[Federal Register Volume 86, Number 187 (Thursday, September 30, 2021)]
[Rules and Regulations]
[Pages 54089-54098]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-19998]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AQ67


Schedule for Rating Disabilities: The Cardiovascular System

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'' or ``rating schedule'') by 
revising the portion of the rating schedule that addresses the 
cardiovascular system. The purpose of this revision is to ensure that 
this portion of the rating schedule uses current medical terminology 
and provides detailed and updated criteria for the evaluation of 
cardiovascular disabilities by incorporating medical advances that have 
occurred since the last review.

DATES: This rule is effective November 14, 2021.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., 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 number.)

SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal 
Register at 84 FR 37594 on August 1, 2019, to amend the regulations 
involving the cardiovascular system. VA provided a 60-day public 
comment period and invited interested persons to submit written 
comments, suggestions, or objections on or before September 30, 2019. 
VA received comments from National Organization of Veterans' Advocates 
(NOVA), Military Disability Made Easy (two comments), Veterans of 
Foreign Wars (VFW), National Veterans Legal Services

[[Page 54090]]

Program (NVLSP), and four individuals. VA has made limited changes 
based on these comments, as discussed below.

Section-by-Section Discussion of Part 4 of Title 38 of the CFR

    General Discussion:
    One commenter requested clarification for the meaning of ``month'' 
and asked that the number of days that a ``month'' represents be 
provided. VA clarifies that the term ``month'' is used to describe the 
procession from one month to the next on the Gregorian calendar. It 
does not denote a specific number of days since the number of days in a 
month vary throughout the year. However, for the purpose of 
understanding how long a temporary evaluation will be effective based 
on ``months,'' VA clarifies that temporary evaluations remain effective 
until the last day of the month in which the temporary evaluation ends. 
As an example, under Diagnostic Code 7000, VA will assign a 100-percent 
evaluation during active infection with valvular heart disease and for 
three months following the cessation of treatment for the active 
infection. If treatment ceased on January 5, 2020, the temporary 
evaluation would end after three months (on approximately April 5, 
2020) and would remain effective until the end of the current month, 
April 30, 2020.
    Sec.  4.100, Application of the evaluation criteria for diagnostic 
codes 7000-7007, 7011, and 7015:
    Three issues within this section were highlighted by multiple 
commenters. One commenter asked why it was necessary to wait for 
significant debilitation before compensation is awarded when using 
disease classification as a basis for compensation. VA notes current 
law requires that VA adopt and apply ``a schedule of ratings of 
reductions in earning capacity from specific injuries or combination of 
injuries'' that are based upon the average impairments of earning 
capacity from injuries or disabilities related to military service in 
civil occupations. See 38 U.S.C. 1155. Second, disease classification 
is not a consistently accurate predictor of either disability or loss 
in earnings capacity. VA makes no changes based on this comment.
    Another commenter asked what are the alternatives that can be used 
instead of metabolic equivalent of task (METs) when METs testing is 
contraindicated for diagnostic codes using the General Rating Formula 
for Diseases of the Heart. VA notes that under certain evaluation 
criteria within the General Rating Formula for Diseases of the Heart, 
medication and selected echocardiogram findings may be used. In 
addition, Note 2 of the General Rating Formula, as proposed, states 
that examiners are permitted to estimate METs level based on an 
interview when testing cannot be conducted. VA makes no changes based 
on this comment.
    Three commenters objected to the removal of congestive heart 
failure (CHF) and left ventricular ejection fraction (LVEF). One 
commenter stated that instead of removing CHF and LVEF, VA should 
require medical examiners to provide a full picture of the heart 
disability, including explaining if CHF or LVEF is not caused by the 
heart condition, in accordance with Sec.  4.10. Another commenter 
questioned the rationale for removing CHF and LVEF because VA argued 
for including those metrics in a 2002 proposed rule. The commenter also 
stated that removing these metrics would be overly restrictive and 
burdensome to veterans with limited access to care. The last commenter 
objected to the removal of CHF and LVEF and cited a 2017 medical 
journal article which concluded that LVEF was the best metric for 
