system, in addition to the current list of spleen 
damage or skin conditions.
    Rickettsial, ehrlichial, and Anaplasma infections cause similar 
nonspecific influenza-like illness in humans, including but not limited 
to, scrub typhus, Rocky Mountain spotted fever, African tick-borne 
fever, ehrlichiosis, and anaplasmosis. Therefore, VA also proposes to 
add a second note to list other rickettsial infections, including 
infections by Ehrlichia and Anaplasma species (members of the order 
Rickettsiales) to account for its occurrence in the U.S. veteran 
population. Johan S. Bakken & J. Stephen Dumler, Ehrlichiosis and 
Anaplasmosis, Medscape.com (2004), https://www.medscape.com/viewarticle/490468_4.

Diagnostic Code 6318

    Currently, DC 6318 represents melioidosis, an acute debilitating 
bacterial disease lasting several weeks or less, which, if left 
untreated, may result in mortality. VA proposes no changes to the 
evaluation criteria, except use of the General Rating Formula.
    As accuracy is essential in diagnosing melioidosis, VA proposes to 
add Note 1 directing that culture or other specific diagnostic 
laboratory tests must confirm both the initial diagnosis and any 
relapse or chronic activity of infection.
    VA would retain the existing information regarding common residuals 
and the instruction to rate residuals under the appropriate body system 
under Note 2.

Diagnostic Code 6319

    VA currently assigns a 100 percent evaluation for DC 6319, Lyme 
disease, when it is active. Lyme disease is an acute illness, usually 
lasting several weeks or less. Therefore, VA proposes to rate Lyme 
disease under the General Rating Formula, without changes to the actual 
evaluation criteria. VA also proposes to amend the existing note 
associated with this DC to account for residuals such as Bell's palsy, 
radiculopathy, ocular, and cognitive dysfunction, in addition to 
arthritis.

Diagnostic Code 6320

    Currently, DC 6320 represents ``Parasitic diseases otherwise not 
specified.'' VA proposes no changes to the evaluation criteria except 
to use the General Rating Formula. VA also proposes to amend the 
existing note associated with this DC with general instructions to rate 
any residuals of this infection under the appropriate body system.

Diagnostic Code 6351

    VA proposes a number of changes to DC 6351, which pertains to human 
immunodeficiency virus (HIV) related illness. Currently, VA provides a 
100 percent evaluation for ``AIDS with recurrent opportunistic 
infections or with secondary diseases affecting multiple body systems; 
HIV-related illness with debility and progressive weight loss, without 
remission, or few or brief remissions.'' VA proposes to remove the 
statement about remission because the CDC considers AIDS a chronic 
condition, and the diagnosis continues once a person is properly 
diagnosed, regardless of improvements in that person's condition.
    When VA last revised the evaluation criteria, the medical community 
considered oral hairy leukoplakia (OHL) a distinctive clinical marker 
of HIV infection. Since then, measurement of the peripheral CD4 cell 
count and HIV viral load have become the standard method for evaluating 
a patient's stage of HIV infection. Sowmya Nanjappa, Anti-retroviral 
Therapy in Treatment-Na[iuml]ve Patients, Medscape.com (June 3, 2016), 
https://emedicine.medscape.com/article/2041458-overview. In addition, 
OHL by itself rarely, if ever, requires specific treatment in patients 
receiving anti-retroviral therapy. James Cade, Hairy Leukoplakia 
Treatment and Management, Medscape.com (December 19, 2018), https://emedicine.medscape.com/article/279269-overview. VA proposes to remove 
reference to OHL in the criteria for a 30 percent evaluation.
    Similarly, VA proposes to modify the reference of oral candidiasis 
to esophageal and lower respiratory tract candidiasis for the criteria 
for a 30 percent evaluation. In the past, oral candidiasis was strongly 
associated with HIV infection. However, the increased use of 
antiretroviral medications has greatly reduced the incidence of this 
condition in HIV-positive individuals. C. Frezzini et al., Current 
Trends of HIV Disease of the Mouth, 34 J. of Oral Pathology & Med. 513, 
513-31 (2005).
    For clarification, VA proposes to replace the phrase ``definite 
medical symptoms'' in the criteria for a 10 percent evaluation with 
``HIV-related constitutional symptoms.'' VA would not change the 
remainder of the criteria for a 10 percent evaluation. The criteria for 
a 0 percent evaluation would not change.
    Existing Note 1 would continue to provide that ``medications 
prescribed as part of a research protocol at an accredited medical 
institution'' are to be considered ``approved medication'' within the 
context of the evaluation criteria. VA proposes to add a reference to 
treatment regimens as part of a research protocol at an accredited 
medical institution because some research protocols use not only new 
medications but also new regimens for already FDA approved medications.
    Existing Note 2 would continue to provide for separate evaluation 
of various manifestations of HIV infection under the appropriate 
diagnostic codes. VA proposes to retain the instruction to evaluate on 
the basis of psychiatric or central nervous system manifestations, 
opportunistic infections, and neoplasms, rather than based on this 
diagnostic code, if a higher overall evaluation results. However, VA 
proposes to substitute the term ``diagnosed psychiatric condition'' for 
the phrase ``psychiatric manifestations.'' VA recognizes that a veteran 
may exhibit psychiatric symptoms, such as depression, which do not rise 
to the level of a diagnosed disability. Such symptoms are more 
appropriately rated under DC 6351 as 10 percent disabling, provided 
there is evidence of activity limitations. Note 2, however, would refer 
to diagnosed, disabling acquired psychiatric illness.
    VA also proposes the addition of a new Note 3 to assist rating 
personnel in applying these revised evaluation criteria. Note 3 would 
include a list of current opportunistic infections, which includes the 
following conditions: Candidiasis of the bronchi, trachea, esophagus, 
or lungs; invasive cervical cancer; coccidioidomycosis; cryptococcosis; 
cryptosporidiosis; cytomegalovirus (particularly CMV retinitis); HIV-
related encephalopathy; herpes simplex-chronic ulcers of greater

