Schedule for Rating Disabilities; Gynecological Conditions and Disorders of the Breast, 10637-10644 [2015-03851]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 80, Number 39 (Friday, February 27, 2015)]
[Proposed Rules]
[Pages 10637-10644]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2015-03851]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP13


Schedule for Rating Disabilities; Gynecological Conditions and 
Disorders of the Breast

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
portion of the VA Schedule for Rating Disabilities (VASRD or rating 
schedule) that addresses gynecological conditions and disorders of the 
breast. The purpose of these changes is to incorporate medical advances 
that have occurred since the last review, update current medical 
terminology, and provide clear evaluation criteria. The proposed rule 
reflects advances in medical knowledge, recommendations from the 
Gynecological Conditions and Disorders of the Breast Work Group (Work 
Group), which is comprised of subject matter experts from both the 
Veterans Benefits Administration (VBA) and the Veterans Health 
Administration (VHA), and comments from experts and the public gathered 
as part of a public forum. The public forum, focusing on revisions to 
the gynecological conditions and disorders of the breast section of the 
VASRD, was held on January 24, 2012.

[[Page 10638]]


DATES: Comments must be received on or before April 28, 2015.

ADDRESSES: Written comments may be submitted through 
www.Regulations.gov; by mail or hand-delivery to Director, Regulation 
Policy and Management (02REG), Department of Veterans Affairs, 810 
Vermont Avenue NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to ``RIN 2900-AP13--Schedule for Rating Disabilities; Gynecological 
Conditions and Disorders of the Breast.'' Copies of comments received 
will be available for public inspection in the Office of Regulation 
Policy and Management, Room 1068, between the hours of 8:00 a.m. and 
4:30 p.m., Monday through Friday (except holidays). Please call (202) 
461-4902 for an appointment. (This is not a toll-free number.) In 
addition, during the comment period, comments may be viewed online 
through the Federal Docket Management System (FDMS) at 
www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, Medical Officer, 
Part 4 VASRD Regulations Staff (211C), Compensation Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Avenue NW., Washington, DC 20420, (202) 461-9700. (This is not a toll-
free telephone number.)

SUPPLEMENTARY INFORMATION: As part of VA's ongoing revision of the VA 
Schedule for Rating Disabilities (VASRD or rating schedule), VA 
proposes changes to 38 CFR 4.116, which pertains to gynecological 
conditions and disorders of the breast. The proposed changes will: (1) 
Update the medical terminology of certain gynecological conditions and 
disorders of the breast, (2) add medical conditions not currently in 
the rating schedule, and (3) refine evaluation criteria based on 
medical advances that have occurred since the last revision and current 
understanding of functional changes associated with or resulting from 
disease or injury (pathophysiology).

Schedule of Ratings--Gynecological Conditions and Disorders of the 
Breast

    Section 4.116 currently lists 19 diagnostic codes encompassing 
conditions involving injury or disease of female reproductive organs 
and of the breast. VA proposes to revise these codes, through addition, 
removal, or other revisions, to reflect current medical science and 
terminology, and functional impairment.

Diagnostic Code 7610 ``Vulva, disease or injury of (including 
vulvovaginitis)''

    Current diagnostic code 7610 addresses impairments associated with 
disease or injury of the vulva. The vulva refers to the exterior 
anatomical portion of the female genitalia and includes the clitoris. 
``Vulva,'' Mayo Clinic, https://www.mayoclinic.org/vulva/img-20005974 
(last visited June 20, 2014). To provide clarity as to the 
applicability of this diagnostic code and to promote consistent and 
adequate evaluations, VA proposes to update the title of this 
diagnostic code to specifically include injury or disease of the 
clitoris, in addition to the vulva.