functional and structural cardiac remodeling. VA appreciates these 
comments but continues with the proposed changes without modification 
for the following reasons.
    First, under certain evaluation criteria within the General Rating 
Formula for Diseases of the Heart, medication and selected 
echocardiogram findings may be used instead of METs. Second, it should 
be noted that Sec.  4.10 requires in part ``full description of the 
effects of disability upon the person's ordinary activity.'' CHF is 
actually a medical diagnosis, and does not, in and of itself, describe 
disability. Additionally, ``ejection fraction (LVEF) is poorly related 
to exercise tolerance (which is measured in METS).'' Topol, E.J., 
``Textbook of Cardiovascular Medicine, 3rd Edition, pg. 1349 (2007). 
MET, on the other hand, is a metric used to describe functional 
capacity or exercise tolerance of an individual performing activities, 
for some of which the difficulty with or inability to perform has a 
profoundly negative effect on earnings capacity. As VA explained in the 
proposed rule, LVEF and CHF are unreliable tools for assessing 
functional limitation and disability due to cardiac disease because 
they may be influenced by numerous factors not directly associated with 
the underlying cardiovascular disease. 84 FR at 37595. Third, on August 
22, 2002, VA published proposed changes to Sec.  4.100 that, while 
providing a basis to include consideration of LVEF and CHF in the 
cardiac disability evaluation, also clarified that VA does not require 
all three tests (i.e., METs, CHF, and LVEF) in order to evaluate a 
cardiac disability. See 67 FR 54394. At the time, VA stated that 
``[o]ur intent in providing alternative criteria was to avoid the need 
for a veteran to undergo additional tests that might be invasive, 
risky, costly, or time-consuming, if one or more objective and reliable 
tests or findings suitable for evaluation purposes are already of 
record.'' Id. at 54395. These proposed changes were finalized in 2006. 
See 71 FR 52457. VA does not consider removing CHF and LVEF as 
inconsistent with its stated intention in 2002. VA's intent has 
consistently been to avoid, whenever possible, invasive, risky, costly, 
or time-consuming tests when ascertaining level of impairment and METs 
testing is the least invasive procedure compared to CHF and LVEF 
testing. Further, although one commenter raised the issue of local 
accessibility of certain testing, VA notes that METs can be obtained 
via provider interview, observation, or actual physical testing.
    Finally, a commenter who objected to the removal of CHF and LEVF 
also cited a 2017 medical journal article that involves functional and 
structural phenotyping of failing hearts to better diagnose, treat, and 
otherwise manage heart failure. The article does not, however, address 
residual disability leading to loss in earnings capacity, which is the 
primary focus of the ratings schedule.
    Sec.  4.104, Schedule of ratings-cardiovascular system:
    Two commenters raised three issues specific to this section. One 
commenter agreed with VA's continued recognition of palpitations and 
arrhythmias as elements within selected evaluation criteria. VA thanks 
the commenter for their input. One commenter disagreed with using METs, 
claiming they are inaccurate within key situations (e.g., normal METs 
values despite cardiac abnormalities; symptomatic only with activities 
requiring greater than 10 METs; and METs are inaccurate for sustained 
activities). Finally, in place of METs, that commenter noted that 
disease is the limiting factor, and should be both measured as well as 
classified to determine compensation levels.
    VA makes no changes based on the immediately preceding comments for 
the following reasons. VA disagrees with the commenter's conclusion 
that METs are inaccurate in situations involving normal function 
despite anatomic abnormalities and during sustained activities. 
Regardless of whether any anatomic/medical/

[[Page 54091]]

structural abnormalities exist, if they are not associated with a 
specific disability or disabilities, then such abnormalities are not a 
basis for disability compensation. Second, the Compendium of Physical 
Activities, which is ``a coding scheme that classifies specific 
physical activity . . . by rate of energy expenditure,'' https://pubmed.ncbi.nlm.nih.gov/10993420/, shows that while the amount of 
energy expended depends on the duration of the activity, the rate of 
energy expenditure is unchanged regardless of how long the energy is 
expended.
    Finally, VA notes that the fact that a disease classification 
system functions well in terms of guiding treatment or predicting 
prognosis does not necessarily imply it is an adequate tool for rating 
disabilities. Pursuant to 38 U.S.C. 1155, VA's rating schedule is 
intended to reflect reductions in earning capacity from specific 
injuries or disabilities incurred in or due to military service, so any 
proposed classification system must fulfill that requirement.

