Schedule for Rating Disabilities; The Organs of Special Sense and Schedule of Ratings-Eye, 32513-32522 [2015-13788]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 80, Number 110 (Tuesday, June 9, 2015)]
[Proposed Rules]
[Pages 32513-32522]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-13788]



[[Page 32513]]

=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP14


Schedule for Rating Disabilities; The Organs of Special Sense and 
Schedule of Ratings--Eye

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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

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 the organs of special sense and schedule of 
ratings--eye. 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 National Academy of Sciences (NAS), and comments from subject 
matter experts and the public garnered as part of a public forum. The 
public forum, focusing on revisions to the organs of special sense and 
schedule of ratings for eye disabilities, was held on January 19-20, 
2012.

DATES: Comments must be received on or before August 10, 2015.

ADDRESSES: Written comments may be submitted through 
www.Regulations.gov; by mail or hand-delivery to Director, Office of 
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-AP14-Schedule for Rating Disabilities; The 
Organs of Special Sense and Schedule of Ratings--Eye.'' 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: Nick Olmos-Lau, M.D., Medical Officer, 
Part 4 VASRD 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 4.77-4.79, which pertain to the organs of 
special sense and disabilities and disease of the eye. The proposed 
changes will: (1) Update the medical terminology of certain eye 
conditions; (2) add medical conditions frequently encountered but not 
currently found 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).

I. Sec.  4.77 Visual Fields

    Current Sec.  4.77(a) requires examiners to record the results of 
visual field testing on a standard Goldmann chart and include the 
Goldmann chart with the examination report. In order to improve the 
efficiency and timeliness of claims processing, VA proposes to 
eliminate the requirement that examiners provide VA with the Goldmann 
chart and instead only require the visual field measurements necessary 
for rating purposes.
    An examination of visual fields requires an examiner to indicate 
the Veteran's maximum visual field at 16 prescribed points of 
measurement. Under the current regulation, if the results of an 
examination do not include the Goldmann chart used for visual field 
testing, it must be returned to the examiner for inclusion of the 
completed chart prior to evaluating the disability. This results in 
unnecessary delays in claims where all relevant information to evaluate 
visual field impairment is present, but is not in the prescribed 
format. In addition to reducing delays in processing time, eliminating 
the chart requirement expands the ability to evaluate disabilities on 
the basis of private treatment records, provided they contain 
sufficient evidence to evaluate the disability. Under the proposed 
change, an examination of a visual field impairment is sufficient for 
rating purposes if it provides, at a minimum, visual field measurements 
of at least 16 meridians 22\1/2\ degrees apart for each eye and it 
indicates the Goldmann equivalent used during testing. As this 
information need not be provided in a chart format, VA proposes to 
amend in current paragraph (a) the phrase ``The examiner must chart at 
least 16 meridians . . .'' to read ``The examiner must document the 
results for at least 16 meridians . . .''.
    Similarly, VA proposes to amend the language in current paragraph 
(a) which directs an examiner to ``include the tracing of either the 
tangent screen or of the 30-degree threshold visual field . . .'' when 
additional testing is required. As above, VA proposes that the examiner 
need only ``document the results'' of the additional testing rather 
than provide the actual tracing itself.
    No other changes to Sec.  4.77 are proposed.