Diagnostic Code 7615 ``Ovary, disease, injury, or adhesions of''

    Current diagnostic code 7615 addresses impairments associated with 
disease, injury or adhesions of the ovaries. VA proposes to place a 
note under diagnostic code 7615 to identify two common diseases 
associated with ovarian dysfunction resulting in abnormal menstrual 
cycles: Dysmenorrhea and secondary amenorrhea. Dysmenorrhea is pain 
associated with menstruation and is the most commonly reported 
menstrual disorder. ``Dysmenorrhea,'' American College of Obstetricians 
and Gynecologists (July 2012), https://www.acog.org/~/media/
For%20Patients/faq046.pdf?dmc=1&ts=20130904T1049007771 (last visited 
Jan. 21, 2014). Secondary amenorrhea occurs when a woman who has been 
having normal menstrual cycles stops menstruating for 6 or more months. 
Tarannum Master-Hunter & Diana L. Heiman, ``Amenorrhea: Evaluation and 
Treatment,'' 73 American Family Physician 1374, 1374-82 (2006). The 
proposed note will state that for the purpose of disability evaluation, 
a disease, injury, or adhesions of the ovaries resulting in ovarian 
dysfunction affecting the menstrual cycle, such as dysmenorrhea and 
secondary amenorrhea, shall be rated under diagnostic code 7615.

Diagnostic Code 7619 ``Ovary, removal of''

    Diagnostic code 7619, ``Ovary, removal of,'' addresses impairment 
associated with complete and partial removal of the ovaries. Service-
connected complete removal of both ovaries is currently evaluated at 
100 percent for the three months following removal and then 30 percent 
thereafter. With the continued expansion of women's roles in military 
service, better understanding of the health effects on women during and 
after service is essential. Women who suffer premature loss of function 
in both ovaries are at increased risk for cardiovascular disease, 
stroke, lung cancer, cognitive impairment or dementia, Parkinsonism, 
osteoporosis, depressive or anxiety symptoms, and sexual dysfunction. 
The risks appear to be greater for women who are younger at the time of 
premature loss of ovarian function. Studies have shown that even women 
who have both ovaries removed ``after the onset of natural menopause 
had an increased risk of deleterious outcomes.'' Lynne T. Shuster et 
al., ``Prophylactic bilateral oophorectomy jeopardizes long-term 
health,'' 18(4), American Society for Reproductive Medicine, Menopausal 
Medicine S1, S1-S5 (2010).
    Currently, a male Veteran is entitled to a 30 percent evaluation 
for service-connected removal of one testicle when the second testicle, 
for reasons unrelated to service, is absent or ceases to function. 38 
CFR 4.115b, Diagnostic Code 7524, Note. However, the current VASRD does 
not provide a similar evaluation for a female Veteran whose second 
ovary is absent or ceases to function for reasons unrelated to service. 
With consideration of the studies discussed above demonstrating the 
significant health risks from removal or loss of function of both 
ovaries, VA proposes to add a note to diagnostic code 7619 in order to 
equalize VA compensation for female Veterans.

Diagnostic Codes 7621 ``Uterus, prolapse,'' 7622 ``Uterus, displacement 
of,'' and 7623 ``Pregnancy, surgical complications of ''

    Current diagnostic codes 7621 through 7623 address impairment 
associated with various degrees of female pelvic organ prolapse. 
Uterine prolapse is evaluated under current diagnostic code 7621, as 
either (1) complete uterine prolapse through the vagina and introitus 
at 50 percent, or (2) incomplete uterine prolapse at 30 percent. 
Uterine displacement is evaluated under current diagnostic code 7622, 
as either (1) marked uterine displacement and frequent or continuous 
menstrual disturbances at 30 percent, or (2) uterine displacement with 
adhesions and irregular menstruation at 10 percent. Finally, surgical 
complications of pregnancy are evaluated under current diagnostic code 
7623, as either (1) with rectocele or cystocele at 50 percent, or (2) 
with relaxation of perineum at 10 percent.
    To update VASRD, VA proposes to consolidate these three diagnostic 
codes into one diagnostic code. Specifically, VA proposes to amend 
diagnostic code

[[Page 10639]]

