[Federal Register Volume 84, Number 148 (Thursday, August 1, 2019)]
[Proposed Rules]
[Pages 37594-37607]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-15904]


 ========================================================================
 Proposed Rules
                                                 Federal Register
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 This section of the FEDERAL REGISTER contains notices to the public of 
 the proposed issuance of rules and regulations. The purpose of these 
 notices is to give interested persons an opportunity to participate in 
 the rule making prior to the adoption of the final rules.
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  Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / 
Proposed Rules  

[[Page 37594]]



DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AQ67


Schedule for Rating Disabilities: The Cardiovascular System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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

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 the cardiovascular system. The proposed 
changes incorporate medical advances that have occurred since the last 
review, update medical terminology, and clarify evaluation criteria 
where necessary.
    Where changes to the scientific and/or medical nature of a given 
condition have been proposed, VA has cited the published, publicly-
available sources for these changes. The proposed changes are not a 
reflection of any particular expert's comments or recommendations, but 
were based on published, peer-reviewed materials. Materials from the 
public forum, held in 2011, are available for public inspection at the 
Office of Regulation Policy and Management (see the ADDRESSES section 
of this rulemaking), and other deliberative materials are cited herein.

DATES: VA must receive comments on or before September 30, 2019.

ADDRESSES: Submit written comments through www.Regulations.gov; by mail 
or hand-delivery to the Director, Office of Regulations Policy and 
Management (00REG), Department of Veterans Affairs, 810 Vermont Ave. 
NW, Room 1064, Washington, DC 20420; or by fax to (202) 273-9026. 
Comments should indicate that they are submitted in response to RIN 
2900-AQ67--Schedule for Rating Disabilities: The Cardiovascular System. 
Copies of comments received will be available for public inspection in 
the Office of Regulation Policy and Management, Room 1068, between the 
hours of 8:00 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, please 
view comments online through the Federal Docket Management System 
(FDMS) at www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, MD, Medical Officer, 
Regulations Staff (211D), 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 VA's ongoing revision of the VA 
Schedule for Rating Disabilities (VASRD or Rating Schedule), VA 
proposes changes to 38 Code of Federal Regulations (CFR) Sec. Sec.  
4.100 and 4.104, which pertain to the cardiovascular system. The 
proposed changes will: (1) Update the medical terminology of certain 
conditions; (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, 
cardiovascular disease or injury (pathophysiology).

I. Sec.  4.100 Application of the Evaluation Criteria for Diagnostic 
Codes 7000-7007, 7011, and 7015-7020

    In almost all cases, the current Sec.  4.100 specifically requires 
testing for metabolic equivalent of tasks when evaluating heart 
diseases. Medical literature more commonly refers to metabolic 
equivalent of tasks as simply metabolic equivalents, or METs. 
Exceptions to METs testing for rating purposes occur when medically 
contraindicated, when the left ejection fraction is 50 percent or less, 
with chronic congestive heart failure, when more than one episode of 
heart failure occurred in the past year, or when VA may assign a 100 
percent evaluation on another basis. 38 CFR 4.100(b). As explained 
below, this proposed rule will eliminate considering ejection fractions 
or congestive heart failure when evaluating cardiovascular disability. 
Therefore, for clarity and simplicity, VA proposes to delete paragraphs 
(b)(2), (b)(3), and (c), and redesignate paragraphs (b)(4) as (b)(2) of 
this section.

II. General Rating Formula for Diseases of the Heart

    VA proposes to revise Sec.  4.104 to include a new General Rating 
Formula for Diseases of the Heart (General Formula). VA will use this 
new General Formula to clarify and standardize the evaluation of many 
cardiovascular diseases. As discussed below, it will provide a more 
timely, efficient, and accurate method of evaluating these diseases.
    The proposed General Formula reflects current concepts in 
cardiovascular disability. The Institute of Medicine (now called the 
National Academy of Medicine) stated, ``It is important for the Rating 
Schedule to be as up-to-date as possible in current medical approaches 
and terminology to serve veterans with disabilities most effectively. 
This ensures that the criteria in the Rating Schedule are based on 
concepts and terms used by medical personnel who provide medical 
evidence, and that evolving understanding of, or recognition of, new 
disabling conditions are reflected.'' Institute of Medicine, Committee 
on Medical Evaluation of Veterans for Disability Compensation, ``A 21st 
Century System for Evaluating Veterans for Disability Benefits,'' 5 
(Michael McGeary et al. eds. 2007).
    As in the current Rating Schedule, the proposed General Formula is 
based primarily on Metabolic equivalents (METs), which objectively and 
accurately measure the cardiac work capacity and which clinicians 
routinely obtain for all patients with heart disease. The examiner 
eliminates spurious results by considering various parameters, such as 
age and expected maximal heart rate achieved when factors other than 
heart disease are present. In situations where a person is unable to 
walk, or walk well, the patient may test on a bicycle or with the use 
of certain medications.
    VA notes that a number of diagnostic codes (DCs) within current 
Sec.  4.104, including DCs 7000-7007, 7011, 7015-7017, and 7019-7020, 
already utilize METs in evaluating their respective cardiovascular 
conditions. Specifically, each level of evaluation (10, 30, 60, and 100 
percent) outlines a range of METs, as well as a list of associated 
symptoms,

[[Page 37595]]

within which an individual must fall to warrant that particular 
evaluation. Additionally, VA may assign higher ratings (e.g., 60 and 
100 percent) for congestive heart failure or left ventricular 
dysfunction as demonstrated by ejection fraction. Finally, VA may also 
assign a 30 percent evaluation with evidence on electrocardiogram, 
echocardiogram, or X-ray of cardiac hypertrophy or dilatation. Lastly, 
VA may assign a 10 percent evaluation if the condition requires 
continuous medication.
    VA proposes to rely on METs as the primary indicator of cardiac 
ability and eliminate other indicators currently found in the VASRD, 
such as ejection fractions or the number of any episodes of acute 
congestive heart failure in the past year. These latter indicators are 
less reliable in assessing cardiac function. Congestive heart failure 
may be due to poor conditioning, salt consumption, poor medication 
compliance, body weight, additional disease burden, or a variety of 
other factors not associated with the underlying cardiovascular disease 
itself. See Joshi, Mohanan et al., ``Factors precipitating Congestive 
Heart Failure--role of patient non-compliance,'' 47 J. Assoc. 
Physicians India 294-95 (Mar. 1999) (emphasizing ``the importance of 
patient non-compliance with prescribed therapy as a leading 
precipitating factor for congestive heart failure . . . which can be 
prevented by appropriate cost saving strategies aimed to improve 
patient compliance.'') Similarly, ejection fractions are unreliable 
because factors unrelated to cardiovascular disability, such as fluid 
intake, salt ingestion, and exercise, may influence them. See 
Ramachandran S. Vasan, MD, et al., ``Congestive heart failure in 
subjects with normal versus reduced left ventricular ejection 
fraction,'' 33(7) 1948-55 (1999). Conversely, METs form the most 
reliable basis of cardiac capability, even after heart disease weakens 
the ability of the heart to function at full capacity. See Charles K. 
Morris, MD, et al., ``Nomogram based on metabolic equivalents and age 
for assessing aerobic exercise capacity in men,'' 22(1) J. Am. College 
of Cardiology, 175-82 (1993).
    The heart is often described as the pump of the human body, and, as 
such, requires power to function. Power is the rate that energy is 
consumed to work. Various types of energy employ different measures of 
rate (power), such as kW (kilowatts) for electrical energy; Btu/hr 
(British Thermal Units per hour) for heat energy; hp (horsepower) for 
mechanical energy; and, for our purposes, METs (metabolic equivalent of 
tasks) for cardiac energy.
    In evaluating cardiovascular disabilities, METs refer to the 
intensity of activities. For example, an activity with a MET of 2, such 
as walking at a slow pace (e.g., 2 mph), would require twice the energy 
that an average person consumes at rest (e.g., sitting quietly), which 
requires 1 MET. See ``The Compendium of Physical Activities,'' Arnold 
School of Public Health- Prevention Research Center, available at 
http://prevention.sph.sc.edu/tools/compendium.htm. VA does not propose 
any alteration to the ranges of METs provided in the current VASRD, nor 
will it eliminate the references to dyspnea, fatigue, angina, 
dizziness, or syncope. Instead, VA proposes to state that these 
symptoms may represent heart failure. VA also proposes to use the more 
common term ``breathlessness'' for the more obscure term ``dyspnea,'' 
and to expand the list of common findings associated with congestive 
heart failure to include arrhythmia and palpitations. See ``Congestive 
Heart Failure,'' Johns Hopkins Medicine, available at http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/congestive_heart_failure.html (last visited Apr. 30, 2014). 
Although VA proposes to eliminate the use of congestive heart failure 
and ejection fraction as indicators for evaluation, it will retain the 
non-MET criteria provided in the current 10 and 30 percent evaluations 
because these criteria remain valid. Id.
    VA proposes to apply the General Formula to those DCs within Sec.  
4.104 that instruct rating personnel to consider METs (among other 
indicators). The DCs using METS as the primary rating criteria include 
7003, 7004, 7005, 7007, 7015, and 7020. On the other hand, DCs 7000, 
7001, 7002, 7006, 7011, 7016, 7017, and 7019 have 100 percent 
evaluation criteria unique to each particular DC. VA does not intend to 
disturb the 100 percent evaluations currently prescribed in these DCs; 
rather, it proposes to apply the General Formula following the total 
evaluations. To ensure clarity and consistency in applying the General 
Formula, VA intends to instruct personnel to rate disabilities under 
Sec.  4.104 using the General Formula unless otherwise directed.
    With respect to DCs 7010, 7011, 7015, and newly proposed DC 7009, 
regardless of the DC, the resulting impairment and disability are 
essentially indistinguishable. To offer more than one evaluation under 
those circumstances would be contrary to Sec.  4.14 (pyramiding). VA 
will provide an instruction immediately before DC 7009 which states 
``For DCs 7009, 7010, 7011, and 7015, a single evaluation will be 
assigned under the diagnostic code which reflects the predominant 
disability picture.''
    The discussion that follows explains the changes to each DC 
affected by the General Formula, and explains additional changes to 
these DCs (e.g., title changes, note changes, etc.).