[[Page 1683]]

than one month's duration, or bronchitis, pneumonia, or esophagitis; 
histoplasmosis; isosporiasis (chronic intestinal); Kaposi's sarcoma; 
lymphoma; Mycobacterium avium complex; tuberculosis; Pneumocystis 
jirovecii (carinii) pneumonia; pneumonia, recurrent; progressive 
multifocal leukoencephalopathy; Salmonella septicemia, recurrent; 
toxoplasmosis of the brain; and wasting syndrome due to HIV. AIDS and 
Opportunistic Infections, CDC (July 23, 2018), https://www.cdc.gov/hiv/basics/livingwithhiv/opportunisticinfections.html.

Diagnostic Code 6354

    VA is proposing no change to the rating criteria for this DC other 
than to update the name from chronic fatigue syndrome (CFS) to systemic 
exertion intolerance disease/chronic fatigue syndrome (CFS). VA would, 
however, clarify the note to indicate that incapacitation requires that 
a licensed physician must prescribe both bed rest and treatment, which 
would be consistent with current VA practice.

Proposed New Diagnostic Codes

    As discussed above, in addition to updating existing DCs, VA 
proposes to add medical conditions not currently listed in the Rating 
Schedule:

Proposed New Diagnostic Code 6312

    VA proposes to add a new DC 6312 for ``Nontuberculosis 
mycobacterial infection'' (NTM). NTM lung infection occurs when a 
person inhales the organism from the environment. Most people do not 
become ill but some susceptible individuals require prolonged treatment 
of one to two years. Without treatment, many people, but not all, will 
develop a progressive lung infection characterized by cough, fatigue, 
and often weight loss. However, death directly related to NTM lung 
disease is relatively rare in immunocompetent individuals.
    Systemic infection, which is the most severe form, is most often 
seen in individuals with other underlying conditions, especially those 
that inhibit immune function. Arry Dieudonne, Atypical Mycobacterium 
Infection, Medscape.com (Feb. 7, 2018), http://emedicine.medscape.com/article/972708-overview.
    Similar to other infectious diseases found in the Rating Schedule, 
VA proposes to assign a 100 percent evaluation during active infection, 
after which a mandatory VA evaluation would be conducted to determine 
the appropriate evaluation based on residuals, if any. Therefore, VA 
proposes a Note 1 to this effect and instructs that any change in 
evaluation based upon that or any subsequent examination shall be 
subject to the provisions of Sec.  3.105(e). Furthermore, the note 
would instruct rating personnel to rate on residuals if there is no 
relapse.
    Establishing the correct diagnosis is essential in determining if 
symptoms are due to NTM or some other disease entity. Diagnostic 
testing has become more accurate and readily available over the years. 
Therefore, VA proposes a Note 2, requiring diagnostic confirmation for 
subsequent relapses.
    VA proposes to include Note 3, which would identify common 
residuals to assist rating personnel in assigning evaluations following 
cessation of the 100 percent evaluation. Residuals of infection 
identified in Note 3 would include skin conditions and conditions of 
the respiratory, central nervous, musculoskeletal, ocular, 
gastrointestinal, and genitourinary systems.

Proposed New Diagnostic Code 6325

    VA proposes to add new DC 6325 which applies to hyperinfection 
syndrome or disseminated strongyloidiasis. Because strongyloidiasis is 
not an acute, self-limited disease, VA would not use the General Rating 
Formula. Similar to other severe infectious diseases, VA proposes to 
assign a 100 percent evaluation during active disease followed by a 
mandatory VA evaluation to determine the appropriate evaluation based 
on any residuals. Systemic infection, which is the most severe form of 
strongyloidiasis, with a mortality rate approaching 90 percent, is most 
often seen in individuals with other underlying conditions, especially 
those with compromised immune function. Parasites--Strongyloides, 
Resources for Health Professionals, CDC (Jan. 6, 2012), http://www.cdc.gov/parasites/strongyloides/. VA is not proposing to list the 
most common residuals because their number is so vast.