7621 to be titled, ``Pelvic organ prolapse due to injury, disease, or 
surgical complications of pregnancy.'' VA proposes this consolidation 
because all of these diagnostic codes represent different types of 
pelvic organ prolapse (displacement) and describe various degrees of 
their displacement to or beyond the vaginal walls. Furthermore, as 
discussed in more detail below, current medicine has a reliable 
classification system that provides for uniform evaluation of 
functional impairment due to pelvic organ prolapse (displacement), 
regardless of which pelvic organ is involved. Therefore, combining the 
evaluations currently found in diagnostic codes 7621 through 7623 would 
better reflect the current understanding of anatomy, physiology, and 
functional impairment due to disease or injury of pelvic organs. VA 
also proposes to place a note under diagnostic code 7621 that will 
describe pelvic organ prolapse and identify common types of prolapse, 
including uterine or vaginal vault prolapse, cystocele, urethrocele, 
rectocele, enterocele, or any combination. This note would assist field 
personnel in selecting the appropriate diagnostic code for these 
diagnosed conditions.
    Currently, diagnostic codes 7621 and 7622 address uterine prolapse 
and uterine displacement, respectively; however, uterine displacement 
is just an outdated reference to uterine prolapse. Therefore, separate 
diagnostic codes are redundant and unnecessary. As for diagnostic code 
7623, it provides for evaluation of pelvic organ displacement such as 
rectocele, cystocele, and relaxation of perineum when due to surgical 
complications of pregnancy. However, all of these pelvic organ 
displacements can occur independently from surgical complications of 
pregnancy. Therefore, an update to VASRD is needed to account for these 
situations.
    This proposed revision is also necessary to eliminate disparate 
treatment of pelvic organ displacement found in the current VASRD. In 
this regard, rectocele or cystocele are rated under current diagnostic 
code 7623 without regard to the severity of the displacement (and, in 
turn, the symptoms associated with the displacement), whereas uterine 
prolapse and displacement (rated under diagnostic codes 7621 and 7622) 
are evaluated based on the degree of displacement.
    Pelvic organs, such as the uterus, bladder or bowel, may protrude 
into the vagina due to weakness in the tissues that normally support 
them. In the most severe cases, part or all of the uterus or vagina can 
protrude beyond the vaginal opening (introitus). Pelvic organ prolapse 
includes anterior vaginal wall prolapse (cystocele, urethrocele), 
posterior vaginal wall prolapse (enterocele, rectocele, perineal 
deficiency) and uterine or vaginal vault prolapse. A woman can present 
with prolapse of one or more of these sites. Christopher Maher et al., 
``Surgical management of pelvic organ prolapse in women,'' Cochrane 
Database of Systematic Reviews (2010), https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004014.pub4/abstract (last accessed Jan. 21, 
2014). A woman's symptoms are largely based on the severity of her 
prolapse. Women with mild cases of uterine prolapse may have no obvious 
symptoms or require no active intervention. However, as the uterus 
slips further out of normal position, it can place pressure on other 
pelvic organs (such as the bladder or bowel) causing a variety of 
symptoms such as a feeling of heaviness or pressure in the pelvis, 
pelvic pain, abdomen or lower back pain, pain during intercourse, a 
protrusion of tissue from the opening of the vagina, recurrent bladder 
infections, constipation, difficulty with urination or urinary 
frequency or urgency. G. Willy Davila et al., ``Vaginal Vault 
Suspension'' (updated Sept. 6, 2013), Medscape, https://emedicine.medscape.com/article/1848619-overview#aw2aab6b9 (last 
accessed Jan. 21, 2014). Therefore, it is essential to identify the 
severity of any pelvic organ prolapse in order to determine the level 
of functional impairment.
    To ensure consistent evaluation of pelvic organ prolapse, VA 
proposes to base its rating criteria on the pelvic organ prolapse (POP) 
classification system. POP presents the herniation of the pelvic organs 
to or beyond the vaginal opening (at the level of the hymen) and is 
described using the findings during pelvic examination. ``Pelvic Organ 
Prolapse,'' American College of Obstetricians and Gynecologists 
Practice Bulletin, Vol. 110, No. 3 (Sept. 2007). The severity of 
prolapse is graded using the standard Pelvic Organ Prolapse 
Quantification (POP-Q) classification system. The POP-Q examination is 
an objective, site-specific system that is used to quantify, describe, 
and stage pelvic support. The POP-Q system has proven interobserver and 
intraobserver reliability. A.F. Hall et al., ``Interobserver and 
intraobserver reliability of the proposed International Continence 
Society, Society of Gynecologic Surgeons, and American Urogynecologic 
Society pelvic organ prolapse classification system,'' 175 Am J Obstet 
Gynecol 1467, 1467-70 (1996).
    As for the functional impairment associated with each stage of 
severity, VA proposes to assign a 50 percent evaluation in cases of 
severe pelvic organ prolapse, where on examination complete or almost 
complete eversion of the total length of the vagina is present, and the 
length of the protrusion beyond the hymen is within 2 centimeters of 
the total vaginal length. VA proposes to assign a 30 percent evaluation 
in cases of moderate prolapse, where on examination, the most severe 
portion of the prolapse is more than 1 centimeter below the hymen, but 
no further than 2 cm less than the total vaginal length. Finally, VA 
proposes to assign a 10 percent evaluation in cases of mild prolapse, 
where on examination, the most severe portion of the prolapse is 
between 1 cm or less above and 1 cm or more below the hymen.
    VA also proposes to eliminate references to frequent or continuous 
menstrual disturbances, adhesions, and irregular menstruation as a 
measure of the degree of uterine displacement, because the symptoms 
noted are either outdated or adequately contemplated by the POP-Q 
system. For example, uterine displacement, also known as uterine 
prolapse, occurs when pelvic floor muscles and ligaments stretch and 
weaken and the uterus slips down into or protrudes out of the vagina. 
Minimal uterine prolapse generally does not require therapy or cause 
any impairment because the patient usually does not have any symptoms. 
However, uterine descent of the cervix at or through the vaginal 
opening (introitus) can become symptomatic. Symptoms of moderate and 
severe uterine prolapse include a sensation of vaginal fullness or 
pressure, back pain, vaginal spotting from ulceration of the protruding 
cervix or vagina, difficulty with sexual intercourse, lower abdominal 
discomfort, and voiding and difficulties with defecation. Typically, 
the patient feels a bulge in the lower vagina or the cervix protruding 
through the vaginal opening. Cystoceles, rectoceles, or enteroceles may 
cause symptoms commonly associated with pelvic organ prolapse and lead 
to patient complaints of difficulty with voiding or bowel movements, 
recurrent urinary infections, and/or ``splinting'' (manually supporting 
the perineum) to defecate. Cespedes RD, Cross CA, McGuire EJ., ``Pelvic 
Prolapse: Diagnosing and Treating Uterine and Vaginal Vault Prolapse,'' 
1(3) MedGenMed (1999). Menstrual abnormalities may occur in women with 
or without pelvic organ