II. Sec.  4.78 Muscle Function

    Section 4.78(a) currently requires muscle function to be examined 
and measured using Goldmann perimeters. However, due to the increasing 
difficulty encountered by evaluation facilities in acquiring and 
repairing Goldmann perimeters, the Tangent Screen has been developed as 
an alternative method for documenting alteration of eye muscle 
function. David F. Chang, Chapter 2. Ophthalmologic Examination, 
Vaughan & Asbury's General Ophthalmology, https://accessmedicine.mhmedical.com/content.aspx?bookid=387&Sectionid=40229319 
(last visited Apr. 29, 2014). The Tangent Screen is an inexpensive 
device, commonly found in many eye clinics, and is used to test for 
diplopia due to eye muscle dysfunction. Like the Goldmann perimeter, 
the results of the Tangent Screen method are documented on a Goldmann 
chart recording sheet, which plots areas of diplopia across the major 
visual fields. Furthermore, the results of both tests are relatively 
similar. See Agnes M.F. Wong, MD, and James A. Sharpe, MD, A Comparison 
of Tangent Screen, Goldmann, and Humphrey Perimetry in the Detection 
and Localization of Occipital Lesions, Ophthalmology 1107:527-544 
(2000). In order to accommodate more modern and readily available 
methods, VA proposes to amend Sec.  4.78(a) to allow for measurement of 
muscle function using either Goldmann perimeters or Tangent Screen 
method.
    Current Sec.  4.78(a) requires examiners to plot the results of 
muscle function testing on a standard Goldmann chart and include the 
chart with the examination report. VA proposes to remove these 
requirements for the same reasons indicated in the section above 
discussing proposed changes to Sec.  4.77. Under the proposed change, 
an examination of muscle function is sufficient for rating purposes if 
it identifies the quadrant(s) and range(s) of degrees in which diplopia 
exists.
    No other changes to Sec.  4.78 are proposed.

[[Page 32514]]

III. Sec.  4.79 Schedule of Ratings--Eye

    Current Sec.  4.79 contains a General Rating Formula for Diagnostic 
Codes 6000 through 6009. This formula evaluates disease of the eye on 
the basis of incapacitating episodes or visual impairment (impairment 
of visual acuity, visual field, and/or muscle function), whichever 
provides the highest evaluation. Currently, ``incapacitating episodes'' 
is defined as a period of acute symptoms severe enough to require 
prescribed bed rest and treatment by a physician or other healthcare 
provider. This definition provides limited applicability of the rating 
formula as bed rest is no longer a uniformly valid method of treatment, 
nor is it a pertinent domain in the field of disability criteria. R.I. 
Cho & E. Savitsky, Ocular Trauma, Combat Casualty Care: Lessons Learned 
from OEF and OIF, 299 (M. Lenhart ed. 2012). Limiting the definition to 
bed rest categorically excludes periods of incapacitation due to eye 
disease requiring intensive treatment and medical management other than 
bed rest, as well as the potential for development of medical 
complications. Therefore, VA proposes to update the definition of an 
incapacitating episode to mean an episode that requires clinic visits 
for treatment for an active eye disease.
    Through its definition, VA intends to require that these visits be 
documented in the medical record by a physician or other health care 
provider and that such visits must relate to the monitoring of 
progress, administration of treatment(s), and the development of 
complications related to the underlying active eye disability. 
Incorporating documented treatment allows for consideration of 
intensive interventional care, the use of complex drugs, and the 
placement of devices when evaluating the severity of a given eye 
disability. By providing evaluations based on the duration of treatment 
for an active eye disease, the proposed criteria more accurately 
reflect occupational disruption and impairment due to eye diseases that 
do not necessarily involve measurable visual impairment. This updated 
definition of incapacitating episodes aligns with modern medical 
practice and the treatment of eye diseases, providing an alternative 
basis for evaluation of eye disabilities in the absence of visual 
impairment. VA also proposes to add a non-exhaustive list of examples 
of treatment to the definition of incapacitating episodes. This list 
would clarify the evaluation criteria to claims processors and ease 
application of the rating schedule by indicating possible treatment 
options for the various eye diseases.
    VA proposes a 60 percent evaluation for documented incapacitating 
episodes requiring 10 or more medical visits for monitoring or 
treatment of an active eye disease or complications per year. A 40 
percent evaluation is proposed for documented incapacitating episodes 
requiring at least 7 but no more than 9 medical visits for monitoring 
or treatment of an active eye disease or complications per year. A 20 
percent evaluation is proposed for documented incapacitating episodes 
requiring at least 4 but no more than 6 medical visits for monitoring 
or treatment of an active eye disease or complications per year. VA 
proposes a 10 percent evaluation for documented incapacitating episodes 
requiring 3 medical visits for monitoring or treatment of an active eye 
disease or complications per year.
    VA would add a note to Sec.  4.79 that would refer raters, when 
evaluating visual impairment due to the particular condition, to 38 CFR 
4.75-4.78 and to Sec.  4.79, diagnostic codes 6061-6090.