A. Diagnostic Code 7000

    DC 7000 currently provides a 100 percent evaluation during active 
infection with valvular heart damage and for three months following the 
cessation of treatment for the active infection. VA proposes no change 
to this provision. Following the three months, VA will evaluate 
residual cardiac disability using the General Rating Formula for 
Diseases of the Heart.

B. Diagnostic Codes 7001 and 7002

    The current DCs 7001 and 7002 (endocarditis and pericarditis, 
respectively) provide a 100 percent evaluation during active infection 
with cardiac involvement, and for three months following the cessation 
of treatment for the active infection. VA proposes no change to these 
provisions. Following the three months, VA will evaluate any residual 
cardiac disability using the General Rating Formula for Diseases of the 
Heart.

C. Diagnostic Codes 7003, 7004, 7005, 7007, and 7020

    VA proposes to evaluate disability due to these conditions 
(pericardial adhesions, syphilitic heart disease, arteriosclerotic 
heart disease, hypertensive heart disease, and cardiomyopathy, 
respectively) using the General Rating Formula.

D. Diagnostic Code 7006

    The current DC 7006 provides a 100 percent evaluation during, and 
for three months following, a documented myocardial infarction. VA 
proposes no change to this provision. Following the three months, VA 
proposes to evaluate residual disability under the General Rating 
Formula.

E. Diagnostic Code 7011

    VA does not propose any change to the current DC 7011 provisions 
establishing a 100 percent evaluation for sustained ventricular 
arrhythmia or ventricular aneurysmectomy from the date of hospital 
admission. However, VA proposes to apply the General Rating Formula 
following the mandatory examination provided six

[[Page 37596]]

months after discharge to determine residual disability rating.
    Additionally, DC 7011 currently includes a note indicating VA will 
conduct a mandatory examination six months following discharge and 
therapy for a sustained arrhythmia or ventricular aneurysmectomy. The 
intent is to monitor the extent of disability following inpatient 
hospitalization for surgical intervention and therapy. VA proposes to 
add the phrase ``discharge from inpatient hospitalization'' to the note 
to clarify that the timing for mandatory re-examination is based upon 
discharge from inpatient hospitalization, rather than discharge from an 
outpatient treatment program. This proposed clarification does not 
represent a change in VA policy.

F. Diagnostic Code 7015

    VA proposes to update this DC to reflect modern treatment and to 
more accurately evaluate impairment by separating the various forms of 
atrioventricular block into two specific categories: benign and non-
benign i.e., the latter requiring immediate treatment. ``Types of Heart 
Block,'' National Heart, Lung, and Blood Institute (July 9, 2012), 
http://www.nhlbi.nih.gov/health/health-topics/topics/hb/types.html 
(last visited April 22, 2014).
    The benign, or less severe, category of atrioventricular block 
includes first-degree heart block (first-degree) and second-degree 
heart block, type I (second-degree type I). First-degree (seen as a 
delayed or prolonged P-R interval on electrocardiogram), involves the 
slowing of the heart's electrical signals, often without any symptoms 
and, therefore, without requiring any treatment. Id. In second-degree 
type I, the electrical signals are slowed more and more with each 
heartbeat until the heart eventually skips a beat. An occasional, 
transitory, and mild symptom may be associated with second-degree type 
I heart block. Id. No specific therapy is required for second-degree 
type I heart block. Ali A. Sovari, ``Second-Degree Atrioventricular 
Block Treatment & Management,'' Medscape--Reference (May 9, 2013) 
http://emedicine.medscape.com/article/161919-treatment (last visited 
April 22, 2014). VA proposes to evaluate the benign form of 
atrioventricular block under the General Rating Formula.
    The non-benign, or more severe, category of atrioventricular block 
include second-degree heart block, type II (second-degree type II) and 
third-degree heart block (third-degree). In second-degree type II, some 
of the heart's electrical signals do not reach the ventricles, which 
may result in symptoms of dizziness, light-headedness, or syncope. In 
addition, individuals with second degree may experience chest pain, 
hypoperfusion, and hypotension. Ali A. Sovari, ``Second-Degree 
Atrioventricular Block Clinical Presentation,'' Medscape--Reference 
(May 9, 2013), http://emedicine.medscape.com/article/161919-clinical 
(last visited April 22, 2014). Second-degree type II presents a much 
more immediate medical risk as it may progress rapidly to complete 
heart block. As a result, affected individuals may receive permanent 
pacemakers. Third-degree heart block occurs when none of the heart's 
electrical signals reach the ventricles, which often requires emergency 
treatment because it can result in cardiac arrest or death. Like 
second-degree type II, this severe type of atrioventricular block 
requires pacemaker implantation. Based on this treatment, VA proposes 
to evaluate the non-benign categories of atrioventricular block 
(second-degree, type II and third-degree) under DC 7018, implantable 
cardiac pacemakers. Given the proposed amendments to DC 7015, the note 
that currently follows is no longer relevant. The VA proposes to remove 
the note following DC 7015.

G. Diagnostic Code 7016

    VA does not propose any change to the current DC 7016 provisions 
establishing a 100 percent evaluation for heart valve replacement 
(prosthesis). However, VA proposes to apply the General Rating Formula 
following the mandatory examination provided six months after discharge 
to determine residual disability rating.
    Additionally, DC 7016 currently includes a note indicating VA will 
examine this disability six months following discharge. The intent is 
to monitor the extent of the disability following hospitalization for 
surgery. Similar to DC 7011, VA proposes to link the evaluation with 
discharge from inpatient hospitalization for this particular 
dysrhythmia. This clarification does not represent a change in VA 
policy.

H. Diagnostic Code 7017

    DC 7017 currently provides a 100 percent evaluation for three 
months following hospital admission for coronary bypass surgery. VA 
proposes no change to this provision. Following the three months, VA 
proposes to evaluate any residual cardiac disability under the General 
Rating Formula.

I. Diagnostic Code 7019

    Currently, DC 7019 provides a 100 percent evaluation from the date 
of hospital admission for cardiac transplantation, continuing for ``an 
indefinite period.'' The current note also states, however, that one 
year following discharge, VA should examine the individual to determine 
the appropriate disability rating, assigning a minimum evaluation of 30 
percent. VA applies 38 CFR 3.105(e) to any change in evaluation. VA 
proposes no changes to this process or the minimum evaluation of 30 
percent. However, VA proposes to eliminate the phrase ``for an 
indefinite period'' and replace it with ``for a minimum of one year.'' 
This will eliminate any confusion as to whether the Veteran's 100 
percent evaluation may be subject to reduction during the year 
following transplantation. Practically, a Veteran will receive a 100 
percent evaluation for at least one year plus hospitalization time as 
VA will not re-evaluate the Veteran until one year following hospital 
discharge. In addition to this change, VA proposes to evaluate residual 
cardiac disability under the General Rating Formula.
    Additionally, DC 7019 currently includes a note indicating VA will 
examine this disability one year following discharge. The note's intent 
is to assess the extent of residual cardiac disability following 
hospitalization for surgery. VA proposes to add the phrase ``discharge 
from inpatient hospitalization'' to clarify when the point at which the 
timing for mandatory examination begins. Discharge from an outpatient 
treatment program does not activate this provision. This clarification 
does not represent a change in VA policy.