Proposed New Diagnostic Code 6326

    VA proposes a new diagnostic code for schistosomiasis, the second 
most common parasitic disease in the world. Parasites--Schistosomiasis, 
CDC (Apr. 30, 2018), http://www.cdc.gov/parasites/schistosomiasis/. 
While the parasite is not found in the United States, it is 
sufficiently prevalent in tropical regions that VA may presume service 
connection if records indicate service in such regions. See 38 CFR 
3.309(b). VA is proposing to add a distinct DC for schistosomiasis 
because it otherwise lacks a means to accurately track such claims and 
can evaluate them only by analogy.
    Most people who contract schistosomiasis are asymptomatic and have 
subclinical disease during both acute and chronic stages of infection. 
Persons with acute infection (also known as Katayama syndrome) may 
present with mild symptoms such as rash, fever, headache, myalgia, and 
respiratory symptoms that are not disabling.
    Chronic disease results from host immune responses to schistosome 
eggs: S. mansoni and S. japonicum. These eggs most commonly lodge in 
the blood vessels of the liver or intestine with chronic inflammation 
leading to bowel wall ulceration, hyperplasia, and polyposis and, with 
heavy infections, to liver fibrosis and portal hypertension.
    S. haematobium eggs tend to lodge in the urinary tract and the 
female genital tract. Female genital schistosomiasis can affect the 
cervix, fallopian tubes, and vagina.
    Central nervous system lesions, such as in the spinal cord or brain 
and inflammatory reactions, may cause the formation of granulomas that 
act as space-occupying lesions.
    VA proposes to evaluate DC 6326 by assigning a 0 percent evaluation 
for acute and asymptomatic chronic infections. Additionally, VA 
proposes to note common residuals of infection, such as liver and 
genitourinary tract conditions. VA would rate residual disability in 
the appropriate system.

Proposed New Diagnostic Code 6329

    VA proposes new DC 6329 to encompass hemorrhagic fevers, including 
dengue, yellow fever, and others. While these fevers are uncommon in 
the United States, they are prevalent in tropical regions and, 
therefore, associated with military deployments. David C. Pigott, 
CBRNE--Viral Hemorrhagic Fevers, Medscape.com (Mar. 16, 2017), https://emedicine.medscape.com/article/830594-overview. VA may presume service 
connection for hemorrhagic fever if records indicate service in certain 
regions. See 38 CFR 3.309(b). VA is proposing to add a distinct DC for 
hemorrhagic fever because it otherwise lacks a means to accurately 
track such claims and can evaluate them only by analogy.
    VA proposes to apply the General Rating Formula and assign a 100 
percent evaluation for active disease because hemorrhagic fever is 
associated with a debilitating, acute, febrile illness that often lasts 
for several weeks at most. VA also proposes to include a note listing 
common residual disabilities of central

[[Page 1684]]

nervous system, liver, or kidney conditions.

Proposed New Diagnostic Code 6330

    VA proposes new DC 6330 for infections caused by Campylobacter 
jejuni. In 2010, VA issued a regulation establishing that Campylobacter 
jejuni is subject to presumptive service connection for certain 
veterans because it is (1) prevalent in Southwest Asia, (2) has been 
diagnosed among U.S. troops serving in the Persian Gulf/Southwest Asia 
Theater of operations, and (3) is known to cause long-term adverse 
health effects. See 75 FR 59968 and 38 CFR 3.317. To monitor claims for 
this infection, VA proposes a diagnostic code specifically for 
Campylobacter jejuni.
    VA proposes to rate Campylobacter jejuni infection under the 
General Rating Formula, meaning that it would receive a 100 percent 
evaluation during active infection. The symptoms of Campylobacter 
jejuni infection consist of diarrhea, cramping, abdominal pain, and 
fever within two to five days after exposure to the bacteria. The 
diarrhea may be bloody and can be accompanied by nausea and vomiting. 
The illness typically lasts about one week. Campylobacter 
(Campylobacteriosis), CDC (Aug. 30, 2017), https://www.cdc.gov/campylobacter/index.html.
    Thereafter, VA would rate the condition based on residuals listed 
in Sec.  3.317(d), ``Long-Term Health Effects Potentially Associated 
With Infectious Diseases,'' such as Guillain-Barre syndrome, reactive 
arthritis, and uveitis.