A. Diseases of the Eye--Organizational Headings

    The current schedule of ratings for the eye contains one general 
category for Diseases of the Eye with a limited listing of diagnoses 
and/or disabilities. This category does not organize the listed 
disabilities in a manner that represents the current scientific 
understanding of the specific anatomy of the eye, etiology of the 
disease, or the disabling effect of the disease itself. When presented 
with a diagnosis that is not listed in the rating schedule, claims 
processors must rate by analogy to a listed diagnosis.
    Section 4.27 directs claims processors to analogize these 
disabilities on the basis of disease similarity and residual disability 
to allow for easy identification of the source of each rating. However, 
it is specifically noted that ``the diagnostic terminology will be that 
of the medical examiner, with no attempt to translate the terms into 
schedule nomenclature.'' Id. In other words, the determination of 
disease type and residual disability is to be made by a medical 
professional; the claims processor should not partake in any type of 
medical determination when deciding how to rate analogously.
    In order to ease the use of analogous codes when evaluating eye 
diseases, VA proposes to organize the Diseases of the Eye into nine 
categories. These diagnostic categories organize the listed 
disabilities into medically logical sets on the basis of diagnostic 
criteria, anatomical location, and disease etiology. By grouping 
disabilities according to medical criteria, the categories would ease 
the use of analogous coding by claims processors. Additionally, the 
categories would allow VA to track the use of analogous codes with more 
specificity, providing data on the need for inclusion of new 
disabilities in future revisions to the VASRD.
    All disabilities contained in Sec.  4.79 would be evaluated under 
the General Rating Formula for Diseases of the Eye unless otherwise 
directed. The organizational categories and specific diagnostic codes 
within each category are as follows:

B. Diseases of the Uveal Tract

    The uveal tract consists of three eye structures: the iris, the 
ciliary body, and the choroid. This category of conditions includes 
infections, inflammations including Tuberculosis of the eye (DC 6010) 
and other diseases involving these three structures of the eye. This 
category would include the following diagnostic codes (DCs): DC 6000, 
choroidopathy, including uveitis, iritis, cyclitis, and choroiditis; 
and DC 6002, scleritis. VA proposes to continue evaluating both 
conditions under the General Rating Formula for Diseases of the Eye, as 
amended above.

C. Diseases of the Retina, Macula, and Vitreous

    The retina is the inner layer of the eye, containing blood vessels 
and nerve structures that connect the eye with the optic nerve and 
brain. The retina participates in light, motion, and color perception 
and image formation. The macula is the visual center of the eye and 
contains receptors that perceive light and color. Vitreous is the 
thick, transparent substance that fills the eye, providing it with 
volume and shape. This category includes the following diagnostic 
codes:
1. Diagnostic Code 6006
    Current DC 6006 addresses retinopathy or maculopathy. VA proposes 
to clarify this code as ``not otherwise specified,'' as new DCs are 
proposed to capture other specified types of retinopathy. If the 
retinopathy diagnosed is not one of the other specified diagnoses, it 
will be evaluated as DC 6006. This condition would continue to be 
evaluated under the General Rating Formula for Diseases of the Eye.
2. Diagnostic Code 6008
    VA proposes to continue evaluating this condition, detachment of 
the retina, under the General Rating Formula for Diseases of the Eye. 
VA proposes no other changes to this diagnostic code.

[[Page 32515]]