III. Proposed Changes to Diagnostic Codes Not Rated Under the General 
Formula

A. Diagnostic Code 7008

    The DC 7008 addresses hyperthyroid heart disease. This DC was 
amended with the final publication of 82 FR 50804, Schedule for Rating 
Disabilities; The Endocrine System, effective December 10, 2017. VA's 
update of the endocrine system (38 CFR 4.117) revised the evaluation 
criteria for hyperthyroidism under DC 7900. See RIN 2900-AO44. 
Specifically, VA eliminated any current rating criteria in DC 7900 that 
referred to cardiovascular findings. Instead, VA evaluates any 
hyperthyroid heart disease under DC 7008, which directs rating 
personnel to evaluate any cardiovascular findings according to the 
appropriate DC. The

[[Page 37597]]

VA does not propose any additional changes for DC 7008 at this time.

B. Diagnostic Code 7010

    VA proposes to change the name of the current DC 7010 from 
supraventricular arrhythmias to the more modern and accurate 
supraventricular tachycardia. Arrhythmia generally refers to an 
irregular heartbeat and includes a heartbeat that is too fast, too 
slow, or irregular. ``What Is an Arrhythmia?'' National Heart, Lung, 
and Blood Institute (July 1, 2011), http://www.nhlbi.nih.gov/health/health-topics/topics/arr/ (last visited April 22, 2014). 
Supraventricular tachycardia is an irregularly fast heartbeat that 
originates above or within the atrioventricular node18 or in the upper 
part of the heart. Id. The various forms of supraventricular 
tachycardia include, but are not limited to, atrial fibrillation, 
atrial flutter, sinus tachycardia, sinoatrial nodal reentrant 
tachycardia, atrioventricular nodal reentrant tachycardia, 
atrioventricular reentrant tachycardia, atrial tachycardia, junctional 
tachycardia, and multifocal atrial tachycardia. Id. VA proposes to add 
an explanatory Note 1 to provide a non-exhaustive list of examples of 
supraventricular tachycardia. VA proposes to use tachycardia, rather 
than arrhythmia, in the title to clarify that rating personnel should 
use this DC to evaluate individuals with abnormally fast heartbeats.
    VA also proposes to update the evaluation criteria for 
supraventricular tachycardia, utilizing hospitalization as a more 
accurate measure of disability. The current criteria in DC 7010 assign 
evaluations based on the number of episodes of supraventricular 
arrhythmias documented by electrocardiogram (ECG or EKG) or Holter 
monitor, without considering the need for hospital treatment. 
Supraventricular tachycardia is usually non-lethal and does not result 
in disabling symptoms in otherwise healthy individuals. See 
``Paroxysmal supraventricular tachycardia'' in ``A.D.A.M. Medical 
Encyclopedia,'' PubMed Health, U.S. National Library of Medicine (June 
18, 2012), http://www.nlm.nih.gov/medlineplus/ency/article/000183.htm 
(last visited Apr. 30, 2014). For example, some patients with 
supraventricular tachycardias have many short episodes throughout the 
day and remain asymptomatic. Id. Others may have atrial fibrillation on 
a permanent basis, also without symptoms. These non-disabling episodes 
do not require hospitalization or treatment, but may be recorded 
incidentally by an ECG or Holter monitor without any other findings. 
Id. Therefore, the mere presence of episodes of supraventricular 
tachycardia, as well as their number, is unrelated to symptomatology or 
disability.
    However, some episodes of supraventricular tachycardia result in 
hypotension, shortness of breath, dizziness, or chest pain in patients 
who are older or have underlying cardiac disorders. Id. These 
symptomatic episodes typically require a controlled medical setting to 
monitor and treat heart rate control, anticoagulation, cardioversion, 
electrophysiological studies, or catheter-based arrhythmia ablation. 
Id. Medical intervention for supraventricular tachycardia more 
accurately indicates impairment, as the purpose of treatment is to 
eliminate or reduce any disabling symptoms. As mentioned previously, 
the mere documentation of supraventricular tachycardia on an ECG or 
Holter monitor does not confirm the existence of symptoms or 
impairment.
    As such, VA proposes to replace the current reference to episodes 
documented by ECG or Holter monitor in DC 7010 with treatment 
interventions. For the purposes of this DC, a treatment intervention 
occurs whenever a symptomatic patient requires intravenous 
pharmacologic adjustment, cardioversion, and/or ablation for symptom 
relief. For clarity, VA proposes to add Note 2 to identify when a 
treatment occurs. VA will assign a 10 percent evaluation for 
supraventricular tachycardia, documented by ECG, with one to four 
treatment interventions per year; VA will assign a 30 percent 
evaluation with five or more treatment interventions per year. VA 
proposes the number of interventions annually because benign, non-
disabling episodes may occur throughout the year. However, only 
episodes that require treatment interventions are most likely 
disabling, because they require treatment within a controlled medical 
setting and typically prevent an individual from working.

C. Diagnostic Code 7018

    DC 7018 currently provides a 100 percent evaluation for two months 
following hospital admission for implantation or reimplantation of a 
cardiac pacemaker. Following these two months, VA evaluates the 
disability under DC 7010, 7011, or 7015, with a minimum evaluation of 
10 percent. Advances in surgical methods and medical technology have 
drastically reduced the recovery time following implantation of a 
cardiac pacemaker.
    Surgical techniques for cardiac pacemakers have changed and 
improved drastically over the past several years and recovery currently 
requires less than 30 days. According to the National Institutes of 
Health (NIH), hospitalization following surgical implantation of a 
pacemaker usually lasts one to two days. ``What to Expect After 
Pacemaker Surgery,'' NIH--National Heart, Lung, and Blood Institute 
(February 28, 2012), http://www.nhlbi.nih.gov/health/health-topics/topics/pace/after.html (last visited April 14, 2014). NIH also 
indicates that mild pain, swelling, and tenderness at the site of 
pacemaker implantation may continue from a few days to a few weeks. Id. 
While healthcare providers may instruct patients to avoid vigorous 
activity, including heavy lifting, for up to one month following 
surgery, most patients may return to their normal activity level within 
a few days. Id. VA proposes to reduce the period of 100 percent 
evaluation from two months to one month. Additionally, VA proposes to 
add a second note to this DC, cross-referencing DC 7009, which will be 
addressed in greater detail below. VA proposes no other changes to this 
DC.

D. Diagnostic Code 7110

    The current DC 7110 addresses impairment due to aortic aneurysm. VA 
proposes to change the name of the code to ``Aortic aneurysm: 
ascending, thoracic, or abdominal'' to clarify the location of aortic 
aneurysm that this DC will evaluate.
    VA proposes to eliminate the 60 percent evaluation for an aortic 
aneurysm that precludes exertion while expanding the criteria for a 100 
percent evaluation to include symptomatic aneurysm (e.g., precludes 
exertion). VA proposes to omit the 60 percent category as it is does 
not provide an adequate evaluation for a symptomatic aneurysm in which 
exertion may hasten rupture. See Emile R. Mohler III, MD, ``Patient 
information: Abdominal aortic aneurysm (Beyond the Basics),'' Up-to-
date (Aug. 21, 2013), http://www.uptodate.com/contents/abdominal-aortic-aneurysm-beyond-the-basics#H4 (last visited May 2, 2014). A 
symptomatic aneurysm presents a medical emergency and requires surgical 
treatment to prevent the aneurysm from rupturing. Id. Under the 
proposed criteria, VA will grant a total evaluation when a patient 
becomes a surgical candidate and is unable to exert him/herself.
    Additionally, if a person cannot exert him/herself due to aortic 
aneurysm but is unable to undergo surgery due to a co-

[[Page 37598]]

morbid medical condition (e.g., kidney dysfunction requiring dialysis), 
VA will grant a total evaluation. Jeffrey Jim, MD and Robert W. 
Thompson, MD, ``Management of symptomatic (non-ruptured) and ruptured 
abdominal aortic aneurysm,'' UpToDate (Feb. 12, 2013), http://www.uptodate.com/contents/management-of-symptomatic-non-ruptured-and-ruptured-abdominal-aortic-aneurysm?source=see_link&anchor=H53322839#H53322839 (last visited May 
5, 2014). ``Although there are rare reports of patient survival 
following ruptured abdominal aortic aneurysm (AAA) without repair, in 
general, expectant management of ruptured AAA is nearly uniformly 
fatal. Thus, when ruptured AAA is identified, repair should be 
undertaken emergently to give the patient the best chance for 
survival.'' Id. As such, expanding the 100 percent evaluation to the 
date a physician recommended surgical correction will include Veterans 
who have severely disabling aneurysms but, due to co-morbid medical 
conditions or other reasons, cannot undergo surgical intervention. This 
100 percent evaluation will continue for six months following hospital 
discharge.
    In addition, VA proposes to add a 0 percent rating if an aneurysm 
is present but does not meet the requirements for surgical correction. 
Asymptomatic aneurysms may expand rapidly until they require surgical 
correction, so they need close medical follow-up. This provision 
allowing service connection for aneurysms not requiring surgery 
eliminates barriers to frequent medical check-ups by VA to monitor the 
progress of those aneurysms.
    VA will also add a directive for raters to evaluate non-
cardiovascular residuals according to the body systems affected. This 
is done to take into acount any disabling residuals related to surgical 
correction (e.g., infection, bowel adhesions, kidney failure, and so 
forth).
    The current DC 7110 also includes a note indicating that VA will 
assign the 100 percent rating as of the date of admission for surgical 
correction. VA will re-evaluate the condition after a mandatory 
examination six months following discharge. VA proposes to add the 
phrase ``discharge from inpatient hospitalization'' to clarify that the 
starting point to calculate the mandatory re-examination begins with 
discharge from inpatient hospitalization. VA also proposes to clarify 
in the rating criteria for a 100 percent evaluation that it shall 
assign the 100 percent evaluation as of the date a physician recommends 
surgical correction. This practice will allow VA to assign 100 percent 
evaluations to individuals who require surgical correction but, due to 
co-morbid medical conditions or other reasons, cannot undergo surgical 
procedures.