[[Page 10640]]

prolapse, but there is usually no causal relationship or association. 
Therefore, the references to menstrual disturbances, irregular 
menstruation and adhesions as symptoms of uterine prolapse 
(displacement) should be removed, because they do not reflect current 
medical science and practice.
    Finally, and as a consequence of this proposed consolidation, VA 
also proposes to delete current diagnostic codes 7622 ``Uterus, 
displacement of'' and 7623 ``Pregnancy, surgical complications of'' as 
the evaluation criteria are now contained in the proposed diagnostic 
code 7621.

Diagnostic Codes 7627 ``Malignant neoplasms of gynecological system or 
breast'' and 7628 ``Benign neoplasms of the gynecological system or 
breast''

    Current diagnostic codes 7627 and 7628 address impairment 
associated with malignant and benign neoplasms of the gynecological 
system and the breast. VA proposes to restructure the current rating 
criteria by separating the evaluations for impairments due to 
gynecological neoplasms from the evaluations for impairments due to 
breast neoplasms. This proposed separation keeps disability 
compensation data related to male breast cancer and non-cancerous 
tumors separate from disability compensation data related to 
gynecological neoplasms and also provides ease of use for disability 
rating specialists. Men possess a small amount of nonfunctioning breast 
tissue (breast tissue that cannot produce milk) that is concentrated in 
the area directly behind the nipple on the chest wall. Like breast 
cancer in women, cancer of the male breast is the uncontrolled growth 
of the abnormal cells of this breast tissue. Male breast cancer 
constitutes about 1 percent of all cases of breast cancers. ``Male 
Breast Cancer,'' National Cancer Institute--National Institutes of 
Health (Updated Sept. 19, 2013), https://www.cancer.gov/cancertopics/pdq/treatment/malebreast/Patient/page1 (last accessed Jan. 21, 2014).
    Therefore, VA proposes to retitle diagnostic code 7627 as, 
``Malignant neoplasms of gynecological system'' and diagnostic code 
7628 as, ``Benign neoplasms of gynecological system.'' Additionally, 
under diagnostic codes 7627 and 7628, VA proposes to clarify the 
existing note which instructs rating specialists to rate chronic 
residuals (following surgery or other treatments). Specifically, VA 
proposes to identify those chronic residuals commonly associated with 
treatment for neoplasms of the gynecological system, to include 
impairment of function due to scars, lymphedema, or disfigurement, as 
well as to direct rating specialists to evaluate any other residual 
impairment of function, including gynecological, under appropriate 
diagnostic code(s) within the appropriate body system. The surgical 
management of gynecologic malignancies and benign diseases has evolved 
over the last decades. However, these sometimes complex procedures 
encompass radical pelvic and upper abdominal surgery, including 
associated urologic and intestinal procedures that may be required to 
remove the neoplasm. Oliver Zivanovic & Dennis Chi, ``Surgical 
Resection and Reconstruction for Advanced and Recurrent Gynecologic 
Malignancies,'' 3 Expert Rev. of Obstetrics & Gynecology 677, 677-690 
(2008). Additionally, VA proposes a minor editorial revision of 
replacing the word ``X-ray'' with the word ``radiation'' as it pertains 
to therapeutic procedure to reflect a change in medical terminology.
    Within this reorganization, VA also proposes to add two new 
diagnostic codes, 7630 ``Malignant neoplasms of the breast'' and 7631 
``Benign neoplasms of the breast and other injuries of the breast'' in 
order to account for impairment due to benign and malignant breast 
tumors (neoplasms) as well as other injuries to the breast not included 