3. Diagnostic Code 6011
    Current DC 6011 instructs claims processors to evaluate retinal 
scars, atrophy, or irregularities as 10 percent disabling if such 
scars, etc., are centrally located and result in an irregular, 
duplicated, enlarged, or diminished image. Alternatively, claims 
processors may evaluate based on visual impairment. VA proposes to 
further expand this alternate rating criteria by directing claims 
processors to evaluate this condition under the General Rating Formula 
for Diseases of the Eye if this would result in a higher evaluation. In 
other words, the only change to the diagnostic code is to allow this 
condition to be evaluated on the basis of ``incapacitating episodes,'' 
in addition to visual impairment or the nature of the scar, atrophy, or 
irregularity itself.
4. New Diagnostic Code 6040
    VA proposes to add a new DC 6040, titled ``Diabetic retinopathy,'' 
in order to account for retinal impairment specifically caused by 
diabetes in the Veteran population. Visual impairment is a common 
complication of diabetes mellitus. Diabetes is the most significant 
cause of visual impairment and blindness in the United States in 
working age adults. James Orcutt et al., Eye Disease in Veterans with 
Diabetes, 27 Diabetes Care B50 (2004). Epidemiologic studies of 
diabetic retinopathy show that 15 years after the onset of diabetes, 
retinopathy appears in 97 percent of patients with type 1 diabetes, 80 
percent of type 2 diabetes treated with insulin, and 55 percent of type 
2 diabetes treated without insulin. Id. The most severe form of 
retinopathy (proliferative) was evident 15 years after the initial 
diagnosis of diabetes in 30 percent of cases with type 1 diabetes, in 
15 percent of those with type 2 diabetes treated with insulin, and in 5 
percent of those not treated with insulin. Id. Of 429,918 patients 
treated at the VA hospital with diabetes in 1998, 9.5 percent developed 
proliferative retinopathy related to diabetes. In addition, the study 
noted that diabetic veterans with lower-extremity amputations have an 
increased risk for developing diabetic retinopathy. Id. at 52.
    Currently, this condition is evaluated under DC 6006 (retinopathy 
or maculopathy) without any method of identifying those cases caused by 
diabetes. Given the significance of diabetes in the Veteran population 
and the likelihood of developing this related eye disease, VA proposes 
to add a separate diagnostic code to properly track and evaluate the 
Veteran population with diabetic retinopathy. VA proposes to continue 
evaluating this condition under the General Rating Formula for Diseases 
of the Eye.
5. New Diagnostic Code 6042
    VA proposes to add a new DC 6042, titled ``Retinal dystrophy 
(including retinitis pigmentosa),'' in order to account for impairment 
due to this condition in the Veteran population. Retinal dystrophy is 
an important and growing group of disorders that cause blindness. 
Included within the larger group of retinal dystrophy is retinitis 
pigmentosa, perhaps the best known and most commonly recognized 
condition. While retinitis pigmentosa is hereditary, the onset of 
symptoms may be delayed until early adult years, meaning impairment may 
not manifest until well after an individual has begun his or her 
military service. In certain situations, disability compensation can be 
provided to Veterans with this condition when the symptoms first 
manifest themselves during active duty military service. To reinforce 
the potential for service-connection for these disabilities, VA 
proposes to add a specific diagnostic code for these conditions.
    In retinitis pigmentosa there is a gradual loss of the eye 
photoreceptors (rods and cones) with a deposition of pigment caused by 
involutional changes of the cells of the retinal pigment epithelium 
layer. Retinitis pigmentosa, A.D.A.M. Medical Encyclopedia, PubMed 
Health, U.S. National Library of Medicine, https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002024/ (last visited Apr. 29, 2014). This leads to 
the gradual onset of night blindness, tripping over objects in the 
visual periphery due to constricion of the peripheral visual field, 
tunnel vision, and eventually total blindness. Id. There is currently 
no known effective treatment for this condition. Id. Given the 
functional effects of this disability, VA proposes to evaluate this 
condition under the General Rating Formula for Diseases of the Eye, 
which would allow for rating based on either visual impairment or on 
incapacitating episodes.