E. Diagnostic Code 7111

    The current DC 7111 provides 100 percent evaluations for aneurysms 
of large arteries which are symptomatic. It also provides 100 percent 
evaluations for indefinite periods of time from the date of hospital 
admission for surgical corrections. VA proposes to amend the latter 
criteria to provide a 100 percent evaluation from the date a physician 
recommends surgical correction, rather than the date of hospital 
admission. Aneurysms of any large artery are known to spontaneously 
rupture, which, depending on its location, can lead to death if not 
immediately addressed by surgery.
    This expansion to the 100 percent evaluation criteria requires that 
VA amend the note in DC 7111. Currently, VA assigns the 100 percent 
rating as of the date of admission for surgical correction, and VA 
assesses any residual disability by a mandatory examination six months 
following discharge. VA proposes to add the phrase ``discharge from 
inpatient hospitalization'' in the criteria note to clarify that the 
timing for the mandatory re-examination is based upon discharge from 
inpatient hospitalization. Additionally, VA proposes to clarify that it 
shall assign the 100 percent evaluation beginning from the date a 
physician recommends surgical correction, in the event individuals who 
require surgical correction cannot undergo it due to co-morbid medical 
conditions or other reasons. The 100 percent evaluation shall continue 
for six months following hospital discharge for surgical correction.
    The current DC 7111 provides rating criteria following surgical 
intervention that is based on the ankle-brachial index, claudication on 
walking certain distances, and other symptoms related to poor blood 
flow to the extremities. These criteria provide for evaluations ranging 
from 20 to 100 percent; notes (1) and (2) provide additional 
information when evaluating post-surgical large artery aneurysms. The 
residual disabilities after post-surgical repair of large artery 
aneurysms are similar to those under DC 7114. For greater ease of use 
and simplicity, VA therefore proposes to remove these criteria and 
notes and replace them with instructions to evaluate post-surgical 
residuals under DC 7114. The section of the preamble below specifically 
addressing DC 7114 discusses any changes related to these criteria and 
notes.

F. Diagnostic Code 7113

    DC 7113, arteriovenous (AV) fistula, traumatic, currently includes 
the phrase ``with edema'' as one of the disabling symptoms present at 
the 50, 40, 30, and 20 percent levels. However, such wording does not 
distinguish between chronic and transitory edema, resulting in 
evaluations that may be based on symptoms that are unrelated to 
arteriovenous fistula or do not adequately represent its chronic 
residual disability. Transitory edema may occur following prolonged 
standing, prolonged sitting during travel, the wearing of tight 
hosiery, taking certain medications, consuming excessive salt, or being 
pregnant. Transitory edema due to these causes is non-disabling and 
typically resolves without complication.
    However, edema due to an AV fistula requires medical treatment and 
may impair function. Therefore, VA proposes to clarify that evaluations 
at the 50, 40, 30, and 20 percent levels under DC 7113 must involve 
``chronic edema'' to better comply with 38 CFR 4.1, which states the 
accurate application of the VASRD requires an emphasis upon ``the 
limitation of activity imposed by the disabling condition.''

G. Diagnostic Code 7114

    The current DC 7114, titled ``Arteriosclerosis obliterans,'' 
addresses impairment of the lower extremities due to narrowing and 
hardening of the arteries. The term ``arteriosclerosis'' is also used 
in current note (2). VA proposes to replace the term ``arteriosclerosis 
obliterans'' with ``peripheral arterial disease'' to conform to current 
medical terminology. Peter Libby et al., ``Braunwald's Heart Disease: A 
Textbook of Cardiovascular Medicine,'' 1491-1515 (8th ed. 2007).
    The evaluation criteria of the current DC 7114 include the ankle/
brachial index (ABI), associated examination findings and symptoms, or 
claudication (pain in the extremities) upon walking certain distances. 
The current criteria, however, have two major shortcomings: (1) They do 
not account for veterans with non-compressible arteries (these veterans 
have either a normal or elevated ABI, which would be non-compensable); 
and (2) they rely in large part on claudication, which is an 
inconsistent measure of disability. To that end, VA will employ a more 
objective approach as outlined below.
    VA will create evaluation criteria based on a modified version of 
the ischemia scoring table found in J. Mills,

[[Page 37599]]

``The Society for Vascular Surgery Lower Extremity Threatened Limb 
Classification System: Risk stratification based on Wound, Ischemia, 
and foot Infection (WIfI)'' J Vasc Surg; vol 59, pg 226. 2014. This 
table uses the ABI, as well as ankle pressure (AP), toe pressure (TP) 
and transcutaneous oximetry (TcPO2) to describe 
four different levels of impairment. The ABI is the ratio of the 
systolic blood pressure measured at the ankle to that measured at the 
antecubital fossa. For VA disability compensation purposes, normal is 
greater than or equal to 0.80. The reason this normal value is used, 
rather than normal values cited in the 2016 ACC/AHA Guidelines is that 
an ABI between 0.90 and 0.81 is not consistently associated with 
objective signs of disability beyond symptomatic complaints (e.g., 
wounds or infections). The AP is the systolic blood pressure measured 
at the ankle. Normal is greater than or equal to 100 mm Hg. The TP is 
the systolic blood pressure measured at the great toe. Normal is 
greater than or equal to 60 mm Hg. TcPO2 is 
measured at the first intercostal space on the foot. Normal is greater 
than or equal to 60 mm Hg. See also M. Kalani ``Transcutaneous Oxygen 
Tension and Toe Blood Pressure as Predictors for Outcome of Diabetic 
Foot Ulcers,'' Diabetes Care, vol. 22, Pgs 147-52. 1999. The levels of 
impairment as described in the previously referenced ischemia scoring 
table directly correlate to levels of disability (i.e., evaluation 
levels). VA will slightly modify this table to describe four levels of 
disability (and thus, evaluation levels) consistent with these 
criteria, while preserving the 20, 40, 60, and 100 percent evaluation 
levels.
    Turning to the three notes associated with DC 7114, VA will make 
two significant revisions. First, VA will revise Note (1) to add 
definitions and normal values for ABI, AP, TP, and 
TcPO2. Next, VA will redesignate current Note (2) 
as Note (3), and current Note (3) as Note (4). Finally, VA will then 
add a new Note (2), which directs the rater to select the value (ABI, 
AP, TP, or TcPO2) which yields the highest level 
of impairment for evaluation.

H. Diagnostic Code 7115

    DC 7115 currently uses lower extremity findings to evaluate 
thrombo-angiitis obliterans (Buerger's Disease). VA proposes new 
criteria for the evaluation of upper extremity disease because 
Buerger's Disease can affect either upper or lower extremities. 
Buerger's disease is a nonatherosclerotic segmental inflammatory 
disease that affects the small and medium-sized arteries, veins, and 
nerves of the arms, legs, and rarely elsewhere. See Topol, E.J., 
Textbook of Cardiovascular Medicine Chap. 108, Pg 1535. (2007). DC 7115 
currently evaluates impairment of the lower extremity using the ankle/
brachial index (ABI) or associated signs and symptoms upon examination 
(as found in current DC 7114). For the reasons discussed above in DC 
7114, VA proposes to clarify the evaluation criteria by using objective 
signs, with the ABI as the primary criteria for the lower extremities. 
VA proposes to delete claudication on walking from all evaluation 
criteria as it inaccurately measures the extent of this disability. VA 
also proposes to remove current Note (1), as DC 7115 will now direct 
rating personnel to evaluate lower extremities under DC 7114 and the 
information regarding the ABI is contained in that diagnostic code. 
With elimination of current Note (1), VA proposes to rename existing 
Note (2) as Note (1) with clarification similar to that proposed in 
Note (3) DC 7114 (as explained above). Additionally, a new Note (2) is 
proposed to give raters examples of trophic changes so it will be 
easier to recognize when encountered in clinical documentation.

