[Federal Register Volume 84, Number 117 (Tuesday, June 18, 2019)]
[Rules and Regulations]
[Pages 28227-28235]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-12682]


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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: Final rule.

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SUMMARY: This document amends the Department of Veterans Affairs (VA) 
Schedule for Rating Disabilities (VASRD) by revising the portion of the 
schedule that addresses infectious diseases, immune disorders, and 
nutritional deficiencies. The effect of this action is to ensure that 
the rating schedule uses current medical terminology and to provide 
detailed and updated criteria for evaluation of infectious diseases, 
immune disorders, and nutritional deficiencies for disability rating 
purposes.

DATES: Effective Date: This final rule is effective August 11, 2019.

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, 
[email protected], (202) 461-9700 (This is not a toll-free 
telephone number).

SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal 
Register at 84 FR 1678 on February 5, 2019, to amend 38 CFR 4.88a and 
4.88b, the portion of the VASRD dealing with infectious diseases, 
immune disorders, and nutritional deficiencies. VA provided a 60-day 
public comment period, and interested persons were invited to submit 
written comments on or before April 8, 2019. VA received 32 comments.
    One commenter supported VA's intent to eliminate obsolete 
terminology and substitute the most up-to-date terms and definitions 
for conditions such as Chronic Fatigue Syndrome. The commenter noted 
that this rule would help to achieve the important public policy goal 
of clear, effective communication among veterans, their health care 
providers, and the Department. Additionally, the commenter observed 
that it is important that what appears to be ``catch-all'' language 
appended to the respective disease evaluation categories be correctly 
phrased to minimize the likelihood that deserving patients will be 
excluded from care. The commenter suggested that VA should consider 
identifying the ``residual effects'' categories explicitly so the 
rating decisions and appeals would be most favorable to the veterans 
seeking care. The commenter further suggested that VA consider 
expressly recognizing that any ambiguity in the rules regarding covered 
residual effects should be resolved in the veteran's favor. VA makes no 
changes based on these comments. The proposed diagnostic codes provided 
examples of common residuals of specific diseases, but also made clear 
that the instruction to rate ``any residual disability'' from a disease 
``includes, but is not limited to'' the listed examples. We believe 
this language is sufficiently clear and broad to ensure that any 
residuals identified in individual cases may be appropriately 
evaluated. We do not believe it is necessary or advisable to seek to 
list in these regulations all of the conditions that may be found to be 
residuals of diseases in specific cases. Further, because these rules 
do not restrict the conditions that may be found in individual cases to 
be residuals of a disease, we do not believe the regulation is 
restrictive or ambiguous on that issue. We note also that the principle 
of resolving reasonable doubt in favor of veterans is established in 38 
CFR 3.102 and 4.3.
    One commenter expressed an opinion that this regulatory update can 
be viewed as a bureaucratic move to disenfranchise veterans eligible 
for unspecified services. The commenter did not offer any specific 
recommendations and did not propose any actions. VA makes no changes 
based on this comment.
    One commenter stated that vector-borne diseases (VBD) are of major 
importance to human health both locally and globally. In addition, the 
commenter highlighted that the precise diagnoses of many of these 
diseases remains a major challenge because of the lack of comprehensive 
data available on accurate and reliable diagnostic methods, 
specifically for borreliosis (Lyme disease). The commenter did not 
offer a specific recommendation or a course of action. VA makes no 
changes based on this comment.
    Two commenters were concerned that by implementing a General Rating 
Formula (GRF) for infectious diseases, VA would drastically change 
veterans' ratings from 100 percent to zero percent, dependent upon 
whether the disease is deemed active or resolved based upon a 
laboratory test. Commenters noted that there is considerable evidence 
that laboratory tests may not always be deemed reliable and that each 
laboratory may have differing references ranges leading to improper 
reading of results. However, VA's proposed GRF did not alter the rating 
principles for infectious diseases, which currently provide--in 
individual diagnostic codes rather than a GRF--for evaluation of active 
diseases and residuals. Instead, we updated the format of the rating 
schedule to indicate that the GFR for infectious diseases would be 
consistent for rating these conditions and also be similar to the use 
of a GFR in other sections of the VASRD, such as in 38 CFR 4.97, 4.116, 
4.130, and others. Currently, VA assigns a 100-percent evaluation for 
each specific infectious disease during an active period; thereafter, 
any residual functional impairment from the infectious disease 
determines the level of disability. VA pointed out that its proposed 
GFR 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 (DCs). Additionally, 
VA did not propose any laboratory testing in its GFR, but instead we 
proposed to confirm the recurrence of active infection for certain 
conditions (DCs 6301, 6304, 6311, 6312, 6316) with overlapping clinical 
symptoms such as pallor, fever and hepatosplenomegaly. By adding a 
specific reference to laboratory testing for each infection, we made an 
effort to distinguish one infection from another. VA makes no changes 
based on this comment.
    Additionally, commenters were concerned that the proposed GRF would 
not consider veterans' ability to maintain gainful employment because 
many infectious diseases, even after negative laboratory test results, 
can cause long-lasting residual symptoms that may last up to eight 
weeks or longer and that lingering, residual symptoms would adversely 
affect a veteran's normal functioning and his/her ability to maintain 
gainful employment. The proposed GRF is designed to assess permanent 
functional impairment that resulted from long-lasting residual symptoms 
rather than rely solely on a specific laboratory test. The proposed