Specific Diagnostic Codes (DCs)

    Proposed new DC 7009, bradycardia (bradyarrhythmia), symptomatic, 
requiring permanent pacemaker implantation and current DC 7018, 
implantable cardiac pacemakers:
    One commenter asked if a 100-percent evaluation for implanted 
pacemakers could be prolonged if recovery time was greater than one 
month. VA proposed to add a new DC 7009 for bradycardia requiring 
permanent pacemaker implantation that would provide a 100-percent 
evaluation for one month following hospitalization for implantation or 
re-implantation. Residuals after the following initial month will be 
evaluated using the General Rating Formula. Aside from total (100 
percent) evaluations provided in the rating schedule, VA also provides 
temporary 100-percent evaluation ratings for any service-connected 
disability that requires hospitalization longer than 21 days or more or 
requires at least one month of convalescence for surgery (or 
immobilization by cast of one major joint or more), if the evidence 
shows that it is warranted. See 38 CFR 4.29-4.30. Since VA has 
provisions in place for post-operative or surgical total evaluations 
for such instances, VA makes no changes based on this comment.
    Proposed new DC 7009, bradycardia (bradyarrhythmia), symptomatic, 
requiring permanent pacemaker implantation and current DCs 7010, 
supraventricular arrhythmias, 7011, ventricular arrhythmias 
(sustained), and 7015, atrioventricular block:
    The proposed rule stated that, for conditions under these DCs, ``a 
single evaluation will be assigned under the diagnostic code that 
reflects the predominant disability picture.'' One commenter asked how 
a ``medical professional'' could ``appeal[ ] or otherwise alter[ ]'' 
the diagnostic code to the extent that person disagrees with that 
instruction. VA clarifies that ``predominant disability picture'' is a 
term of art that generally describes the disability that allows for the 
highest compensable evaluation. To the extent the commenter means to 
ask whether an examiner can provide additional information beyond what 
he or she believes is contemplated by the applicable diagnostic code, 
the answer is that an examiner should always strive to provide a 
complete picture of the claimant's disability, including any salient 
details, and provide medical reasoning to justify any conclusions 
drawn, which is consistent with the examiner's obligations under 38 CFR 
4.10. If a veteran is service connected for two of these disabilities, 
a VA rating specialist will consider the probative value of this report 
in selecting the disability that warrants the highest evaluation to 
evaluate both conditions, consistent with the rater's obligation ``to 
interpret reports of examination in the light of the whole recorded 
history, reconciling the various reports into a consistent picture so 
that the current rating may accurately reflect the elements of 
disability present.'' 38 CFR 4.2.
    If the claimant or the claimant's representative believes another 
service-connected condition is more disabling to the point that it 
warrants a higher evaluation than the original condition, the claimant 
or the claimant's representative may present evidence in support of 
that argument in whatever posture is most appropriate at the time. For 
example, the claimant may raise that argument in a notice of 
disagreement if filed within one year of the rating decision 
notification letter containing the disputed disability picture 
assessment, or the claimant may file an increased rating claim if the 
other service-connected condition has become the prominent disability 
any time after the initial rating decision becomes final. At that time, 
if the rating specialist determines the evidence supports the 
claimant's argument, VA will assign a new higher evaluation to reflect 
the appropriate disability picture. VA makes no changes based on this 
comment.
    DC 7010, Supraventricular Arrythmias:
    Four different commenters raised multiple concerns with this DC. 
Two commenters raised the issue of hospitalizations, one objecting to 
the use in the revised evaluation criteria and the other asking what 
level of hospitalization is required to receive an evaluation. VA used 
the term ``hospitalizations'' in giving a general description of the 
evaluation criteria revisions, but the proposed rule goes on to state 
VA's actual intent, which was to use specific treatment interventions 
such as intravenous pharmacologic adjustment, cardioversion, and/or 
ablation from a provider that are intended to treat acutely disabling 
symptoms. Hospitalization may or may not be associated with these 
treatment interventions, so it was excluded as a description within the 
evaluation criteria. VA regrets any confusion resulting from the use of 
the word ``hospitalizations'' in association with this DC and continues 
with the proposed changes without modification.
    Three commenters proposed oral medication be used within evaluation 
criteria. One commenter proposed adding emergency room (ER) visits to 
the evaluation criteria. Still another commenter proposed adding vagal 
maneuvers to the evaluation criteria. VA agrees to incorporate oral 
medications and vagal maneuvers but declines to revise the evaluation 
criteria to incorporate ER visits. As previously stated, the evaluation 
criteria will be based on residual disability from treatment 
interventions to resolve disabling symptoms. ER visits do not 
necessarily require intravenous pharmacologic adjustment, 
cardioversion, or ablation to block or control the condition and any 
associated disability. When they do, the proposed evaluation criteria 
can accommodate this situation.
    Finally, two commenters stated that the criteria did not account 
for other symptoms associated with supraventricular tachycardia, 
specifically extreme fatigue and tachycardia that induces hypotension, 
shortness of breath, dizziness, and chest pain. VA declines to revise 
the evaluation criteria to incorporate symptoms of extreme fatigue, 
hypotension, shortness of breath, dizziness, and chest pain. This DC 
specifically addresses supraventricular tachycardia; however, if the 
condition also causes ventricular arrhythmias (i.e., tachycardia and 
bradycardia), an evaluation can be assigned using DC 7011 under the 
general rating formula, which considers symptoms of fatigue,