I. Diagnostic Code 7117

    Currently, DC 7117 addresses impairment due to Raynaud's syndrome, 
in which cold or stress abnormally reduces blood flow in the 
extremities. Raynaud's syndrome (also called secondary Raynaud's 
phenomenon) is often confused with Raynaud's disease (also called 
primary Raynaud's phenomenon or primary Raynaud's), which is different 
in terms of etiology and severity. While both conditions present with 
vasospasm, Raynaud's disease (primary Raynaud's phenomenon) has few, if 
any, long term residuals. In contrast, Raynaud's syndrome (secondary 
Raynaud's phenomenon) is associated with another illness, most commonly 
an autoimmune disease. The residuals tend to be permanent, more 
extensive, and more disabling. To improve clarity, ensure more accurate 
evaluations, and promote consistency and usability of the VASRD, VA 
proposes to focus DC 7117 on Raynaud's syndrome (secondary Raynaud's 
phenomenon) only, while creating a new DC 7124 for Raynaud's disease 
(primary Raynaud's phenomenon or primary Raynaud's). In addition, VA 
proposes to use the existing note to emphasize that DC 7117 is only for 
evaluating Raynaud's syndrome (secondary Raynaud's phenomenon), and add 
a note emphasizing that Raynaud's disease (primary Raynaud's 
phenomenon) should be rated under DC 7124.
    As stated, Raynaud's syndrome (secondary Raynaud's phenomenon) and 
Raynaud's disease (primary Raynaud's phenomenon) are unrelated in both 
etiology and severity. According to the NIH's National Heart, Lung, and 
Blood Institute, Raynaud's syndrome (secondary Raynaud's phenomenon) is 
typically caused by autoimmune diseases such as scleroderma, lupus, 
rheumatoid arthritis, atherosclerosis, or polycythemia. ``Raynaud 
Phenomenon.'' Medscape (September 6, 2017), http://emedicine.medscape.com/article/331197-overview (last visited September 
12, 2017).
    On the other hand. the cause of Raynaud's disease (primary 
Raynaud's phenomenon) is not known. Id. Raynaud's disease (primary 
Raynaud's phenomenon) is more common and tends to be less severe than 
Raynaud's syndrome (secondary Raynaud's phenomenon). Ray W. Gifford, 
Jr. & Edgar A. Hines, Jr., ``Raynaud's Disease Among Women and Girls,'' 
16 Circulation 1012, 1019 (1957). VA discusses how to properly evaluate 
Raynaud's disease (primary Raynaud's phenomenon) below in the section 
proposing the new DC 7124. No other changes are proposed to DC 7117.

J. Diagnostic Code 7120

    DC 7121 currently evaluates post-phlebitic syndrome of any 
etiology, with its rating criteria identical to that used in DC 7120, 
Varicose veins. VA currently maintains separate DCs for these 
disabilities to monitor in the Veteran population the incidence and 
outcome of claims for these specific and separate diagnoses. However, 
for clarity, consistency, and improved ease of use, VA proposes to 
delete the duplicative rating criteria and instruct rating personnel to 
evaluate DC 7120, Varicose veins, under DC 7121, Post-phlebitic 
syndrome. VA does not propose any changes to the content of DC 7121 
itself.

K. Diagnostic Code 7122

    VA last amended the rating criteria for DC 7122, Cold injury 
residuals, in 1998. 63 FR 37778. In the time since, medicine has 
documented new chronic residuals of cold injury. Therefore, VA proposes 
to update the criteria to include the findings specifically noted by 
the Veterans Health Initiative, Department of Veterans Affairs, ``Cold 
Injury: Diagnosis and Management of Long-Term Sequelae,'' revised in 
March 2002. https://www.publichealth.va.gov/docs/vhi/coldinjury.pdf
    This study collected medical and anecdotal information on cold 
injury

[[Page 37600]]

residuals from veterans. The study indicated that the effects of cold 
weather injuries may be irreversible and worsen with age. Id. at 15. 
The residuals of cold injuries include residual pain, numbness, cold 
sensitivity, tissue loss, nail abnormalities, color changes, locally 
impaired sensation, hyperhidrosis, x-ray abnormalities, anhydrosis, 
muscle atrophy, muscle fibrosis, deformity in flexion and/or extension 
of certain joints, loss of fat pads in the fingers and toes, bone 
death, skin ulcers, and carpal or tarsal tunnel syndrome. Id. at 24-25. 
VA proposes to include these updated residuals of cold injuries within 
this DC, which assigns evaluations based on the number of cold injury 
residuals present.

IV. Proposed New Diagnostic Codes

A. New Diagnostic Code 7009

    VA proposes to add a new DC 7009, titled ``Bradycardia 
(Bradyarrhythmia), symptomatic, requiring permanent pacemaker 
implantation,'' to account for impairment in the Veteran population due 
to this condition. Individuals generally have a normal resting heart 
rate ranging from 60 to 100 beats per minute. Individuals with 
bradycardia, however, have a resting heart rate of less than 60 beats 
per minute. ``Bradycardia,'' Harvard Health Topic at Drugs.com, http://www.drugs.com/health-guide/bradycardia.html (last visited May 5, 2014). 
Notably, asymptomatic bradycardia occurs normally in individuals when 
sleeping and in many healthy, athletic adults. Id. See also 
``Bradycardia (Slow Heart Rate)--Topic Overview,'' WebMD (Nov. 21, 
2011), http://www.webmd.com/heart-disease/tc/bradycardia-slow-heart-rate-overview (last visited May 5, 2014). It should be noted that 
asymptomatic bradycardia is a medical finding, does not require medical 
intervention, and is not subject to service-connected compensation.
    Symptomatic bradycardia can be caused by changes due to aging, 
certain medications, diseases, and infections, all of which can damage 
the heart and slow its electrical impulses. See Amy Scholten, MPH, 
``Bradycardia (Bradyarrhythmia),'' NYU Langone Cardiac and Vascular 
Institute, 2-3 (Feb. 2008). When medical management for symptomatic 
bradycardia is not effective, a pacemaker implant is the treatment of 
choice. Id. at 3. Implantation of a pacemaker aids in normalizing the 
heart rate and returning the individual to baseline cardiac function. 
VA proposes to evaluate this condition at 100 percent for one month 
following hospitalization for implantation or re-implantation. 
Following the initial month, the disability will be evaluated using the 
General Rating Formula. To assist rating personnel in understanding and 
evaluating bradycardia, VA also proposes to include a note under DC 
7009 which defines bradycardia and describes the five general classes 
of bradyarrhythmias.

B. New Diagnostic Code 7124

    VA proposes to add a new DC 7124, titled ``Raynaud's disease (also 
known as primary Raynaud's phenomenon or primary Raynaud's):.'' The 
VASRD currently evaluates Raynaud's disease using the criteria under DC 
7117, which is for ``Raynaud's syndrome,'' a different and more severe 
disability. Therefore, VA proposes a new DC to specifically evaluate 
Raynaud's disease. This DC will also include notes to define 
characteristic attacks as well as to emphasize rating Raynaud's 
syndrome (Raynaud's phenomenon, Secondary Raynaud's) under DC 7117.
    As stated previously, Raynaud's disease is more common and tends to 
be less severe than Raynaud's syndrome. The Mayo Clinic performed a 
study involving 474 women and girls with Raynaud's disease. Follow-up 
information obtained from 307 of those who received conservative 
treatment confirmed the benign nature of the disease, with no deaths 
attributed to it and extremely little disability. The study found that 
uncomplicated Raynaud's disease may be inconvenient because of the need 
to protect the extremities from cold and trauma, but it is not 
disabling.
    Raynaud's disease, the less severe form of Raynaud's, rarely 
involves trophic changes because it involves brief spasms of the 
arteries rather than occlusion of the peripheral arteries. See ``What 
is Raynaud's?'' National Heart, Lung, and Blood Institute (Mar. 21, 
2014), https://www.nhlbi.nih.gov/health/health-topics/topics/raynaud/ 
(last visited May 5, 2014). Furthermore, when trophic changes are 
present, they are limited to the distal skin of the digits. ``Raynaud's 
disease,'' Mayo Clinic (Oct. 20, 2011), http://www.mayoclinic.org/diseases-conditions/raynauds-disease/basics/complications/con-20022916 
(last visited May 5, 2014). Therefore, VA proposes a non-compensable 
evaluation when Raynaud's disease manifests without lasting impairment 
in the form of trophic changes. VA proposes a 10 percent evaluation 
with residual trophic changes (e.g., skin changes such as thinning, 
atrophy fissuring, ulceration, scarring, absence of hair; nail changes 
(clubbing, deformities).) VA proposes the addition of a note to provide 
examples of trophic changes for clarification purposes, consistent with 
other proposed changes.
    VA also proposes to include a note to clarify and assist assigning 
evaluations under this DC by defining a characteristic attack of 
Raynaud's disease. As with DC 7117, this note will also indicate that 
evaluations under this code are for the disease as a whole. To further 
promote clarity and consistency, another proposed note would emphasize 
that the purpose of DC 7124 is to evaluate only Raynaud's disease, as 
opposed to Raynaud's syndrome. A veteran cannot receive simultaneous 
ratings under both DC 7117 and DC 7124, because Raynaud's disease and 
Raynaud's syndrome cannot be comorbid conditions.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as revised by this 
proposed rulemaking, would represent VA's implementation of its legal 
authority on this subject. Other than future amendments to these 
regulations or governing statutes, no contrary guidance or procedures 
are authorized. All existing or subsequent VA guidance must be read to 
conform with this proposed rulemaking if possible or, if not possible, 
such guidance is superseded by this rulemaking.