[[Page 28228]]

GFR directs rating personnel to rate any residual effect of acute and/
or chronic infection and to determine the degree of disability within 
the appropriate body system using the same principles as they exist in 
the current rating schedule. VA's disability compensation benefits are 
based on the extent of average impairment of earning capacity from the 
service-connected injury or disease and this focus is reflected 
throughout the rating schedule. Therefore, VA makes no changes based on 
this comment.
    One commenter expressed concern regarding West Nile Virus 
infection, stating infected individuals could experience headaches, 
body aches, joint pains, vomiting, diarrhea, or rash during an acute 
phase of the disease and that the residual symptoms could last for an 
extended period. The commenter specifically noted a severe complication 
of the West Nile Virus infection that affects the central nervous 
system in its acute phase and that such complications could become 
clinically permanent. The commenter proposed to list specific 
neuroinvasive diseases such as meningitis and encephalitis as residuals 
of West Nile Virus in Sec.  4.88b and to be rated under the applicable 
DC code(s). The commenter further interpreted the note under DC 6335 
that VA would rate West Nile virus infection residuals and residuals 
listed in Sec.  3.317 together and was concerned that this approach 
would cause confusion and limit this DC to only a subset of Persian 
Gulf veterans who served in the Southwest Asia Theater of Operations 
and are entitled to presumptive service connection. VA clarifies that 
the note under DC 6335 concerning Sec.  3.317 is intended solely to 
serve as a reference that provides guidance to the adjudicator in 
rating a disease under this DC. The reference to Sec.  3.317 is not 
intended nor can it be read to restrict application of DC 6335 to 
veterans with Southwest Asia service. As West Nile infection and other 
similar infectious diseases have complex disability pictures that are 
not commonly seen by VA adjudicators, the inclusion of the Sec.  
3.317(d) reference under DC 6335 is specifically meant to assist our 
adjudicators in understanding the nature of the disease and, most 
critically, the usual residual disabilities of the disease. Referencing 
Sec.  3.317(d) in the note for infectious diseases like the West Nile 
virus serves to impart understanding to VA adjudicators that such 
infectious diseases may result in various residuals or complications 
with physical, functional, or cognitive effects and enables 
adjudicators to accurately rate veterans with these diseases. In 
response and in order to minimize any confusion, VA has removed the 
notes that reference 38 CFR 3.317(d) from the Infectious Diseases 
rating criteria for DCs 6301, 6304, 6316, 6330, 6331, 6333-6335. VA has 
added the reference to 38 CFR 3.317(d) as a note in a new introductory 
paragraph before the rating schedule for infectious diseases, immune 
disorders, and nutritional deficiencies in 38 CFR 4.88b.
    Additionally, commenters expressed a concern that the proposed GRF 
will negatively affect veterans' care and treatment. VA appreciates 
commenters' concerns; however, VA's Rating Schedule for Disabilities 
does not regulate veterans' access to clinical care. Further, as 
explained above, the provisions in the proposed GRF for rating active 
diseases and residuals are consistent with the existing provisions 
under individual diagnostic codes in Sec.  4.88b and will not 
significantly change how VA evaluates these conditions. VA makes no 
changes based on these comments.
    One commenter supported the need for greater simplification of the 
rating schedule and disability determination process and was concerned 
that this proposed update to the schedule for infectious disease, 
immune disorders and nutritional deficiencies excludes nurse 