[[Page 54092]]

syncope (hypotension), breathlessness, dizziness, and angina (chest 
pain). VA points to the instruction concerning DCs 7009, 7010, 7011, 
and 7015, which only allow for a single evaluation for all four DCs 
based on the one that reflects the pre-dominant disability picture.
    DC 7011, Ventricular Arrhythmias (Sustained):
    One commenter recommended VA include ``discharge from inpatient 
cardiac rehabilitation'' as another event before waiting six months to 
conduct the mandatory reexamination for a sustained arrhythmia or 
ventricular aneurysmectomy. This recommendation was made to ensure VA 
claims processors do not disallow the application of the provisions of 
Sec.  4.29 in cases where the veteran is receiving cardiac 
rehabilitation, which the commenter believed to be a mistake.
    The 100-percent evaluation under DC 7011, which is assigned for 
sustained ventricular arrhythmias following discharge from inpatient 
hospitalization, already contemplates activities the veteran may be 
subject to after sustained arrhythmia or ventricular aneurysmectomy, 
such as cardiac rehabilitation. In addition, a 100-percent evaluation 
under DC 7011 is assigned for an indefinite period and can remain even 
after the initial six-month mandatory reexamination, if the findings of 
the VA examination contemplated in the Note to DC 7011 warrant such a 
determination. Finally, VA confirms that it is appropriate to not apply 
the provisions of Sec.  4.29 in cases where the veteran is currently 
receiving a temporary total rating for a disability for which 
hospitalization was required. Therefore, inpatient cardiac 
rehabilitation that occurs at any point during the indefinite 
assignment of a 100-percent rating under this DC cannot also qualify 
for benefits under the provisions of Sec.  4.29, which provide a 
temporary total disability rating for a service-connected disability 
requiring hospital treatment in a VA or VA-approved hospital for a 
period in excess of 21 days. Therefore, VA makes no changes based on 
this comment. VA does, however, take this opportunity to clarify that 
the hospitalization referenced in DC 7011 is intended to only apply to 
inpatient cardiac hospitalization.
    DC 7015, Atrioventricular Block:
    One commenter asked if a block can be reclassified between benign 
or non-benign. The commenter mischaracterizes how an evaluation changes 
from benign to non-benign, so VA would like to clarify how a veteran 
receives an evaluation for an atrioventricular block and how that 
evaluation changes. An evaluation occurs whenever a veteran submits an 
electrocardiogram (ECG) with either benign or non-benign 
atrioventricular block findings. Instead of re-classification, it is 
during a follow-up examination when the ECG conversion to a non-benign 
atrioventricular block is identified. It is the submission of that 
second (non-benign) ECG that changes the evaluation from VA raters. VA 
makes no changes based on this comment.
    DC 7019, Cardiac Transplantation:
    One commenter sought clarification about the one-year time periods 
for rating and the mandatory evaluation. The commenter went on further 
to assert it did not make sense for VA to stipulate that the 100 
percent evaluation under this DC only last for one year starting from 
the hospital admission but mandate reexamination one year after 
discharge. VA reiterates that it proposed to replace the phrase ``for 
an indefinite period'' concerning the length of the 100 percent 
evaluation with the phrase ``for a minimum of one year.'' This means 
that the 100 percent evaluation can exceed one year depending on the 