D. Glaucoma

    Glaucoma is a group of diseases that can damage the eye's optic 
nerve and can result in loss of vision. Glaucoma, MayoClinic, https://www.mayoclinic.org/diseases-conditions/glaucoma/basics/symptoms/con-20024042 (last visited Apr. 29, 2014). The most common types of 
glaucoma are open-angle glaucoma and angle-closure glaucoma. Id.
    Angle closure glaucoma is due to a blockage of the fluid (aqueous 
humor) drainage canals, causing a rapid and dangerous increase in eye 
pressure. This is an acute emergency that can lead to permanent visual 
loss. These conditions can be primary or secondary to an injury, 
medication, inflammation, tumor, or other medical condition. Id. This 
category includes the following diagnostic codes:
1. Diagnostic Code 6012
    Current DC 6012, angle-closure glaucoma, lists evaluation criteria 
based on either visual impairment or on incapacitating episodes, 
whichever results in a higher evaluation. In addition, a minimum 10 
percent evaluation is provided for the requirement of continuous 
medication. For clarity and uniformity with the remainder of Sec.  
4.79, VA proposes to include the general instruction to evaluate this 
disability under the General Rating Formula for Diseases of the Eye 
with a minimum evaluation of 10 percent when continuous medication is 
required.
2. Diagnostic Code 6013
    Current DC 6013, open-angle glaucoma, states to evaluate on the 
basis of visual impairment due to this condition. VA proposes to direct 
evaluation under the General Rating Formula for Diseases of the Eye, 
which includes evaluation on the basis of visual impairment or 
incapacitating episodes, whichever provides a higher evaluation. This 
proposal expands the evaluation criteria to provide an alternative 
measure of disability outside the realm of visual impairment for this 
disability, allowing VA to more accurately and adequately capture the 
disabling effects.
    Current DC 6013 also provides a minimum 10 percent evaluation if 
continuous medication is required for treatment. VA proposes no change 
to this minimum evaluation.

E. Ocular Neoplasms and Trauma

    This category includes current diagnostic codes for neoplasms of 
the eye (both malingnant and benign) as well as eye traumas. This 
category includes the following diagnostic codes:
1. Diagnostic Code 6007
    VA proposes to continue evaluating DC 6007, intraocular hemorrhage, 
under the General Rating Formula for Diseases of the Eye. VA proposes 
no other changes to this diagnostic code.

[[Page 32516]]

2. Diagnostic Code 6009
    Current DC 6009, unhealed eye injury, includes orbital trauma, as 
well as penetrating and non-penetrating eye injury. VA proposes to 
continue evaluating this condition under the General Rating Formula for 
Diseases of the Eye. VA also proposes to add a note stating that this 
code includes orbital trauma, as well as penetrating and non-
penetrating eye injury. This note would facilitate the identification 
and recording of significant eye injuries in one DC.
3. Diagnostic Code 6014
    Current DC 6014 evaluates malignant neoplasm of the eyeball only. 
VA proposes to replace the word ``eyeball'' with ``eye'' to conform 
with modern medical terminology. The preferred nomenclature in medicine 
for the organ of vision is the eye. While eyeball and eye are used 
interchangeably, it is customary to use the word eye when referring to 
diseases or anatomy. American Academy of Ophthalmology, Introducing 
Ophthalmology: A Primer for Office Staff, 8 (3d ed. 2013). 
Additionally, VA proposes to clarify that this diagnostic code includes 
malignant neoplasms of the orbit and adnexa. The most prevalent 
intraocular malignant neoplasms include uveal melanoma, intraocular 
lymphoma, and intraocular metastasis. These malignancies affect not 
only the eyeball, but often involve the orbit and adnexa. To ensure 
these malignancies are adequately evaluated under the VASRD, VA 
proposes to clarify that DC 6014 is not limited to neoplasms of the 
eyeball only. Malignant neoplasms of the skin are still excluded as 
these are evaluated under current DC 7818 within a different body 
system. VA proposes no changes to the evaluation criteria for DC 6014.
4. Diagnostic Code 6015
    Current DC 6015 evaluates benign neoplasm of the eyeball and adnexa 
only. VA proposes to replace the word ``eyeball'' with ``eye'' to 
conform with modern medical terminology. Id. Additionally, VA proposes 
to expand the applicability of this diagnostic code to include benign 
neoplasms of the orbit, this includes lid tumors in adults, cavernous 
hemangioma, dermoid, epidermal cysts and other conditions. By expanding 
the applicability, the VASRD would provide a specific diagnostic code 
for the evaluation of benign growths of the orbit and adnexa. Benign 
neoplasms of the skin are still excluded as these are evaluated under 
current DC 7819 within a different body system. VA proposes no changes 
to the evaluation criteria for DC 6015.

F. Conditions of the Lacrimal System

    The lacrimal system consists of the lacrimal glands and the 
nasolacrimal duct. This system is responsible for the secretion and 
drainage of tears and, when properly functioning, serves to moisten, 
lubricate, and protect the surface of the eye. Cat N. Burkat MD, and 
Mark J. Lucarelli MD, Anatomy of the Lacrimal System, The Lacrimal 
System: Diagnosis, Management, and Surgery, https://link.springer.com/book/10.1007%2F978-0-387-35267-1. This category includes DC 6025, which 
pertains to disorders of the lacrimal apparatus (epiphora, 
dacrocystitis, etc.). VA proposes no changes to this diagnostic code.