practitioners and their patients. Specifically, the commenter noted 
that the proposed criteria for determining incapacitation related to 
systemic exertion intolerance disease (SEID)/chronic fatigue syndrome 
(CFS) require bed rest and treatment prescribed by a licensed physician 
and that a physician who administered diagnostic tests ruled out 
ongoing exertion or other medical conditions associated with fatigue. 
The commenter requested that the Veterans Health Administration (VHA) 
revise this proposed rating schedule update and add ``or nurse 
practitioner'' after the word ``physician'' in all sections. The 
commenter also asked that, in future revisions of the rating schedule, 
VHA recognize that thousands of veterans receive care from nurse 
practitioners and to include nurse practitioners in the language of the 
rating schedule. VA clarifies that this rulemaking pertains to the 
Veterans Benefits Administration (VBA) and addresses disability 
evaluations due to the functional impairment related to service-
connected health conditions. This rulemaking does not address the scope 
of clinical practice for nurse practitioners. However, VBA will assess 
whether amendments to the list of qualifying heath care providers are 
necessary and such amendments, if any, will be addressed in a future 
proposal. VA makes no changes based on this comment.
    One commenter stated that it is unfair that a National Guard 
soldier who was called to active duty and then immediately released 
upon return from the Middle East has to have manifested one of the 
infectious diseases listed in Sec.  3.317 within one year from 
separation (aside from three exceptions), whereas an active duty 
solider who redeploys from Iraq or Afghanistan and serves several more 
years on active duty only has to show the disease within a year after 
separation, which may be several years after service in Iraq or 
Afghanistan. This comment relates to the time period prescribed in 38 
CFR 3.317(c)(3) for applying the presumption of service connection for 
infectious diseases in veterans who served in the Southwest Asia 
theater of operations during the Persian Gulf War. The proposed rules 
pertained only to the criteria for evaluating the severity of service-
connected infectious diseases, immune disorders, and nutritional 
deficiencies. They did not propose to address matters concerning the 
establishment of service connection or the operation of presumptions of 
service connection for any diseases. Accordingly, the comment is beyond 
the scope of this rulemaking. VA makes no changes based on this 
comment.
    Multiple commenters including individual veterans, Veterans 
Advocacy Organizations, Veterans Service Organizations, and other 
professional organizations expressed a wide range of concerns regarding 
the proposed changes to the definition of chronic fatigue syndrome 
(CFS) under Sec.  4.88a and the name change for DC 6354. Commenters 
thought the name change of Chronic Fatigue Syndrome (CFS) to Systemic 
Exertion Intolerance Disease/Chronic Fatigue Syndrome (SEID/CFS) was 
unwarranted and that it would create unnecessary confusion among 
medical providers, including non-VA medical providers. Commenters also 
stated that that the new name, Systemic Exertion Intolerance Disease 
(SEID), has not been adopted by any federal agency, nor by researchers 
and clinicians and that the CDC, National Institutes of Health (NIH), 
research publications, and materials for patients and health care 
providers all use the term ME/CFS. Commenters felt that VA's use of the 
term SEID/CFS would introduce confusion among medical providers and 
patients at VA and reduce VA's ability to coordinate with other federal 
agencies.
    Commenters expressed that the proposed changes to the definition of 
CFS does not conform to the Kansas

[[Page 28229]]