Executive Orders 12866 and 13563

    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

[[Page 37601]]

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 to be a significant regulatory action under Executive 
Order 12866, because it raises novel legal or policy issues arising out 
of legal mandates, the President's priorities, or the principles set 
forth in this Executive Order. 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 Fiscal Year to Date. This proposed rule 
is not expected to be subject to the requirements of EO13771 because 
this proposed rule is expected to result in no more than de minimis 
costs.

Paperwork Reduction Act

    This regulatory action contains provisions constituting a 
collection of information under the provisions of the Paperwork 
Reduction Act (44 U.S.C. 3501 et seq.).
    The information collection requirements for 38 CFR 3.151 are 
associated with this rule, but do not constitute a new or revised 
collection of information; OMB has already approved these requirements 
under control number 2900-0747.

Regulatory Flexibility Act

    The Secretary hereby certifies that the adoption of this 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 rule would not directly affect any small entities; 
only individuals could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this rule 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 1 year. This rule will have no such effect on State, 
local, and tribal governments, or on the private sector.

Catalog of Federal Domestic Assistance

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

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to submit it to the Office of 
the Federal Register for electronic publication as an official document 
of the Department of Veterans Affairs. Robert L. Wilkie, Secretary, 
Department of Veterans Affairs, approved this document on April 10, 
2019, for publication.

    Dated: July 23, 2019.
Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
the Secretary, Department of Veterans Affairs.

    For the reasons set out in the preamble, VA 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.  4.100 paragraph (b) to read as follows:


Sec.  4.100  Application of the evaluation criteria for diagnostic 
codes 7000-7007, 7011, and 7015-7020.

* * * * *
    (b) Even if the requirement for a 10% (based on the need for 
continuous medication) or 30% (based on the presence of cardiac 
hypertrophy or dilatation) evaluation is met, METs testing is required 
in all cases except:
    (1) When there is a medical contraindication.
    (2) When a 100% evaluation can be assigned on another basis.

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


0
3. Amend Sec.  4.104 by:
0
a. Adding the General Rating Formula for Diseases of the Heart
0
b. Adding the instruction to DCs 7000, 7001, 7002, 7006, 7017 to 
evaluate disability using the General Rating Formula to evaluate 
residual disability after three months
0
c. Adding the instruction to DCs 7003, 7004, 7005, 7007, and 7020 to 
evaluate disability using the General Rating Formula
0
d. Adding the instruction to DCs 7011, 7016 to evaluate disability 
using the General Rating Formula by mandatory examination six months 
after discharge
0
e. Revising the evaluation criteria for DC 7015
0
f. Revising the evaluation criteria for DC 7019
0
g. Retitling and revise the evaluation criteria for DC 7010
0
h. Revising the evaluation criteria for DC 7018
0
i. Retitling and revise the evaluation criteria for DC 7110
0
j. Revising the evaluation criteria for DC 7111
0
k. Revising DC 7113 to add explanatory information
0
l. Revising the evaluation criteria for DC 7114
0
m. Revising the evaluation criteria for DC 7115
0
n. Revising the evaluation criteria for DC 7117
0
o. Revising the evaluation criteria for DC 7120
0
p. Revising the evaluation criteria for DC 7122
0
q. Adding new DC 7009
0
r. Adding new DC 7124.
    The revisions and additions read as follows:


Sec.  4.104   Schedule of ratings--cardiovascular system.

[[Page 37602]]



------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
                          Diseases of the Heart
------------------------------------------------------------------------
Unless otherwise directed, use this general rating
 formula to evaluate diseases of the heart.
Note (1): Evaluate cor pulmonale, which is a form of
 secondary heart disease, as part of the pulmonary
 condition that causes it.
Note (2): One MET (metabolic equivalent) is the energy
 cost of standing quietly at rest and represents an
 oxygen uptake of 3.5 milliliters per kilogram of body
 weight per minute. When the level of METs at which
 breathlessness, fatigue, angina, dizziness, or syncope
 develops is required for evaluation, and a laboratory
 determination of METs by exercise testing cannot be
 done for medical reasons, a medical examiner may
 estimate the level of activity (expressed in METs and
 supported by specific examples, such as slow stair
 climbing or shoveling snow) that results in those
 symptoms.
Note (3): For this general formula, heart failure
 symptoms include, but are not limited to,
 breathlessness, fatigue, angina, dizziness, arrhythmia,
 palpitations, or syncope.
General Rating Formula for Diseases of the Heart:
    Workload of 3.0 METs or less results in heart                    100
     failure symptoms...................................
    Workload of 3.1-5.0 METs results in heart failure                 60
     symptoms...........................................
    Workload of 5.1-7.0 METs results in heart failure                 30
     symptoms; or evidence of cardiac hypertrophy or
     dilatation confirmed by echocardiogram or
     equivalent (e.g., multigated acquisition scan or
     magnetic resonance imaging)........................
    Workload of 7.1-10.0 METs results in heart failure                10
     symptoms; or continuous medication required for
     control............................................
7000 Valvular heart disease (including rheumatic heart
 disease), 7001 Endocarditis, or 7002 Pericarditis:
    During active infection with cardiac involvement and             100
     for three months following cessation of therapy for
     the active infection...............................
    Thereafter, with diagnosis confirmed by findings on
     physical examination and either echocardiogram,
     Doppler echocardiogram, or cardiac catheterization,
     use the General Rating Formula.
7003 Pericardial adhesions.
7004 Syphilitic heart disease:
    Note: Evaluate syphilitic aortic aneurysms under DC
     7110 (Aortic aneurysm: Ascending, thoracic,
     abdominal).
7005 Arteriosclerotic heart disease (coronary artery
 disease).
    Note: If non-service-connected arteriosclerotic
     heart disease is superimposed on service-connected
     valvular or other non-arteriosclerotic heart
     disease, request a medical opinion as to which
     condition is causing the current signs and
     symptoms.
7006 Myocardial infarction:
    During and for three months following myocardial                 100
     infarction, confirmed by laboratory tests..........
    Thereafter, use the General Rating Formula.
7007 Hypertensive heart disease.
7008 Hyperthyroid heart disease:
    Rate under the appropriate cardiovascular diagnostic
     code, depending on particular findings.
For DCs 7009, 7010, 7011, and 7015, a single evaluation
 will be assigned under the diagnostic code which
 reflects the predominant disability picture.
7009 Bradycardia (Bradyarrhythmia), symptomatic,
 requiring permanent pacemaker implantation:
    For one month following hospital discharge for                   100
     implantation or re-implantation....................
Thereafter, use the General Rating Formula.
    Note (1): Bradycardia (bradyarrhythmia) refers to
     conduction abnormalities that produce a heart rate
     less than 60 beats/min. There are five general
     classes of bradyarrhythmias:
        --Sinus bradycardia, including sinoatrial block;
        --Atrioventricular (AV) junctional (nodal)
         escape rhythm;
        --AV heart block (second or third degree) or AV
         dissociation;
        --Atrial fibrillation or flutter with a slow
         ventricular response; and
        --Idioventricular escape rhythm.
    Note (2): Asymptomatic bradycardia (bradyarrhythmia)
     is a medical finding which does not require medical
     intervention, thus, it is not entitled to service
     connection.
7010 Supraventricular tachycardia:
    Confirmed by ECG, with five or more treatment                     30
     interventions per year.............................
    Confirmed by ECG, with one to four treatment                      10
     interventions per year.............................
    Note (1): Examples of supraventricular tachycardia
     include, but are not limited to, atrial
     fibrillation, atrial flutter, sinus tachycardia,
     sinoatrial nodal reentrant tachycardia,
     atrioventricular nodal reentrant tachycardia,
     atrioventricular reentrant tachycardia, atrial
     tachycardia, junctional tachycardia, and multifocal
     atrial tachycardia.
    Note (2): For the purposes of this diagnostic code,
     a treatment intervention occurs whenever a
     symptomatic patient requires intravenous
     pharmacologic adjustment, cardioversion, and/or
     ablation for symptom relief.
7011 Ventricular arrhythmias (sustained):
    For an indefinite period from the date of hospital               100
     admission for initial medical therapy for a
     sustained ventricular arrhythmia; or for an
     indefinite period from the date of hospital
     admission for ventricular aneurysmectomy; or with
     an automatic implantable cardioverter-defibrillator
     (AICD) in place....................................
    Thereafter, use the General Rating Formula.
    Note: Six months following discharge from inpatient
     hospitalization for sustained ventricular
     arrhythmia or for ventricular aneurysmectomy,
     disability evaluation shall be conducted by
     mandatory VA examination using the General Rating
     Formula. Apply the provisions of Sec.   3.105(e) of
     this chapter to any change in evaluation based upon
     that or any subsequent examination.
7015 Atrioventricular block:
    Benign (First-Degree and Second-Degree, Type I):
        Evaluate under the General Rating Formula.
    Non-Benign (Second-Degree, Type II and Third-
     Degree):
        Evaluate under DC 7018 (implantable cardiac
         pacemakers).
7016 Heart valve replacement (prosthesis):
    For an indefinite period following date of hospital              100
     admission for valve replacement....................
    Thereafter, use the General Rating Formula.