G. Corneal Diseases

    The cornea is the eye's outermost layer. It is a clear, dome-shaped 
surface, overlying the pupil, that covers the front of the eye. Facts 
About the Cornea and Corneal Disease, National Eye Institute, https://www.nei.nih.gov/health/cornealdisease/ (last visited Apr. 29, 2014). 
The cornea functions as a lens which focuses light on the retina. Id. 
An injury to the cornea generally produces redness, itching, tearing, 
and, depending on the severity of the injury, pain and blurring of 
vision. Id. This category includes the following diagnostic codes:
1. Diagnostic Code 6001
    VA proposes to continue evaluating DC 6001, keratopathy, under the 
General Rating Formula for Diseases of the Eye. VA proposes no other 
changes to this diagnostic code.
2. Diagnostic Codes 6017 and 6018
    Current DC 6017 states to evaluate trachomatous conjunctivitis on 
the basis of visual impairment when this condition is active, with a 
minimum evaluation of 30 percent. Current DC 6018 states to evaluate 
chronic conjunctivitis (nontrachomatous) on the basis of visual 
impairment when this condition is active, with a minimum evaluation of 
10 percent.
    VA proposes to direct evaluation of active trachomatous and 
nontrachomatous conjunctivitis under the General Rating Formula for 
Diseases of the Eye, which includes evaluation on the basis of visual 
impairment or incapacitating episodes, whichever provides a higher 
evaluation. This proposal expands the evaluation criteria to provide an 
alternative measure of disability outside the realm of visual 
impairment for these disabilities, allowing VA to more accurately and 
adequately capture the disabling effects. VA proposes to retain the 
respective minimum evaluations for cases of active conjunctivitis.
    Once conjunctivitis (trachomatous or nontrachomatous) is found to 
be inactive, current DCs 6017 and 6018 state to evaluate based on 
residuals, including visual impairment or disfigurement under DC 7800. 
VA proposes no change to these evaluation criteria.
3. Diagnostic Code 6035
    Current DC 6035 states to evaluate keratoconus on the basis of 
visual impairment due to this condition. VA proposes to direct 
evaluation under the General Rating Formula for Diseases of the Eye, 
which includes evaluation on the basis of visual impairment or 
incapacitating episodes, whichever provides a higher evaluation. This 
proposal expands the evaluation criteria to provide an alternative 
measure of disability outside the realm of visual impairment for this 
disability, allowing VA to more accurately and adequately capture the 
disabling effects.
4. Diagnostic Code 6036
    Current DC 6036 states to evaluate status post corneal transplant 
on the basis of visual impairment due to this condition, with a minimum 
evaluation of 10 percent in the presence of pain, photophobia, and 
glare sensitivity. VA proposes to direct evaluation under the General 
Rating Formula for Diseases of the Eye, which includes evaluation on 
the basis of visual impairment or incapacitating episodes, whichever 
provides a higher evaluation. This proposal expands the evaluation 
criteria to provide an alternative measure of disability outside the 
realm of visual impairment for this disability, allowing VA to more 
accurately and adequately capture the disabling effects. VA intends to 
retain the minimum evaluation of 10 percent in the presence of pain, 
photophobia, and glare sensitivity.

H. External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow

    The external eye disease category consists of a group of conditions 
involving the ocular-related structures, which have direct contact with 
the environment, and includes the eyelids, eyelashes, and eyebrows. 
While the cornea has direct contact with the environment as well, VA 
has provided a separate category for diseases of the cornea. The 
external eye diseases category includes nine conditions of the 
eyelashes, eyelids, and eyebrows listed in the current VASRD. This 
category

