[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