[[Page 37603]]

 
    Note: Six months following discharge from inpatient
     hospitalization, disability evaluation shall be
     conducted by mandatory VA examination using the
     General Rating Formula. Apply the provisions of
     Sec.   3.105(e) of this chapter to any change in
     evaluation based upon that or any subsequent
     examination.
7017 Coronary bypass surgery:...........................
    For three months following hospital admission for                100
     surgery............................................
    Thereafter, use the General Rating Formula.
7018 Implantable cardiac pacemakers:
    For one month following hospital discharge for                   100
     implantation or re-implantation....................
    Thereafter:
        Evaluate as supraventricular tachycardia (DC
         7010), ventricular arrhythmias (DC 7011), or
         atrioventricular block (DC 7015).
        Minimum.........................................              10
    Note (1): Evaluate automatic implantable
     cardioverter-defibrillators (AICDs) under DC 7011.
7019 Cardiac transplantation:
    For a minimum of one year from the date of hospital              100
     admission for cardiac transplantation..............
    Thereafter:
        Evaluate under the General Rating Formula.
        Minimum.........................................              30
    Note: One year following discharge from inpatient
     hospitalization, determine the appropriate
     disability rating by mandatory VA examination.
     Apply the provisions of Sec.   3.105(e) of this
     chapter to any change in evaluation based upon that
     or any subsequent examination.
7020 Cardiomyopathy.
------------------------------------------------------------------------
                   Diseases of the Arteries and Veins
------------------------------------------------------------------------
7110 Aortic aneurysm: Ascending, thoracic, or abdominal:
    If 5 centimeters (cm) or larger in diameter; or, if              100
     symptomatic (e.g., precludes exertion) and a
     physician recommends surgical correction, for the
     period beginning on the date a physician recommends
     surgical correction and continuing for six months
     following hospital discharge for surgical
     correction (including any type of graft insertion).
    If less than 5 cm in diameter; or, surgical                        0
     correction not recommended.........................
    Evaluate non-cardiovascular residuals of surgical
     correction according to organ systems affected.
    Note: Six months following discharge from inpatient
     hospitalization for surgery, disability evaluation
     shall be determined by mandatory VA examination of
     cardiovascular residuals using the General Rating
     Formula for Diseases of the Heart. 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.
7111 Aneurysm, any large artery:
    If symptomatic; or, for the period beginning on the              100
     date a physician recommends surgical correction and
     continuing for six months following discharge from
     inpatient hospital admission for surgical
     correction.........................................
    Following surgery: Evaluate under DC 7114
     (peripheral arterial disease).
    Note: Six months following discharge from inpatient
     hospitalization for surgery, 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.
 
                              * * * * * * *
7113 Arteriovenous fistula, traumatic:
    With high-output heart failure......................             100
    Without heart failure but with enlarged heart, wide               60
     pulse pressure, and tachycardia....................
    Without cardiac involvement but with chronic edema,
     stasis dermatitis, and either ulceration or
     cellulitis:
        Lower extremity.................................              50
        Upper extremity.................................              40
    Without cardiac involvement but with chronic edema
     or stasis dermatitis:
        Lower extremity.................................              30
        Upper extremity.................................              20
7114 Peripheral arterial disease:
    At least one of the following: Ankle/brachial index              100
     less than or equal to 0.39; ankle pressure less
     than 50 mm Hg; toe pressure less than 30 mm Hg; or
     transcutaneous oxygen tension less than 30 mm Hg...
    At least one of the following: Ankle/brachial index               60
     of 0.40-0.53; ankle pressure of 50-65 mm Hg; toe
     pressure of 30-39 mm Hg; or transcutaneous oxygen
     tension of 30-39 mm Hg.............................
    At least one of the following: Ankle/brachial index               40
     of 0.54-0.66; ankle pressure of 66-83 mm Hg; toe
     pressure of 40-49 mm Hg; or transcutaneous oxygen
     tension of 40-49 mm Hg.............................
    At least one of the following: Ankle/brachial index               20
     of 0.67-0.79; ankle pressure of 84-99 mm Hg; toe
     pressure of 50-59 mm Hg; or transcutaneous oxygen
     tension of 50-59 mm Hg.............................
    Note (1): The ankle/brachial index (ABI) is the
     ratio of the systolic blood pressure at the ankle
     divided by the simultaneous brachial artery
     systolic blood pressure. For the purposes of this
     diagnostic code, normal ABI will be greater than or
     equal to 0.80. The ankle pressure (AP) is the
     systolic blood pressure measured at the ankle.
     Normal AP is greater than or equal to 100 mm Hg.
     The toe pressure (TP) is the systolic blood
     pressure measured at the great toe. Normal TP is
     greater than or equal to 60 mm Hg. Transcutaneous
     oxygen tension (TcPO2) is measured at the first
     intercostal space on the foot. Normal TcPO2 is
     greater than or equal to 60 mm Hg. All measurements
     must be determined by objective testing.
    Note (2): Select the highest impairment value of
     ABI, AP, TP, or TcPO2 for evaluation.
    Note (3): Evaluate residuals of aortic and large
     arterial bypass surgery or arterial graft as
     peripheral arterial disease.
    Note (4): These evaluations involve a single
     extremity. If more than one extremity is affected,
     evaluate each extremity separately and combine
     (under Sec.   4.25), using the bilateral factor
     (Sec.   4.26), if applicable.
7115 Thrombo-angiitis obliterans (Buerger's Disease):

[[Page 37604]]

 
    Lower extremity: Rate under DC 7114.
    Upper extremity:
        Deep ischemic ulcers and necrosis of the fingers             100
         with persistent coldness of the extremity,
         trophic changes with pains in the hand during
         physical activity, and diminished upper
         extremity pulses...............................
        Persistent coldness of the extremity, trophic                 60
         changes with pains in the hands during physical
         activity, and diminished upper extremity pulses
        Trophic changes with numbness and paresthesia at              40
         the tips of the fingers, and diminished upper
         extremity pulses...............................
        Diminished upper extremity pulses...............              20
    Note (1): These evaluations involve a single
     extremity. If more than one extremity is affected,
     evaluate each extremity separately and combine
     (under Sec.   4.25), using the bilateral factor
     (Sec.   4.26), if applicable.
    Note (2): Trophic changes include, but are not
     limited to, skin changes (thinning, atrophy,
     fissuring, ulceration, scarring, absence of hair)
     as well as nail changes (clubbing, deformities).
7117 Raynaud's syndrome (also known as secondary
 Raynaud's phenomenon or secondary Raynaud's)...........
    With two or more digital ulcers plus auto-amputation             100
     of one or more digits and history of characteristic
     attacks............................................
    With two or more digital ulcers and history of                    60
     characteristic attacks.............................
    Characteristic attacks occurring at least daily.....              40
    Characteristic attacks occurring four to six times a              20
     week...............................................
    Characteristic attacks occurring one to three times               10
     a week.............................................
    Note (1): For purposes of this section,
     characteristic attacks consist of sequential color
     changes of the digits of one or more extremities
     lasting minutes to hours, sometimes with pain and
     paresthesias, and precipitated by exposure to cold
     or by emotional upsets. These evaluations are for
     Raynaud's syndrome as a whole, regardless of the
     number of extremities involved or whether the nose
     and ears are involved.
    Note (2): This section is for evaluating Raynaud's
     syndrome (secondary Raynaud's phenomenon or
     secondary Raynaud's). For evaluation of Raynaud's
     disease (primary Raynaud's phenomenon, or primary
     Raynaud's), see DC 7124.
 
                              * * * * * * *
7120 Varicose veins:
    Evaluate under diagnostic code 7121.
 