Criteria (2000), the Centers for Disease Control (CDC) Chronic 
Multisymptom Illness (CMI) criteria, and to those used in VA-funded 
research into Gulf War Illness (GWI) and that the proposed definition 
is not compatible with the department of Defense (DoD) Congressionally 
Directed Medical Research Programs (CDMRP) for CMI. Commenters stated 
that VA's proposed combination of the Institute of Medicine (IOM) 
reevaluation of CFS as SEID with the 1994 Fukuda criteria for CFS 
presents an amalgamation that is not based in evidence nor discussed in 
any publications. The commenters expressed concern that VA did not 
follow any recommendations from the IOM, the Gulf War Research Advisory 
Committee (RAC), CDC, or other agencies and this combination is for an 
entirely new entity that is not known by World Health Organization, 
International Classification of Diseases, Tenth Revision (ICD-10) or 
other medical classification system and that the VA proposed definition 
is not compatible with the one mandated by DoD's CDMRP for CMI and the 
Kansas Criteria to qualify for GWI research funding.
    Commenters noted that VA did not consult the RAC on these proposed 
changes and stated that the RAC is responsible for understanding the 
definitions and entirety of the condition. Commenters also were 
concerned that the proposed changes would leave those Gulf War veterans 
who receive care and services for CFS, vulnerable to VA manipulation of 
their care and services. The commenters suggested that CFS should be 
studied by the Gulf War research community, the veteran community, CFS 
researchers, the RAC, and independent medical professionals and that VA 
rely on the recommendations from these parties as a guide for new 
criteria updates and to ascertain if these changes are even warranted. 
Commenters also stated that VA would be directly and negatively 
impacting more than 300,000 Gulf War veterans suffering from Gulf War 
Illness by not relying on the studies from these parties and by 
combining, in whole or in part, the 2015 Systemic Exertion Intolerance 
Disease (SEID) and the 1994 Fukuda CDC criteria for Chronic Fatigue 
Syndrome (CFS) into what would be called SEID/CFS.
    Commenters felt that VA's adoption of the Fukuda criteria is a step 
backwards that will perpetuate diagnostic inaccuracy and cause harm to 
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients 
served by the VA. Commenters referenced the 2015 IOM Report to state 
that the Fukuda criteria were overly broad because they do not require 
the hallmark symptom of post-exertional malaise and should not be used 
because of the possibility of misdiagnosing patients with other 
conditions. Commenters believed that VA's reliance on outdated Fukuda 
diagnostic criteria would cause harm to veterans with ME/CFS through 
misdiagnosis and cause a mismatch with the diagnostic criteria in use 
elsewhere. Commenters suggested that VA adopt ME/CFS or ME/CFS/SEID 
title for the illness to stay in alignment with the greater ME/CFS 
community, to include patients, doctors, and researchers. Commenters 
felt that VA's proposed revisions were based on financial reasons in 
order to revoke benefits from existing veterans and prevent other 
veterans from receiving this combined diagnosis of SEID/CFS.
    Commenters also provided questions and recommended that VA adopt 
ME/CFS instead of SEID/CFS; reject the Fukuda criteria; and adopt the 
IOM diagnostic criteria.
    Another recommendation was for VA to revise Sec.  4.88a to more 
closely mirror the diagnostic standard endorsed by the IOM and CDC and 
eliminate the listed exclusions to allow the veterans' examining and/or 
treating physician to make a final determination as to the appropriate 
diagnosis for veterans. In addition, commenters recommended that VA 
should broaden the group of medical professionals authorized to 
prescribe bed rest and treatment to meet the incapacitation standard.
    While VA received some support for updating its definition of CFS, 
VA considered these comments and concerns and concluded that this 
proposed update to Sec.  4.88a is premature and that additional 
research is needed to provide a more comprehensive way to determine the 
disabling effects of CFS and associated conditions. Therefore, VA is 
withdrawing its proposal to amend Sec.  4.88a Chronic Fatigue Syndrome. 
To ensure that the full range of relevant factors is adequately 
addressed, VA intends to establish a work group to specifically address 
this condition. Upon assessment of the work group's findings, VA will 
determine whether amendments to Sec.  4.88a are necessary and such 
amendments, if any, will be addressed in a future proposal.
    VA makes one clarifying change to the criteria for a 10 percent 
disability rating under DC 6351, HIV-related illness. In the proposed 
rule, VA proposed to replace the phrase ``definite medical symptoms'' 
with ``HIV-related constitutional symptoms'' but stated that we would 
otherwise make no change to the criteria for a 10 percent evaluation. 
The prior criteria for a 10 percent evaluation read: ``Following 
development of definite medical symptoms, T4 cells of 200 or more and 
less than 500, and on approved medication(s), or with evidence of 
depression or memory loss with employment limitations.'' We proposed to 
revise this to read: ``Following development of HIV-related 
constitutional 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.'' In its review of the final rule, VA 
realized that the prior text for a 10 percent disability rating was 
unclear because it listed four criteria, separated by commas, but used 
``and'' between the second and third criteria, while using ``or'' 
between the third and fourth criteria. The proposed text listed three 
criteria, separated by semicolons, with the second of those criteria 
encompassing both the second and third criteria of the prior text, 
joined by the word ``and''. We recognize that the combination of 
punctuation and conjunctions in both the prior and the propsed text 
could create confusion. Accordingly, VA revises the text for a 10 
percent disability rating to read: ``Following development of HIV-
related constitutional symptoms; T4 cell count between 200 and 500; use 
of approved medication(s); or with evidence of depression or memory 
loss with employment limitations.'' This clarifies that the text 
includes four separate criteria, consistent with the prior text, but 
will eliminate the potential confusion caused by the term ``and'' 
between two of those criteria. This will ensure that the provision is 
implemented in the manner most consistent with VA's intent and most 
favorable to veterans. 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.