circumstances of the case, including the date of discharge as well as 
the date of the reexamination. VA makes no changes based on this 
comment.
    DC 7110, Aortic Aneurysm:
    Two commenters provided input for this DC. One commenter felt the 
evaluation criteria were confusing, particularly the criteria for the 
zero-percent evaluation. The other commenter asked if veterans 
previously receiving a 60-percent evaluation with an aortic aneurysm 
that precluded exertion would be evaluated under the proposed 100-
percent evaluation.
    First, VA clarifies that a veteran previously receiving a 60-
percent evaluation with an aortic aneurysm that precluded exertion will 
now be entitled to a 100-percent evaluation. Second, VA originally 
proposed to provide a 100-percent evaluation under this DC when the 
aneurysm size is five centimeters or larger or when the aneurysm is 
symptomatic (e.g., precludes exertion) and surgical correction was 
recommended. A zero-percent evaluation would have been assignable if 
surgery was not recommended and the aneurysm was smaller than five 
centimeters. Based on the comment, and to provide additional clarity, 
VA revises the evaluation criteria to specify that a 100-percent 
evaluation applies when (1) the aneurysm is five centimeters or larger 
in diameter; (2) the aneurysm is symptomatic; or (3) surgical 
correction is required. The current note addressing the circumstances 
triggering mandatory VA examination will be edited for clarity and will 
indicate that the 100-percent evaluation period begins on the date the 
physician recommends surgical correction, as described in the proposed 
rule.
    DC 7120, Varicose Veins:
    One commenter noted the proposed criteria under DC 7120 states 
``evaluate under diagnostic code 7121;'' however, DC 7121 was not 
listed in the proposed rating schedule. VA thanks the commenter for 
this comment. DC 7121 was not listed in the proposed rule because there 
is no change to the criteria that currently exists under that DC.
    Technical Corrections:
    Several technical corrections were made for ease of reading or 
parity in rating schedule language to the following DCs: 7009, 7010, 
7011, 7110, and 7124. These corrections were minor and non-substantive 
in nature and did not change the meaning or substance of the criteria 
or notes.

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. 
The Office of Information and Regulatory Affairs has determined that 
this rule is a significant regulatory action under Executive Order 
12866.
    The Regulatory Impact Analysis associated with this rulemaking can 
be found as a supporting document at www.regulations.gov.

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). The certification is based on the fact that no small entities or 
businesses assign evaluations for disability claims. Therefore, 
pursuant to 5 U.S.C. 605(b), the initial and final regulatory 
flexibility analysis requirements of 5 U.S.C. 603 and 604 do not apply.

[[Page 54093]]

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 year. This final rule would have no such effect on 
State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

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

Catalog of Federal Domestic Assistance

    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.

Congressional Review Act

    Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), 
the Office of Information and Regulatory Affairs designated this rule 
as not a major rule, as defined by 5 U.S.C. 804(2).

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved this 
document on June 23, 2021, 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.