elsewhere in the VASRD. This addition would allow VA to adequately 
evaluate and track disabilities due to benign breast neoplasms as well 
as other injuries, such as blast trauma. VA proposes to place two notes 
under diagnostic codes 7630 and 7631 to identify common chronic 
residuals associated with injuries of the breast and benign and 
malignant breast tumors and to instruct rating specialists to rate 
accordingly. Breast surgery is the most common choice of treatment for 
benign and malignant tumors of the breast and is an established risk 
factor for development of scars, lymphedema, or disfigurement. These 
chronic post-treatment residuals result in functional impairment such 
as limitation of arm, shoulder, and wrist motion, or loss of grip 
strength, or loss of sensation, or residuals from harvesting of muscles 
for reconstructive purposes. Angelique F. Vitug & Lisa A. Newman, 
``Complications in Breast Surgery,'' 87 Surgical Clinics of North 
America 431, 431-451 (2007).
    The proposed notes will therefore instruct rating specialists to 
rate chronic residuals according to impairment of function due to 
scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, 
and wrist motion, or loss of grip strength, or loss of sensation, or 
residuals from harvesting of muscles for reconstructive purposes), and/
or under diagnostic code 7626, if appropriate. Again, no change to the 
existing evaluation criteria (found in current diagnostic codes 7627 
and 7628) is proposed.

New Diagnostic Code 7632 ``Female sexual arousal disorder (FSAD)''

    VA proposes to add a new diagnostic code 7632, titled ``Female 
sexual arousal disorder (FSAD),'' in order to account for impairment 
due to this condition in the female Veteran population. FSAD refers to 
the continual or recurrent inability of a woman to accomplish or 
maintain an ample lubrication-swelling reaction during sexual 
intercourse. This lack of physical response may be either lifelong or 
acquired, and either generalized or situation-specific. FSAD is the 
second most common sexual health concern for women, affecting 26 
percent of adult women. Emma Hitt, ``Alprostadil Shows Efficacy in 
Female Sexual Arousal Disorder'' (May 25, 2012), Medscape, https://www.medscape.com/viewarticle/764590 (last accessed Jan. 21, 2014). 
Current statistics show that FSAD affects an estimated 30 to 45 million 
women in the United States alone. Medscape Medical News, ``Potential 
Drug Therapy for Female Sexual Dysfunction Presented'' (June 28, 2000), 
Medscape, https://www.medscape.com/viewarticle/411930 (last accessed 
Jan. 21, 2014). Clinical research shows that some aspects of FSAD are 
likely caused in part by decreased blood flow to the genital area. 
Therefore, poor genital blood flow is believed to contribute to FSAD 
similar to the role of vascular disease in male erectile dysfunction. 
Medscape Medical News, ``New Approaches to Female Sexual Arousal 
Disorder'' (May 31, 2001), Medscape, https://www.medscape.com/viewarticle/434478 (last accessed Jan. 21, 2014). Although treatment of 
sexual dysfunction in men has been improved by currently marketed 
pharmaceuticals there are no US Food and Drug Administration (FDA) 
approved treatments for FSAD. FDA recently issued draft guidance for 
industry regarding clinical development of drug products for FSAD.
    Currently, male Veterans with service connected penile deformity 
and loss of erectile power receive a 20 percent disability evaluation 
under diagnostic code 7522 and are eligible for special monthly 
compensation. In cases where there is no penile deformity present, but 
there is service connected loss of erectile power, VA's policy is to 
evaluate male Veterans analogous to diagnostic code 7522, assigning a 0 
percent rating; Eligibility for special