Proposed New Diagnostic Code 6331

    VA proposes a new diagnostic code to encompass infections caused by 
Coxiella burnetii. In 2010, VA issued a regulation establishing that 
infection due to Coxiella burnetii (Q fever) is subject to presumptive 
service connection for certain veterans because it is (1) prevalent in 
Southwest Asia, (2) has been diagnosed among U.S. troops serving in the 
Persian Gulf/Southwest Asia theater of operations, and (3) is known to 
cause long-term adverse health effects. See 75 FR 59968 and 38 CFR 
3.317. To track claims for this infection, VA proposes a diagnostic 
code specifically for Coxiella burnetii infection (Q fever).
    VA proposes assigning a 100 percent evaluation during active 
infection according to the General Rating Formula. Thereafter, VA would 
rate the condition based on residuals listed in Sec.  3.317(d), such as 
chronic hepatitis, endocarditis, osteomyelitis, post Q-fever chronic 
fatigue syndrome, and vascular infections.

Proposed New Diagnostic Code 6333

    VA proposes a new diagnostic code to encompass infections caused by 
nontyphoidal Salmonella. In 2010, VA issued a regulation establishing 
that nontyphoidal salmonellosis is subject to presumptive service 
connection for certain veterans. See 75 FR 59968 and 38 CFR 3.317. To 
track claims decisions regarding this infection and to more 
consistently rate it, VA proposes a diagnostic code specifically for 
nontyphoidal salmonellosis.
    VA proposes to assign a 100 percent evaluation during active 
infection according to the General Rating Formula. Thereafter, VA would 
rate the condition based on residuals, including those listed in Sec.  
3.317(d), such as reactive arthritis.

Proposed New Diagnostic Code 6334

    VA proposes a new diagnostic code to encompass infections caused by 
Shigella, which would be rated under the General Rating Formula. In 
2010, VA issued a regulation presuming service connection for Shigella 
infection in certain veterans. See 75 FR 59968 and 38 CFR 3.317. To 
allow for better tracking of decisions on claims for this infection and 
to more consistently rate it, VA proposes a diagnostic code 
specifically for Shigella infection.
    VA would rate the condition based on residuals, including those 
listed in Sec.  3.317(d), such as hemolytic-uremic syndrome, and 
reactive arthritis.

Proposed New Diagnostic Code 6335

    VA proposes a new diagnostic code to encompass infections caused by 
West Nile virus. In 2010, VA issued a regulation presuming service 
connection for West Nile virus in certain veterans. See 75 FR 59968. To 
better track claims decisions regarding this infection, VA proposes a 
separate diagnostic code for West Nile virus, which would be rated 
under the General Rating Formula.
    VA would rate the condition based on residuals, including those 
listed in Sec.  3.317(d), such as variable physical, functional, or 
cognitive disability.

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). 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 E.O. 
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 website at 
http://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''
    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 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, 5 
U.S.C. 601-612. This proposed rule would 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.

[[Page 1685]]

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 given year. This proposed rule would 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 Numbers and Titles

    The Catalog of Federal Domestic Assistance program numbers and 
titles for this rule are 64.102, Compensation for Service-Connected 
Deaths for Veterans' Dependents; 64.105, Pension to Veterans, Surviving 
Spouses, and Children; 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 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. Robert L. 
Wilkie, Secretary, Department of Veterans Affairs, approved this 
document on January 29, 2019, for publication.

    Dated: January 29, 2019.
Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
the Secretary, Department of Veterans Affairs.

    For the reasons stated in the preamble, the Department of Veterans 
Affairs proposes to amend 38 CFR part 4 as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

0
1. The authority citation for part 4 continues to read as follows:

    Authority:  38 U.S.C. 1155, unless otherwise noted.

0
2. Revise Sec.  4.88a to read as follows:


Sec.  4.88a  Systemic exertion intolerance disease/chronic fatigue 
syndrome (CFS).