[[Page 32517]]

includes the following diagnostic codes in which no change is proposed 
to the current evaluation criteria: DC 6020, Ectropion; DC 6021, 
Entropion; DC 6022, Lagophthalmos; DC 6023, Loss of eyebrows, complete, 
unilateral or bilateral; DC 6024, Loss of eyelashes, complete, 
unilateral or bilateral; DC 6032, Loss of eyelids, partial or complete; 
and DC 6037, Pinguecula. It also includes the following diagnostic 
codes with specific proposed changes.
    Current DC 6034 states to evaluate pterygium on the basis of visual 
impairment, disfigurement (DC 7800), conjunctivitis (DC 6018), etc., 
depending on the particular findings. Similarly, current DC 6091 states 
to evaluate symblepharon on the basis of visual impairment, 
lagophthalmos (DC 6022), disfigurement (DC 7800), etc., depending on 
the particular findings.
    In both cases, VA proposes to replace the direction to evaluate on 
the basis of visual impairment with the General Rating Formula for 
Diseases of the Eye, which includes evaluation on the basis of visual 
impairment or incapacitating episodes, whichever provides a higher 
evaluation. This proposal expands the evaluation criteria to provide an 
alternative measure of disability outside the realm of visual 
impairment for these disabilities, allowing VA to more accurately and 
adequately capture the disabling effects. VA also proposes to include 
the phrase ``and combine in accordance with Sec.  4.25'' to the rating 
instructions of DCs 6034 and 6091. The current language allows for 
multiple evaluations to be assigned and combined depending on the 
particular findings, but it is not entirely clear to the reader. 
Therefore, this addition would ensure consistency and clarity for field 
application.
    VA proposes no other changes to these diagnostic codes.

I. Disease of the Lens

    The lens is a crystalline, transparent structure covered by a 
capsule and suspended by a ligament that weakens with age. Henry Gray, 
Anatomy of the Human Body, 1019-20 (20th ed. 1918). The lens capsule is 
lined in the anterior portion by an epithelium that generates new lens 
fibers at the equators. Id. In addition to malformation and 
malposition, the main lens pathology is cataract formation. A cataract 
is a lens opacity which produces visual impairment by obscuration and 
altered light refraction. Facts About Cataract, National Eye Institute, 
https://www.nei.nih.gov/health/cataract/cataract_facts.asp (last 
visited Apr. 29, 2014). This category includes evaluation criteria for 
DC 6029, Aphakia or dislocation of crystalline lens for which VA 
proposes no changes. It also includes the following diagnostic codes 
with specific proposed changes.
    Current DC 6027 states to evaluate preoperative cataracts on the 
basis of visual impairment. VA proposes to direct evaluation of 
preoperative cataracts under the General Rating Formula for Diseases of 
the Eye, which includes evaluation on the basis of visual impairment or 
incapacitating episodes, whichever provides a higher evaluation. This 
proposal expands the evaluation criteria to provide an alternative 
measure of disability outside the realm of visual impairment for this 
disability, allowing VA to more accurately and adequately capture the 
disabling effects.
    Current DC 6027 also provides two evaluation options for 
postoperative cataracts depending on the presence or absence of a 
replacement lens. If a replacement lens is present, current DC 6027 
states to evaluate on the basis of visual impairment. VA proposes to 
direct the evaluation of postoperative cataracts with a replacement 
lens under the General Rating Formula for Diseases of the Eye for the 
same reasons discussed above. If there is no replacement lens present, 
current DC 6027 states to evaluate based on aphakia (DC 6029). VA 
proposes only to insert the applicable DC. No substantive change is 
proposed.