Effective Date of Final Rule

    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 August 11, 2019, 
the date VBMS-R system updates related to this final rule will be 
complete.

[[Page 28230]]

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 
the 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. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of sections 603 
and 604.

Unfunded Mandates

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

Paperwork Reduction Act

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

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance program numbers and 
titles for this rule are 64.102, 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 May 20, 2019, for publication.

    Dated: May 20, 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 amends 38 CFR part 4 as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

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

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


0
2. Amend Sec.  4.88b by:
0
a. Adding introductory text;
0
b. Adding the entry ``General Rating Formula for Infectious Diseases:'' 
before the entry for diagnostic code 6300;
0
c. Revising the entries for diagnostic codes 6300 through 6302 and 6304 
through 6311;
0
d. Adding in numerical order an entry for diagnostic code 6312;
0
e. Revising the entries for diagnostic codes 6316 through 6320;
0
f. Adding in numerical order entries for diagnostic codes 6325, 6326, 
6329 through 6331, and 6333 through 6335; and
0
g. Revising the entries for diagnostic codes 6351 and 6354.
    The additions and revisions read as follows:


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

    Note: Rate any residual disability of infection within the 
appropriate body system as indicated by the notes in the evaluation 
criteria. As applicable, consider the long-term health effects 
potentially associated with infectious diseases as listed in Sec.  
3.317(d) of this chapter, specifically Brucellosis, Campylobacter 
jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium 
Tuberculosis, Nontyphoid Salmonella, Shigella, Visceral 
Leishmaniasis, and West Nile virus.


------------------------------------------------------------------------
                                                                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.

[[Page 28231]]

 
    Note: Rate residuals of cholera and non-cholera vibrio
     infections, such as renal failure, skin, and
     musculoskeletal conditions, within the appropriate
     body system.
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 and bone marrow
     disease.
    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, and
     central nervous system conditions.
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 treponema 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.
6312 Nontuberculosis mycobacterium 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.
 
                              * * * * * * *
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.
6317 Rickettsial, ehrlichia, 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.

[[Page 28232]]

 
    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:
    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.
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.
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.
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.
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.
 
                              * * * * * * *
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; 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 Chronic fatigue syndrome (CFS):

[[Page 28233]]

 
    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 of at least
         six weeks total duration 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 of at least four but
         less than six weeks total duration 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 of at least
         two but less than four weeks total duration per
         year..............................................
        Which wax and wane but result in periods of                   10
         incapacitation of at least one but less than two
         weeks total duration 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
3. In appendix A to part 4, amend entry 4.88b by:
0
a. Revising the entry before the entry for diagnostic code 6300;
0
b. Revising the entry for diagnostic code 6300;
0
c. Adding in numerical order an entry for diagnostic code 6301;
0
d. Revising the entries for diagnostic codes 6302 and 6304 through 
6309;
0
e. Adding in numerical order entries for diagnostic codes 6310 through 
6312;
0
f. Revising the entries for diagnostic codes 6316 through 6320;
0
g. Adding in numerical order entries for diagnostic codes 6325, 6326, 
6329 through 6331, and 6333 through 6335; and
0
h. 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.
------------------------------------------------------------------------
 