    (a) For VA purposes, the diagnosis of Systemic Exertion Intolerance 
Disease/Chronic Fatigue Syndrome (CFS) must meet the following 
conditions:
    (1) A severe chronic fatigue that significantly interferes with 
daily activities and work.
    (2) The individual concerned concurrently has four or more of the 
following eight symptoms:
    (i) Post-exertion malaise lasting more than 24 hours
    (ii) Unrefreshing sleep
    (iii) Significant impairment of short-term memory or concentration
    (iv) Muscle pain
    (v) Pain in the joints without swelling or redness
    (vi) Headaches of a new type, pattern, or severity
    (vii) Tender lymph nodes in the neck or armpit
    (viii) Sore throat that is frequent or recurring
    (3) These symptoms:
    (i) Cannot have first appeared before the fatigue
    (ii) Have persisted or recurred during six or more consecutive 
months of illness, and
    (iii) Are not due to ongoing exertion or other medical conditions 
associated with fatigue, as ruled out by a physician who administered 
relevant diagnostic tests.
    (b) Several past or current medical conditions exclude the 
diagnosis of systemic exertion intolerance disease/CFS to include:
    (1) Any active condition that may explain the presence of chronic 
fatigue, such as untreated hypothyroidism, sleep apnea, narcolepsy, and 
iatrogenic conditions such as side effects of medication.
    (2) Some illnesses, including some types of cancers and chronic 
cases of hepatitis B or C virus infection, which could explain the 
presence of chronic fatigue, and which have not clearly and completely 
resolved.
    (3) Any past or current diagnosis of: major depressive disorder 
with psychotic or melancholic features, bipolar affective disorders, 
anorexia nervosa, bulimia nervosa, or any subtype of schizophrenia, 
delusional disorders, or dementias.
    (4) Alcohol or other substance abuse, occurring within two years of 
the onset of chronic fatigue and any time afterwards.
    (5) Severe obesity, defined as having a body mass index equal to or 
greater than 45. [Body mass index = weight in kilograms / (height in 
meters)\2\].
    (6) Examination or testing detects any abnormality that strongly 
suggests an exclusionary condition that needs to be treated or resolved 
before attempting further diagnosis. Once fully treated, diagnose 
accordingly if the individual still meets criteria for Systemic 
Exertion Intolerance Disease (SEID)/Chronic Fatigue Syndrome (CFS).
0
3. Amend Sec.  4.88b by:
0
a. Revising the entries for diagnostic codes 6300 through 6302 and 6304 
through 6311;
0
b. Adding in numerical order an entry for diagnostic code 6312;
0
c. Revising the entries for diagnostic codes 6316 through 6320;
0
d. Adding in numerical order entires for diagnostic codes 6325, 6326, 
6329 through 6331, and 6333 through 6335; and
0
e. Revising the entries for diagnostic codes 6351 and 6354.
    The revisions and additions read as follows:


Sec.  4.88b   Schedule of ratings-infectious diseases, immune 
disorders, and nutritional deficiencies.

------------------------------------------------------------------------
                                                                Rating
------------------------------------------------------------------------
General Rating Formula for Infectious Diseases:
    For active disease.....................................          100
    After active disease has resolved, rate at 0 percent
     for infection. Rate any residual disability of
     infection within the appropriate body system.
6300 Vibriosis (Cholera, Non-cholera):
    Evaluate under the General Rating Formula.
    Note: Rate residuals of cholera and non-cholera Vibrio
     infections, such as renal failure, skin, and
     musculoskeletal conditions, within the appropriate
     body system.

[[Page 1686]]

 
6301 Visceral leishmaniasis:
    As active disease......................................          100
    Note 1: Continue a 100 percent evaluation beyond the
     cessation of treatment for active disease. Six months
     after discontinuance of such treatment, determine the
     appropriate disability rating 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.
     Thereafter, rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, liver damage, bone marrow disease,
     and those residuals listed in Sec.   3.317(d) of this
     chapter.
    Note 2: Confirm the recurrence of active infection by
     culture, histopathology, or other diagnostic
     laboratory testing.
6302 Leprosy (Hansen's disease):
    As active disease......................................          100
    Note: Continue a 100 percent evaluation beyond the
     cessation of treatment for active disease. Six months
     after discontinuance of such treatment, determine the
     appropriate disability rating 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.
     Thereafter, rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, skin lesions, peripheral
     neuropathy, or amputations.
6304 Malaria:
    Evaluate under the General Rating Formula.
    Note 1: The diagnosis of malaria, both initially and
     during relapse, depends on the identification of the
     malarial parasites in blood smears or other specific
     diagnostic laboratory tests such as antigen detection,
     immunologic (immunochromatographic) tests, and
     molecular testing such as polymerase chain reaction
     tests.
    Note 2: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, liver or splenic damage, central
     nervous system conditions, and those residuals listed
     in Sec.   3.317(d) of this chapter.
6305 Lymphatic filariasis, to include elephantiasis:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, epididymitis, lymphangitis,
     lymphatic obstruction, or lymphedema affecting
     extremities, genitals, and/or breasts.
6306 Bartonellosis:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, endocarditis or skin lesions.
6307 Plague:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection.
6308 Relapsing Fever:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, liver or spleen damage, iritis,
     uveitis, or central nervous system involvement.
6309 Rheumatic fever:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, heart damage.
6310 Syphilis, and other treponemal infections:
    Note : Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, diseases of the nervous system,
     vascular system, eyes, or ears (see DC 7004, DC 8013,
     DC 8014, DC 8015, and DC 9301).
6311 Tuberculosis, miliary:
    As active disease......................................          100
    Inactive disease: See Sec.  Sec.   4.88c and 4.89.
    Note 1: Confirm the recurrence of active infection by
     culture, histopathology, or other diagnostic
     laboratory testing.
    Note 2: Rate under the appropriate body system any
     residual disability of infection which includes, but
     is not limited to, skin conditions and conditions of
     the respiratory, central nervous, musculoskeletal,
     ocular, gastrointestinal, and genitourinary systems
     and those residuals listed in Sec.   4.88c of this
     chapter.
6312 Nontuberculosis mycobacterial infection:
    As active disease......................................          100
    Note 1: Continue the rating of 100 percent for the
     duration of treatment for active disease followed by a
     mandatory VA exam. If there is no relapse, rate on
     residuals. 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.
    Note 2: Confirm the recurrence of active infection by
     culture, histopathology, or other diagnostic
     laboratory testing.
    Note 3: Rate under the appropriate body system any
     residual disability of infection which includes, but
     is not limited to, skin conditions and conditions of
     the respiratory, central nervous, musculoskeletal,
     ocular, gastrointestinal, and genitourinary systems
     and those residuals listed in Sec.   4.88c of this
     chapter.
 