[[Page 10641]]

monthly compensation due to loss of use of a creative organ (SMC-K) is 
also considered. See 38 CFR 4.20 and 4.115b, Diagnostic Code 7522.
    In order to ensure gender parity, VA proposes the creation of a new 
diagnostic code 7632 ``Female sexual arousal disorder (FSAD).'' There 
is no diagnostic code in current Sec.  4.116 which allows for analogous 
rating of female sexual arousal disorder, to include consideration of 
special monthly compensation. Under proposed diagnostic code 7632, 
female Veterans with service connected FSAD but without physical damage 
to female genitalia would be evaluated at 0 percent with a note 
directing rating personnel to consider eligibility for special monthly 
compensation (SMC-K).

Technical Amendments

    VA also proposes several technical amendments. We would add a 
citation reference to 38 U.S.C. 1155 at the end of Sec.  4.116, and we 
would update Appendix A, B, and C of part 4 to reflect the above noted 
proposed amendments.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action,'' requiring review by the Office of 
Management and Budget (OMB), unless OMB waives such review, as ``any 
regulatory action that is likely to result in a rule that may: (1) Have 
an annual effect on the economy of $100 million or more or adversely 
affect in a material way the economy, a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or State, local, or tribal governments or communities; (2) 
Create a serious inconsistency or otherwise interfere with an action 
taken or planned by another agency; (3) Materially alter the budgetary 
impact of entitlements, grants, user fees, or loan programs or the 
rights and obligations of recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in this Executive Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this proposed rule have been examined, and it has been 
determined not to be a significant regulatory action under Executive 
Order 12866. VA's impact analysis can be found as a supporting document 
at https://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of this 
rulemaking and its impact analysis are available on VA's Web site at 
https://www.va.gov/orpm/, by following the link for ``VA Regulations 
Published From FY 2004 Through Fiscal Year to Date.''

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would not affect any small entities. 
Only certain VA beneficiaries could be directly affected. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of sections 603 
and 604.

Unfunded Mandates

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

Paperwork Reduction Act

    This proposed 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 64.009, Veterans Medical Care Benefits; 
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.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Jose D. 
Riojas, Chief of Staff, Department of Veterans Affairs, approved this 
document on December 1, 2014, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Dated: February 20, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management, Office of 
the General Counsel, U.S. Department of Veterans Affairs.

    For the reasons set out in the preamble, VA proposes to amend 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.  4.116 as follows:
0
a. Revise the entry for diagnostic code 7610;
0
b. Add a note at the end of the entries for diagnostic codes 7615 and 
7619;
0
c. Revise the entry for diagnostic code 7621;
0
d. Remove the entries for diagnostic codes 7622 and 7623;
0
e. Revise the entries for diagnostic codes 7627 and 7628;
0
f. Add entries for diagnostic codes 7630 through 7632 in numerical 
order; and
0
g. Add an authority citation at the end of the section.
    The revisions and additions to read as follows:


Sec.  4.116  Schedule of ratings--gynecological conditions and 
disorders of the breast.

[[Page 10642]]



------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
 
                              * * * * * * *
7610 Vulva or clitoris, disease or injury of (including
 vulvovaginitis).
 
                              * * * * * * *
7615 * * *
    Note: For the purpose of VA disability evaluation, a
     disease, injury, or adhesions of the ovaries
     resulting in ovarian dysfunction affecting the
     menstrual cycle, such as dysmenorrhea and secondary
     amenorrhea, shall be rated under diagnostic code
     7615.
 