                              * * * * * * *
7122 Cold injury residuals:
    With the following in affected parts:
        Arthralgia or other pain, numbness, or cold                   30
         sensitivity plus two or more of the following:
         Tissue loss, nail abnormalities, color changes,
         locally impaired sensation, hyperhidrosis,
         anhydrosis, X-ray abnormalities (osteoporosis,
         subarticular punched-out lesions, or
         osteoarthritis), atrophy or fibrosis of the
         affected musculature, flexion or extension
         deformity of distal joints, volar fat pad loss
         in fingers or toes, avascular necrosis of bone,
         chronic ulceration, carpal or tarsal tunnel
         syndrome.......................................
        Arthralgia or other pain, numbness, or cold                   20
         sensitivity plus one of the following: Tissue
         loss, nail abnormalities, color changes,
         locally impaired sensation, hyperhidrosis,
         anhydrosis, X-ray abnormalities (osteoporosis,
         subarticular punched-out lesions, or
         osteoarthritis), atrophy or fibrosis of the
         affected musculature, flexion or extension
         deformity of distal joints, volar fat pad loss
         in fingers or toes, avascular necrosis of bone,
         chronic ulceration, carpal or tarsal tunnel
         syndrome.......................................
        Arthralgia or other pain, numbness, or cold                   10
         sensitivity....................................
    Note (1): Separately evaluate amputations of fingers
     or toes, and complications such as squamous cell
     carcinoma at the site of a cold injury scar or
     peripheral neuropathy, under other diagnostic
     codes. Separately evaluate other disabilities
     diagnosed as the residual effects of cold injury,
     such as Raynaud's syndrome (which is otherwise
     known as secondary Raynaud's phenomenon), muscle
     atrophy, etc., unless they are used to support an
     evaluation under diagnostic code 7122.
    Note (2): Evaluate each affected part (e.g., hand,
     foot, ear, nose) separately and combine the ratings
     in accordance with Sec.  Sec.   4.25 and 4.26.
 
                              * * * * * * *
7124 Raynaud's disease (also known as primary Raynaud's
 phenomenon or primary Raynaud's):......................
    Characteristic attacks associated with trophic                    10
     change(s), such as tight, shiny skin...............
    Characteristic attacks without trophic change(s)....               0
    Note (1): For purposes of this section,
     characteristic attacks consist of intermittent and
     episodic color changes of the digits of one or more
     extremities, lasting minutes or longer, with
     occasional pain and paresthesias, and precipitated
     by exposure to cold or by emotional upsets. These
     evaluations are for the disease as a whole,
     regardless of the number of extremities involved or
     whether the nose and ears are involved.
    Note (2): Trophic changes include, but are not
     limited to, skin changes (thinning, atrophy,
     fissuring, ulceration, scarring, absence of hair)
     as well as nail changes (clubbing, deformities).
    Note (3): This section is for evaluating Raynaud's
     disease (primary Raynaud's phenomenon or primary
     Raynaud's). For evaluation of Raynaud's syndrome
     (also known as secondary Raynaud's phenomenon, or
     secondary Raynaud's), see DC 7117.
------------------------------------------------------------------------


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


0
4. Amend Appendix A to Part 4 by:
0
a. Adding an entry for the General Rating Formula for Diseases of the 
Heart to 4.104;
0
 b. Revising the entries for diagnostic codes 7000 through 7008;
0
c. Adding, in numerical order, an entry for diagnostic code 7009;
0
d. Revising the entries for diagnostic codes 7010, 7011, 7015 through 
7020, 7110 through 7111, 7113 through 7115, 7117, and 7121 through 
7122; and
0
e. Adding, in numerical order, an entry for diagnostic code 7124.
    The revisions and additions read as follows:

[[Page 37605]]



Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                              Diagnostic
           Sec.                code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.104.....................  ..............  General Rating Formula for
                                             Diseases of the Heart
                                             [Effective date of final
                                             rule].
                                      7000  Evaluation July 6, 1950;
                                             evaluation September 22,
                                             1928, evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7001  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7002  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7003  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7004  Criterion September 22,
                                             1978; evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7005  Evaluation September 9,
                                             1975; evaluation September
                                             22, 1978; evaluation
                                             January 12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7006  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule]
                                      7007  Evaluation September 22,
                                             1978; evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7008  Evaluation January 12, 1998;
                                             evaluation [Effective date
                                             of final rule].
                                      7009  Added [Effective date of
                                             final rule].
                                      7010  Evaluation January 12, 1998;
                                             title, criterion [Effective
                                             date of final rule].
                                      7011  Evaluation January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
 
                              * * * * * * *
                                      7015  Evaluation September 9,
                                             1975; criterion January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7016  Added September 9, 1975;
                                             criterion January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
                                      7017  Added September 22, 1978;
                                             evaluation January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7018  Added January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7019  Added January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
                                      7020  Added January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
 
                              * * * * * * *
                                      7110  Evaluation September 9,
                                             1975; evaluation January
                                             12, 1998; title, criterion,
                                             note [Effective date of
                                             final rule].
                                      7111  Criterion September 9, 1975;
                                             evaluation January 12,
                                             1998; note, criterion
                                             [Effective date of final
                                             rule].
 
                              * * * * * * *
                                      7113  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7114  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; title, criterion,
                                             note [Effective date of
                                             final rule].
                                      7115  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; note, criterion,
                                             evaluation [Effective date
                                             of final rule].
 
                              * * * * * * *
                                      7117  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; title, note
                                             [Effective date of final
                                             rule].
 
                              * * * * * * *
                                      7121  Criterion July 6, 1950;
                                             evaluation March 10, 1976;
                                             evaluation January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7122  Last sentence of Note
                                             following July 6, 1950;
                                             evaluation January 12,
                                             1998; criterion August 13,
                                             1998; criterion [Effective
                                             date of final rule].
 
                              * * * * * * *
                                      7124  Added [Effective date of
                                             final rule].
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Amend Appendix B to Part 4, Sec.  4.104 by:
0
 a. Adding, in numerical order, an entry for diagnostic code 7009;
0
b. Revising diagnostic codes 7010, 7110, 7114, and 7117; and
0
c. Adding, in numerical order, an entry for diagnostic code 7124.
    The revisions and additions read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
   Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
            The Cardiovascular System--Diseases of the Heart
------------------------------------------------------------------------
 
                              * * * * * * *
7009....................  Bradycardia (Bradyarrhythmia), symptomatic,
                           requiring permanent pacemaker implantation.
 

[[Page 37606]]

 
                              * * * * * * *
7010....................  Supraventricular tachycardia.
 
                              * * * * * * *
7110....................  Aortic aneurysm: ascending, thoracic,
                           abdominal.
 
                              * * * * * * *
7114....................  Peripheral arterial disease.
 
                              * * * * * * *
7117....................  Raynaud's syndrome (secondary Raynaud's
                           phenomenon).
 
                              * * * * * * *
7124....................  Raynaud's disease (primary Raynaud's
                           phenomenon, primary Raynaud's).
 
                              * * * * * * *
------------------------------------------------------------------------

0
6. Revise Appendix C to Part 4, Sec.  4.104 by:
0
a. Revising the entry for Aneurysm: Aortic: ascending, thoracic, 
abdominal;
0
b. Adding, in alphabetical order, under the entry for Bones an entry 
for Bradycardia (Bradyarrhthmia), symptomatic, requiring permanent 
pacemaker implantation;
0
c. Revising the entries for Hypertension (isolated systolic, diastolic, 
or combined systolic and diastolic hypertension) and Peripheral 
arterial disease;
0
d. Adding, in alphabetical order, under the entry for Pyelonephritis, 
chronic, an entry for Raynaud's disease (primary Raynaud's phenomenon, 
primary Raynaud's); and
0
e. Revising the entries for Raynaud's syndrome (Raynaud's phenomenon, 
secondary Raynaud's) and Supraventricular tachycardia.
    The revisions and additions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Aneurysm:
    Aortic: ascending, thoracic, abdominal..............            7110
    Large artery........................................            7111
    Small artery........................................            7118
 
                              * * * * * * *
Arrhythmia:
    Ventricular.........................................            7011
 
                              * * * * * * *
Bones:
    Bradycardia.........................................            7009
    (Bradyarrhythmia), symptomatic, requiring permanent
     pacemaker implantation.............................
 
                              * * * * * * *
Peripheral arterial disease.............................            7114
 
                              * * * * * * *
Raynaud's disease (primary Raynaud's)...................            7124
Raynaud's syndrome (Raynaud's phenomenon, secondary                 7117
 Raynaud's).............................................
 
                              * * * * * * *
Supraventricular tachycardia............................            7010
 
                              * * * * * * *
------------------------------------------------------------------------


[[Page 37607]]

[FR Doc. 2019-15904 Filed 7-31-19; 8:45 am]
 BILLING CODE 8320-01-P