                              * * * * * * *
4.88b.....................  ..............  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
                                             August 11, 2019.
                                      6300  Criterion August 30, 1996;
                                             title, criterion, and note
                                             August 11, 2019.
                                      6301  Criterion, note August 11,
                                             2019.
                                      6302  Criterion September 22,
                                             1978; criterion August 30,
                                             1996; criterion, note
                                             August 11, 2019.
                                      6304  Evaluation August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6305  Criterion March 1, 1989;
                                             evaluation August 30, 1996;
                                             title, criterion, note
                                             August 11, 2019.
                                      6306  Evaluation August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6307  Criterion May 13, 2018;
                                             criterion, note August 11,
                                             2019.
                                      6308  Criterion August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6309  Added March 1, 1963;
                                             criterion March 1, 1989;
                                             criterion August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6310  Criterion, note August 11,
                                             2019.
                                      6311  Criterion, note August 11,
                                             2019.
                                      6312  Added August 11, 2019.
 
                              * * * * * * *
                                      6316  Evaluation March 1, 1989;
                                             evaluation August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6317  Criterion August 30, 1996;
                                             title, criterion, note
                                             August 11, 2019.
                                      6318  Added March 1, 1989;
                                             criterion August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6319  Added August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6320  Added August 30, 1996;
                                             criterion, note August 11,
                                             2019.
                                      6325  Added August 11, 2019.
                                      6326  Added August 11, 2019.
                                      6329  Added August 11, 2019.
                                      6330  Added August 11, 2019.
                                      6331  Added August 11, 2019.
                                      6333  Added August 11, 2019.
                                      6334  Added August 11, 2019.
                                      6335  Added August 11, 2019.
 
                              * * * * * * *
                                      6351  Added March 1, 1989;
                                             evaluation March 24, 1992;
                                             criterion August 30, 1996;
                                             criterion, note August 11,
                                             2019.
 
                              * * * * * * *
                                      6354  Added November 29, 1994;
                                             criterion August 30, 1996;
                                             title, criterion, note
                                             August 11, 2019.
 
                              * * * * * * *
------------------------------------------------------------------------


[[Page 28234]]


0
4. 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 Nutrional Deficiencies
--------------------------------------------------------------------------------------------------------------------------------------------------------
6300.............................................  Vibriosis (Cholera, Non-cholera).
 
                                                                      * * * * * * *
--------------------------------------------------------------------------------------------------------------------------------------------------------
6305.............................................  Lymphatic filariasis, to include elephantiasis.
 
                                                                      * * * * * * *
--------------------------------------------------------------------------------------------------------------------------------------------------------
6312.............................................  Nontuberculosis mycobacterium infection.
 
                                                                      * * * * * * *
--------------------------------------------------------------------------------------------------------------------------------------------------------
6317.............................................  Rickettsial, ehrlichia, 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.
 
                                                                      * * * * * * *
--------------------------------------------------------------------------------------------------------------------------------------------------------


0
5. 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. Removing the entry for ``Lymphatic filariasis'';
0
e. Adding in alphabetical order entries for ``Lymphatic filariasis, to 
include elephantiasis'', ``Nontuberculosis mycobacterium infection'', 
``Nontyphoid salmonella infection'', ``Rickettsial, erlichial, and 
Anaplasma infections'', ``Schistosomiasis'' and ``Shigella 
infections'';
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,                 6329
 and others.........................................
 
                              * * * * * * *
Hyperinfection syndrome or disseminated                             6325
 strongyloidiasis...................................
 
                              * * * * * * *
Lymphatic filariasis, to include elephantiasis......                6305

[[Page 28235]]

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


[FR Doc. 2019-12682 Filed 6-17-19; 8:45 am]
BILLING CODE 8320-01-P