                              * * * * * * *
7619 * * *
    Note: In cases of the removal of one ovary as the
     result of a service-connected injury or disease,
     with the absence or nonfunctioning of a second
     ovary unrelated to service, an evaluation of 30
     percent will be assigned for the service-connected
     ovarian loss.
 
                              * * * * * * *
7621 Pelvic organ prolapse due to injury, disease, or
 surgical complications of pregnancy.
    Severe prolapse: Complete or almost complete                      50
     eversion of the total length of the vagina shown on
     examination, with the length of the protrusion (or
     prolapse) extending beyond the hymen within 2 cm of
     total vaginal length...............................
    Moderate prolapse: On examination the most severe                 30
     portion of the prolapse is more than 1 cm below the
     hymen, but protrudes no further than 2 cm less than
     the total vaginal length...........................
    Mild prolapse: On examination the most severe                     10
     portion of the prolapse is between 1 cm or less
     above the hymen and 1 cm or more below the hymen...
    Note: Pelvic organ prolapse occurs when a pelvic
     organ such as bladder, urethra, uterus, vagina,
     small bowel, or rectum drops (prolapse) from its
     normal place in the abdomen. Conditions associated
     with pelvic organ prolapse include: Uterine or
     vaginal vault prolapse, cystocele, urethrocele,
     rectocele, enterocele, or any combination thereof.
 
                              * * * * * * *
7627 Malignant neoplasms of gynecological system........             100
    Note: A rating of 100 percent shall continue beyond
     the cessation of any surgical, radiation,
     antineoplastic chemotherapy or other therapeutic
     procedures. Six months after discontinuance of such
     treatment, the appropriate disability rating shall
     be determined 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. Rate
     chronic residuals to include scars, lymphedema,
     disfigurement, and/or other impairment of function
     under the appropriate diagnostic code(s) within the
     appropriate body system.
7628 Benign neoplasms of gynecological system. Rate
 chronic residuals to include scars, lymphedema,
 disfigurement, and/or other impairment of function
 under the appropriate diagnostic code(s) within the
 appropriate body system.
 
                              * * * * * * *
7630 Malignant neoplasms of the breast..................             100
    Note: A rating of 100 percent shall continue beyond
     the cessation of any surgical, radiation,
     antineoplastic chemotherapy or other therapeutic
     procedure. Six months after discontinuance of such
     treatment, the appropriate disability rating shall
     be determined 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. Rate
     chronic residuals according to impairment of
     function due to scars, lymphedema, or disfigurement
     (e.g., limitation of arm, shoulder, and wrist
     motion, or loss of grip strength, or loss of
     sensation, or residuals from harvesting of muscles
     for reconstructive purposes), and/or under
     diagnostic code 7626.
7631 Benign neoplasms of the breast and other injuries
 of the breast. Rate chronic residuals according to
 impairment of function due to scars, lymphedema, or
 disfigurement (e.g., limitation of arm, shoulder, and
 wrist motion, or loss of grip strength, or loss of
 sensation, or residuals from harvesting of muscles for
 reconstructive purposes), and/or under diagnostic code
 7626.
7632 Female sexual arousal disorder (FSAD)..............           \1\ 0
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation under Sec.
  3.350 of this chapter.

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

0
3. Amend Appendix A to Part 4 as follows:
0
a. At Sec. 4.116, revise the entries for diagnostic codes 7610, 7615, 
7619, 7621, 7622, 7623, 7627, and 7628; and
0
b. At Sec. 4.116, add entries for diagnostic codes 7630 through 7632 in 
numerical order.
    The revisions and additions to read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 
1946

----------------------------------------------------------------------------------------------------------------
                                       Diagnostic
                Sec.                    code No.
----------------------------------------------------------------------------------------------------------------
 
                                                  * * * * * * *
4.116.
 
                                                  * * * * * * *
                                               7610  Criterion May 22, 1995; title [effective date of final
                                                      rule].

[[Page 10643]]

 
 
                                                  * * * * * * *
                                               7615  Criterion May 22, 1995; note [effective date of final
                                                      rule].
 