                              * * * * * * *
6316 Brucellosis:
    Evaluate under the General Rating Formula.
    Note 1: Culture, serologic testing, or both must
     confirm the initial diagnosis and recurrence of active
     infection.
    Note 2: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, meningitis, liver, spleen and
     musculoskeletal conditions, and those residuals listed
     in Sec.   3.317(d) of this chapter.
6317 Rickettsial, erlichial, and Anaplasma infections:
    Evaluate under the General Rating Formula.
    Note 1: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, bone marrow, spleen, central
     nervous system, and skin conditions.
    Note 2: This diagnostic code includes, but is not
     limited to, scrub typhus, Rickettsial pox, African
     tick-borne fever, Rocky Mountain spotted fever,
     ehrlichiosis, or anaplasmosis.
6318 Melioidosis:

[[Page 1687]]

 
    Evaluate under the General Rating Formula.
    Note 1: Confirm by culture or other specific diagnostic
     laboratory tests the initial diagnosis and any relapse
     or chronic activity of infection.
    Note 2: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, arthritis, lung lesions, or
     meningitis.
6319 Lyme disease:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, arthritis, Bell's palsy,
     radiculopathy, ocular, or cognitive dysfunction.
6320 Parasitic diseases otherwise not specified:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection.
 
                              * * * * * * *
6325 Hyperinfection syndrome or disseminated
 strongyloidiasis:
    As active disease......................................          100
    Note: Continue the rating of 100 percent through active
     disease followed by a mandatory VA exam. If there is
     no relapse, rate on residual disability. 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.
6326 Schistosomiasis:
    As acute or asymptomatic chronic disease...............            0
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, conditions of the liver, intestinal
     system, female genital tract, genitourinary tract, or
     central nervous system.
6329 Hemorrhagic fevers, including dengue, yellow fever,
 and others:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, conditions of the central nervous
     system, liver, or kidney.
6330 Campylobacter jejuni infection:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, Guillain-Barre syndrome, reactive
     arthritis, or uveitis as specified in Sec.   3.317(d)
     of this chapter.
6331 Coxiella burnetii infection (Q fever):
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, chronic hepatitis, endocarditis,
     osteomyelitis, post Q-fever chronic fatigue syndrome,
     or vascular infections as specified in Sec.   3.317(d)
     of this chapter.
6333 Nontyphoid Salmonella infections:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, reactive arthritis as specified in
     Sec.   3.317(d) of this chapter.
6334 Shigella infections:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, hemolytic-uremic syndrome or
     reactive arthritis as specified in Sec.   3.317(d) of
     this chapter.
6335 West Nile virus infection:
    Evaluate under the General Rating Formula.
    Note: Rate under the appropriate body system any
     residual disability of infection, which includes, but
     is not limited to, variable physical, functional, or
     cognitive disabilities as specified in Sec.   3.317(d)
     of this chapter.
 
                              * * * * * * *
6351 HIV-related illness:
    AIDS with recurrent opportunistic infections (see Note           100
     3) or with secondary diseases afflicting multiple body
     systems; HIV-related illness with debility and
     progressive weight loss...............................
    Refractory constitutional symptoms, diarrhea, and                 60
     pathological weight loss; or minimum rating following
     development of AIDS-related opportunistic infection or
     neoplasm..............................................
    Recurrent constitutional symptoms, intermittent                   30
     diarrhea, and use of approved medication(s); or
     minimum rating with T4 cell count less than 200.......
    Following development of HIV-related constitutional               10
     symptoms; T4 cell count between 200 and 500, and use
     of approved medication(s); or with evidence of
     depression or memory loss with employment limitations.
    Asymptomatic, following initial diagnosis of HIV                   0
     infection, with or without lymphadenopathy or
     decreased T4 cell count...............................
    Note 1: In addition to standard therapies and regimens,
     the term ``approved medication(s)'' includes treatment
     regimens and medications prescribed as part of a
     research protocol at an accredited medical
     institution.
    Note 2: Diagnosed psychiatric illness, central nervous
     system manifestations, opportunistic infections, and
     neoplasms may be rated separately under the
     appropriate diagnostic codes if a higher overall
     evaluation results, provided the disability symptoms
     do not overlap with evaluations otherwise assignable
     above.
    Note 3: The following list of opportunistic infections
     are considered AIDS-defining conditions, that is, a
     diagnosis of AIDS follows if a person has HIV and one
     more of these infections, regardless of the CD4 count--
     candidiasis of the bronchi, trachea, esophagus, or
     lungs; invasive cervical cancer; coccidioidomycosis;
     cryptococcosis; cryptosporidiosis; cytomegalovirus
     (particularly CMV retinitis); HIV-related
     encephalopathy; herpes simplex-chronic ulcers for
     greater than one month, or bronchitis, pneumonia, or
     esophagitis; histoplasmosis; isosporiasis (chronic
     intestinal); Kaposi's sarcoma; lymphoma; Mycobacterium
     avium complex; tuberculosis; Pneumocystis jirovecii
     (carinii) pneumonia; pneumonia, recurrent; progressive
     multifocal leukoencephalopathy; Salmonella septicemia,
     recurrent; toxoplasmosis of the brain; and wasting
     syndrome due to HIV.
6354 Systemic exertional intolerance disease/chronic
 fatigue syndrome (CFS):