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 amends 38 CFR part 4 as 
follows:

PART 4--SCHEDULE FOR RATING DISABILITIES

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

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

Subpart B--Disability Ratings

0
2. Amend Sec.  4.100 by revising paragraph (b) and adding an authority 
at the end of the section 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 introductory text under the heading ``Diseases of the 
Heart'';
0
b. Revising notes 1 and 2;
0
c. Adding note 3;
0
d. Adding an entry for ``General Rating Formula for Diseases of the 
Heart'' after note 3;
0
e. Revising the entries for DCs 7000, 7001, 7002, 7003, 7004, 7005, 
7006, 7007, and 7008;
0
f. Adding an entry for DC 7009;
0
g. Revising the entries for DCs 7010, 7011, 7015, 7016, 7017, 7018, 
7019, 7020, 7110, 7111, 7113, 7114, 7115, 7117, 7120, and 7122; and
0
h. Adding DC 7124.
    The revisions and additions read as follows:


Sec.  4.104  Schedule of ratings--cardiovascular system.

                          Diseases of the Heart
 [Unless otherwise directed, use this general rating formula to evaluate
                         diseases of the heart.]
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
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..........

[[Page 54094]]

 
    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 that
 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
 bradyarrhythmia: 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 only. It is not a disability subject
 to compensation.
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; or, confirmed by ECG with
     either continuous use of oral medications to
     control or use of vagal maneuvers to control.......
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 inpatient              100
     hospital admission for initial medical therapy for
     a sustained ventricular arrhythmia; or, for an
     indefinite period from the date of inpatient
     hospital admission for ventricular aneurysmectomy;
     or, with an automatic implantable cardioverter-
     defibrillator (AICD) in place......................
Note: When inpatient hospitalization for sustained
 ventricular arrhythmia or ventricular aneurysmectomy is
 required, a 100-percent evaluation begins on the date
 of hospital admission with a mandatory VA examination
 six months following hospital discharge. Evaluate post-
 surgical residuals under 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.
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: 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:
    Evaluate at 100 percent if the aneurysm is any one               100
     of the following: Five centimeters or larger in
     diameter; symptomatic (e.g., precludes exertion);
     or requires surgery................................
    Otherwise...........................................               0
    Evaluate non-cardiovascular residuals of surgical
     correction according to organ systems affected.

[[Page 54095]]

 
Note: When surgery is required, a 100-percent evaluation
 begins on the date a physician recommends surgical
 correction with a mandatory VA examination six months
 following hospital discharge. Evaluate post-surgical
 residuals under the General Rating Formula. 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):
    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), see DC 7124.
 
                              * * * * * * *
7120 Varicose veins:
    Evaluate under diagnostic code 7121.
 

[[Page 54096]]

 
                              * * * * * * *
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):
    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). For evaluation of
 Raynaud's syndrome (also known as secondary Raynaud's
 phenomenon, or secondary Raynaud's), see DC 7117.
------------------------------------------------------------------------

* * * * *

0
4. Amend appendix A to part 4 under 4.104 by:
0
a. Adding an entry for ``General Rating Formula for Diseases of the 
Heart'' above the entry for diagnostic code 7000;
0
b. Revising the entries for DCs 7000 through 7008;
0
c. Adding in numerical order an entry for DC 7009;
0
d. Revising the entries for DCs 7010, 7011, 7015 through 7020, 7110, 
7111, 7113 through 7115, 7117, 7120, and 7122; and
0
e. Adding in numerical order an entry for DC 7124.
    The additions and revisions read as follows:

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 November
                                        14, 2021.
                                 7000  Evaluation July 6, 1950;
                                        evaluation September 22, 1978,
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7001  Evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7002  Evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7003  Evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7004  Criterion September 22, 1978;
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7005  Evaluation September 9, 1975;
                                        evaluation September 22, 1978;
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7006  Evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7007  Evaluation September 22, 1978;
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7008  Evaluation January 12, 1998;
                                        criterion December 10, 2017;
                                        evaluation November 14, 2021.
                                 7009  Added November 14, 2021.
                                 7010  Evaluation January 12, 1998;
                                        title, criterion November 14,
                                        2021.
                                 7011  Evaluation January 12, 1998;
                                        note, criterion November 14,
                                        2021.
 
                              * * * * * * *
                                 7015  Evaluation September 9, 1975;
                                        criterion January 12, 1998;
                                        criterion November 14, 2021.
                                 7016  Added September 9, 1975;
                                        criterion January 12, 1998;
                                        note, criterion November 14,
                                        2021.
                                 7017  Added September 22, 1978;
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.