                                                  * * * * * * *
                                               7619  Criterion May 22, 1995; note [effective date of final
                                                      rule].
 
                                                  * * * * * * *
                                               7621  Criterion May 22, 1995; evaluation [effective date of final
                                                      rule].
                                               7622  Removed [effective date of final rule].
                                               7623  Removed [effective date of final rule].
 
                                                  * * * * * * *
                                               7627  Criterion March 10, 1976; criterion May 22, 1995; title,
                                                      note [effective date of final rule].
                                               7628  Added May 22, 1995; title, criterion [effective date of
                                                      final rule].
 
                                                  * * * * * * *
                                               7630  Added [effective date of final rule].
                                               7631  Added [effective date of final rule].
                                               7632  Added [effective date of final rule].
 
                                                  * * * * * * *
----------------------------------------------------------------------------------------------------------------

0
4. Amend Appendix B to Part 4 as follows:
0
a. Revise the entries for diagnostic codes 7610, 7621, 7627, and 7628; 
and
0
b. Add entries for diagnostic codes 7630 through 7632 in numerical 
order.
    The revisions and additions to read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
  Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
          Gynecological Conditions and Disorders of the Breast
------------------------------------------------------------------------
7610...................  Vulva or clitoris, disease or injury of
                          (including vulvovaginitis).
 
                              * * * * * * *
7621...................  Pelvic organ prolapse due to injury or disease
                          or surgical complications of pregnancy.
 
                              * * * * * * *
7627...................  Malignant neoplasms of gynecological system.
7628...................  Benign neoplasms of gynecological system.
 
                              * * * * * * *
7630...................  Malignant neoplasms of the breast.
7631...................  Benign neoplasms of the breast and other
                          injuries of the breast.
7632...................  Female sexual arousal disorder (FSAD).
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Amend Appendix C to Part 4 as follows:
0
a. Add in alphabetical order the heading ``Female sexual arousal 
disorder (FSAD)'' and its diagnostic code ``7632''.
0
b. Under the heading ``Injury'' add in alphabetical order new entry 
``Breast'' and its diagnostic code ``7631''.
0
c. Under the heading ``Neoplasms: Benign:'' add in alphabetical order 
an entry ``Breast'' and its diagnostic code ``7631''.
0
d. Under the heading ``Neoplasms: Benign:'' remove ``Gynecological or 
breast'' and in its place add the entry ``Gynecological''.
0
e. Under the heading ``Neoplasms: Malignant:'' add in alphabetical 
order new entry ``Breast'' and its diagnostic code ``7630''.
0
f. Under the heading ``Neoplasms: Malignant:'' remove ``Gynecological 
or breast'' and in its place add the entry ``Gynecological''.
0
g. Add in alphabetical order the heading ``Pelvic organ prolapse due to 
injury or disease or surgical complications of pregnancy, including 
uterine or vaginal vault prolapse, cystocele, urethrocele, rectocele, 
enterocele, or combination'' and its diagnostic code ``7621''.
0
h. Remove the heading ``Pregnancy, surgical complications'' and its 
diagnostic code ``7623''.

[[Page 10644]]

0
i. Under the heading ``Uterus'' remove the entry ``Displacement'' and 
its diagnostic code ``7622''.
0
j. Remove the heading ``Vulva disease or injury of'' and add in its 
place ``Vulva or clitoris, disease or injury of''.
    The additions and revisions to read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Female sexual arousal disorder (FSAD)...................            7632
 
                              * * * * * * *
Injury:
 
                              * * * * * * *
    Breast..............................................            7631
 
                              * * * * * * *
Neoplasms:
    Benign:
        Breast..........................................            7631
 
                              * * * * * * *
        Gynecological...................................            7628
 
                              * * * * * * *
    Malignant:
        Breast..........................................            7630
 
                              * * * * * * *
        Gynecological...................................            7627
 
                              * * * * * * *
Pelvic organ prolapse due to injury or disease or                   7621
 surgical complications of pregnancy, including uterine
 or vaginal vault prolapse, cystocele, urethrocele,
 rectocele, enterocele, or combination..................
 
                              * * * * * * *
Vulva or clitoris, disease or injury of.................            7610
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2015-03851 Filed 2-26-15; 8:45 am]
BILLING CODE 8320-01-P