[[Page 1688]]

 
    Debilitating fatigue, cognitive impairments (such as
     inability to concentrate, forgetfulness, or
     confusion), or a combination of other signs and
     symptoms:
        Which are nearly constant and so severe as to                100
         restrict routine daily activities almost
         completely and which may occasionally preclude
         self-care.........................................
        Which are nearly constant and restrict routine                60
         daily activities to less than 50 percent of the
         pre-illness level; or which wax and wane,
         resulting in periods of incapacitation totaling at
         least six weeks per year..........................
        Which are nearly constant and restrict routine                40
         daily activities from 50 to 75 percent of the pre-
         illness level; or which wax and wane, resulting in
         periods of incapacitation totaling at least four
         but less than six weeks per year..................
        Which are nearly constant and restrict routine                20
         daily activities by less than 25 percent of the
         pre-illness level; or which wax and wane,
         resulting in periods of incapacitation totaling at
         least two but less than four weeks per year.......
        Which wax and wane but result in periods of                   10
         incapacitation totaling at least one but less than
         two weeks per year; or symptoms controlled by
         continuous medication.............................
        Note: For the purpose of evaluating this
         disability, incapacitation exists only when a
         licensed physician prescribes bed rest and
         treatment.
------------------------------------------------------------------------

0
4. In appendix A to part 4 by:
0
a. Revising the entries for diagnostic codes 6300-6302, 6304-6311;
0
b. Adding in numerical order an entry for diagnostic code 6312;
0
c. Revising the entries for diagnostic codes 6316-6320;
0
d. Adding in numerical order entries for diagnostic codes 6325, 6326, 
6329 through 6331, and 6333 through 6335; and
0
e. Revising the entries for diagnostic codes 6351 and 6354.
    The revisions and additions read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                              Diagnostic
           Sec.                code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.88a.....................  ..............  March 11, 1969; re-
                                             designated Sec.   4.88b
                                             November 29, 1994; Sec.
                                             4.88a added to read
                                             ``Chronic fatigue
                                             syndrome''; criterion
                                             November 29, 1994; title,
                                             criterion [insert effective
                                             date of final rule].
4.88b.....................  ..............  Added March 11, 1969; re-
                                             designated Sec.   4.88c
                                             November 29, 1994; Sec.
                                             4.88a re-designated to Sec.
                                               4.88b November 29, 1994;
                                             General Rating Formula for
                                             Infectious Diseases added
                                             [insert effective date of
                                             final rule].
                                      6300  Criterion August 30, 1996;
                                             title, criterion, and note
                                             [insert effective date of
                                             final rule].
                                      6301  Criterion, note [insert
                                             effective date of final
                                             rule].
                                      6302  Criterion September 22,
                                             1978; criterion August 30,
                                             1996; criterion, note
                                             [insert effective date of
                                             final rule].
                                      6304  Evaluation August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6305  Criterion March 1, 1989;
                                             evaluation August 30, 1996;
                                             title, criterion, note
                                             [insert effective date of
                                             final rule].
                                      6306  Evaluation August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6307  Criterion May 13, 2018;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6308  Criterion August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6309  Added March 1, 1963;
                                             criterion March 1, 1989;
                                             criterion August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6310  Criterion, note [insert
                                             effective date of final
                                             rule].
                                      6311  Criterion, note [insert
                                             effective date of final
                                             rule].
                                      6312  Added [insert effective date
                                             of final rule].
 