[[Page 54097]]

 
                                 7018  Added January 12, 1998; criterion
                                        November 14, 2021.
                                 7019  Added January 12, 1998; note,
                                        criterion November 14, 2021.
                                 7020  Added January 12, 1998; criterion
                                        November 14, 2021.
 
                              * * * * * * *
                                 7110  Evaluation September 9, 1975;
                                        evaluation January 12, 1998;
                                        title, criterion, note November
                                        14, 2021.
                                 7111  Criterion September 9, 1975;
                                        evaluation January 12, 1998;
                                        note, criterion November 14,
                                        2021.
 
                              * * * * * * *
                                 7113  Evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7114  Added June 9, 1952; evaluation
                                        January 12, 1998; title,
                                        criterion, note November 14,
                                        2021.
                                 7115  Added June 9, 1952; evaluation
                                        January 12, 1998; note,
                                        criterion, evaluation November
                                        14, 2021.
 
                              * * * * * * *
                                 7117  Added June 9, 1952; evaluation
                                        January 12, 1998; title, note
                                        November 14, 2021.
 
                              * * * * * * *
                                 7120  Note following July 6, 1950;
                                        evaluation January 12, 1998;
                                        criterion November 14, 2021.
                                 7122  Last sentence of Note following
                                        July 6, 1950; evaluation January
                                        12, 1998; criterion August 13,
                                        1998; criterion November 14,
                                        2021.
 
                              * * * * * * *
                                 7124  Added November 14, 2021.
 
                              * * * * * * *
------------------------------------------------------------------------


0
5. Amend appendix B to part 4 at ``The Cardiovascular System'' 
section'':
0
a. Under the heading ``Diseases of the Heart--
0
i. By adding in numerical order an entry for diagnostic code 7009; and
0
ii. By revising the entry for diagnostic code 7010;
0
b. Under the heading ``Diseases of the Arteries and Veins''--
0
i. By revising diagnostic codes 7110, 7114, and 7117; and
0
ii. By adding in numerical order an entry for diagnostic code 7124.
    The additions and revisions 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.
7010.........................  Supraventricular tachycardia.
 
                              * * * * * * *
------------------------------------------------------------------------
                   Diseases of the Arteries and Veins
------------------------------------------------------------------------
 
                              * * * * * * *
7110.........................  Aortic aneurysm: ascending, thoracic,
                                abdominal.
 
                              * * * * * * *
7114.........................  Peripheral arterial disease.
 
                              * * * * * * *
7117.........................  Raynaud's syndrome (secondary Raynaud's
                                phenomenon, secondary Raynaud's).
 
                              * * * * * * *
7124.........................  Raynaud's disease (primary Raynaud's).
 
                              * * * * * * *
------------------------------------------------------------------------


0
6. Amend appendix C to part 4 by:
0
a. Revising the entry for ``Aneurysm'';
0
b. Removing the entries for ``Arrhythmia'' (with its sub-entries 
``Supraventricular'' and ``Ventricular'') and ``Arteriosclerosis 
obliterans'';

[[Page 54098]]

0
c. Adding in alphabetical order entries for ``Bradycardia 
(Bradyarrhthmia), symptomatic, requiring permanent pacemaker 
implantation'', ``Peripheral arterial disease'', and ``Raynaud's 
disease (primary Raynaud's)'';
0
d. Revising the entry for Raynaud's syndrome''; and
0
e. Adding entries for ``Supraventricular tachycardia'' and 
``Ventricular arrhythmia''.
    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
 
                              * * * * * * *
Bradycardia (Bradyarrhythmia), symptomatic, requiring               7009
 permanent pacemaker implantation.......................
 
                              * * * * * * *
Peripheral arterial disease.............................            7114
 
                              * * * * * * *
Raynaud's disease (primary Raynaud's)...................            7124
Raynaud's syndrome (secondary Raynaud's phenomenon,                 7117
 secondary Raynaud's)...................................
 
                              * * * * * * *
Supraventricular tachycardia............................            7010
 
                              * * * * * * *
Ventricular arrhythmia..................................            7011
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2021-19998 Filed 9-29-21; 8:45 am]
BILLING CODE 8320-01-P