                              * * * * * * *
                                      6316  Evaluation March 1, 1989;
                                             evaluation August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6317  Criterion August 30, 1996;
                                             title, criterion, note
                                             [insert effective date of
                                             final rule].
                                      6318  Added March 1, 1989;
                                             criterion August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6319  Added August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6320  Added August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6325  Added [insert effective date
                                             of final rule].
                                      6326  Added [insert effective date
                                             of final rule].
                                      6329  Added [insert effective date
                                             of final rule].
                                      6330  Added [insert effective date
                                             of final rule].
                                      6331  Added [insert effective date
                                             of final rule].
                                      6333  Added [insert effective date
                                             of final rule].
                                      6334  Added [insert effective date
                                             of final rule].
                                      6335  Added [insert effective date
                                             of final rule].
 
                              * * * * * * *
                                      6351  Added March 1, 1989;
                                             evaluation March 24, 1992;
                                             criterion August 30, 1996;
                                             criterion, note [insert
                                             effective date of final
                                             rule].
                                      6354  Added November 29, 1994;
                                             criterion August 30, 1996;
                                             title, criterion, note
                                             [insert effective date of
                                             final rule].
 
                              * * * * * * *
------------------------------------------------------------------------


[[Page 1689]]

0
5. Amend appendix B to part 4 by:
0
a. Revising the entries for diagnostic codes 6300 and 6305;
0
b. Adding in numerical order an entry for diagnostic code 6312;
0
c. Revising the entry for diagnostic code 6317; and,
0
d. Adding in numerical order entries for diagnostic codes 6325, 6326, 
6329 through 6331, and 6333 through 6335.
    The revisions and additions read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
      Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
   INFECTIOUS DISEASES, IMMUNE DISORDERS AND NUTRITIONAL DEFICIENCIES
------------------------------------------------------------------------
 
                              * * * * * * *
6300..........................  Vibriosis (Cholera, Non-cholera).
 
                              * * * * * * *
6305..........................  Lymphatic filariasis, to include
                                 elephantiasis.
 
                              * * * * * * *
6312..........................  Nontuberculosis mycobacterial infection.
 
                              * * * * * * *
6317..........................  Rickettsial, erlichial, and Anaplasma
                                 infections.
 
                              * * * * * * *
6325..........................  Hyperinfection syndrome or disseminated
                                 strongyloidiasis.
6326..........................  Schistosomiasis.
6329..........................  Hemorrhagic fevers, including dengue,
                                 yellow fever, and others.
6330..........................  Campylobacter jejuni infection.
6331..........................  Coxiella burnetii infection (Q Fever).
6333..........................  Nontyphoid salmonella infections.
6334..........................  Shigella infections.
6335..........................  West Nile virus infection.
 
                              * * * * * * *
6351..........................  HIV-related infection.
6356..........................  Systemic exertional intolerance disease/
                                 chronic fatigue syndrome (CFS).
------------------------------------------------------------------------

0
6. Amend appendix C to part 4 by:
0
a. Adding in alphabetical order an entry for ``Campylobacter jejuni 
infection'';
0
b. Removing the entry for ``Cholera, Asiatic'';
0
c. Adding in alphabetical order entries for ``Coxiella burnetii 
infection (Q Fever)'', ``Hemorrhagic fevers, including dengue, yellow 
fever, and others'', and ``Hyperinfection syndrome or disseminated 
strongyloidiasis'';
0
d. Revise the entry for ``Lymphatic filariasis'';
0
e. Adding in alphabetical order entries for ``Nontuberculosis 
mycobacterial infection'', ``Nontyphoid salmonella infection'', 
``Rickettsial, erlichial, and Anaplasma infections'', Shigella 
infections, and ``Schistosomiasis'';
0
f. Removing the entry for ``Typhus, scrub''; and
0
g. Adding in alphabetical order entries for ``Vibriosis (Cholera, Non-
cholera)'' and ``West Nile virus infection''
    The additions and revisions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Campylobacter jejuni infection..........................            6330
 
                              * * * * * * *
Coxiella burnetii infection (Q Fever)...................            6331
 
                              * * * * * * *
Hemorrhagic fevers, including dengue, yellow fever, and             6329
 others)................................................
 
                              * * * * * * *
Hyperinfection syndrome or disseminated strongyloidiasis            6325
 
                              * * * * * * *
Lymphatic filariasis, to include elephantiasis..........            6305

[[Page 1690]]

 
 
                              * * * * * * *
Nontyphoid salmonella infection.........................            6333
 
                              * * * * * * *
Nontuberculosis mycobacterial infection.................            6312
 
                              * * * * * * *
Rickettsial, erlichial, and Anaplasma Infections........            6317
 
                              * * * * * * *
Schistosomiasis.........................................            6326
 
                              * * * * * * *
Shigella infections.....................................            6334
 
                              * * * * * * *
Vibriosis (Cholera, Non-cholera)........................            6300
 
                              * * * * * * *
West Nile virus infection...............................            6335
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2019-00636 Filed 2-4-19; 8:45 am]
 BILLING CODE 8320-01-P