J. Neuro-Ophthalmic Conditions

    This category includes a listing of the most common and pertinent 
neuro-ophthalmic conditions, to include diseases of the anterior visual 
pathways, optic nerve disorders, cranial nerve palsies resulting in 
visual impairment, disorders of eye movements, and pupillary disorders. 
The field of neuro-ophthalmology bridges the gap between neurology and 
ophthalmology by providing particular attention to visual impairment 
due to diseases of the neural structures involved in vision. Since a 
substantial portion of the brain is involved with vision, many brain 
disorders produce visual impairment. This category includes the 
following diagnostic codes in which no change is proposed to the 
current evaluation criteria: DC 6016, Nystagmus, central; DC 6019, 
Ptosis, unilateral or bilateral; and DC 6030, Paralysis of 
accommodation (due to neuropathy of the Oculomotor Nerve (cranial nerve 
III)). It also includes the following diagnostic code with specific 
proposes changes.
1. Diagnostic Code 6026
    Current DC 6026 states to evaluate optic neuropathy on the basis of 
visual impairment due to this condition. VA proposes to direct 
evaluation under the General Rating Formula for Diseases of the Eye, 
which includes evaluation on the basis of visual impairment or 
incapacitating episodes, whichever provides a higher evaluation. This 
proposal expands the evaluation criteria to provide an alternative 
measure of disability outside the realm of visual impairment for this 
disability, allowing VA to more accurately and adequately capture the 
disabling effects.
2. New Diagnostic Code 6046
    VA proposes to add a new DC 6046, titled ``Post-chiasmal 
disorders.'' This category includes a variety of central visual 
disorders with brain involvement. This category incorporates ophthalmic 
residuals from traumatic brain injury (TBI) or other causes of cerebral 
injury, such as infectious, vascular conditions, or degenerative 
conditions. Post-chiasmal disorders may be associated with cognitive 
changes caused by the structural or functional alteration of the brain 
tissue, which are often associated with TBI. See James Garrity MD, 
Overview of Optic Nerve Disorders, The Merck Manual Home Health 
Handbook, https://www.merckmanuals.com/home/eye_disorders/optic_nerve_disorders/overview_of_optic_nerve_disorders.html (last 
visited Apr. 29, 2014) (each optic nerve splits at a structure in the 
brain called the optic chiasm). The alteration can lead to brain 
dysfunction which can manifest as a variety of visual impairments. 
Given the increased awareness and understanding of the chronic 
residuals of TBI in the medical community, particularly amongst the 
Veteran population, VA proposes this new diagnostic code to provide 
adequate and proper evaluations for Veterans with post-chiasmal 
disorders. Due to the varying presentation of post-chiasmal disorders, 
VA proposes to evaluate these conditions under the General Rating 
Formula for Diseases of the Eye to maximize the options available for 
an accurate evaluation.

IV. Technical Amendments

    VA also 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

[[Page 32518]]

approaches that maximize net benefits (including potential economic, 
environmental, public health and safety effects, and other advantages; 
distributive impacts; and equity). Executive Order 13563 (Improving 
Regulation and Regulatory Review) emphasizes the importance of 
quantifying both costs and benefits, reducing costs, harmonizing rules, 
and promoting flexibility. Executive Order 12866 (Regulatory Planning 
and Review) defines a ``significant regulatory action,'' which requires 
review by the Office of Management and Budget (OMB), as ``any 
regulatory action that is likely to result in a rule that may: (1) Have 
an annual effect on the economy of $100 million or more or adversely 
affect in a material way the economy, a sector of the economy, 
productivity, competition, jobs, the environment, public health or 
safety, or State, local, or tribal governments or communities; (2) 
Create a serious inconsistency or otherwise interfere with an action 
taken or planned by another agency; (3) Materially alter the budgetary 
impact of entitlements, grants, user fees, or loan programs or the 
rights and obligations of recipients thereof; or (4) Raise novel legal 
or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in 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 proposed rule is exempt from the 
initial and final regulatory flexibility analysis requirements of 
sections 603 and 604.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in the expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any 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. Robert A. 
McDonald, Secretary of Veterans Affairs, approved this document on May 
10, 2015, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Approved: June 2, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management.

    For the reasons set out in the preamble, VA proposes to amend 38 
CFR part 4, subpart B as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

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

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

0
2. Amend Sec.  4.77 by revising paragraph (a) to read as follows:


Sec.  4.77  Visual fields.

    (a) Examination of visual fields. Examiners must use either 
Goldmann kinetic perimetry or automated perimetry using Humphrey Model 
750, Octopus Model 101, or later versions of these perimetric devices 
with simulated kinetic Goldmann testing capability. For phakic (normal) 
individuals, as well as for pseudophakic or aphakic individuals who are 
well adapted to intraocular lens implant or contact lens correction, 
visual field examinations must be conducted using a standard target 
size and luminance, which is Goldmann's equivalent III/4e. For aphakic 
individuals not well adapted to contact lens correction or pseudophakic 
individuals not well adapted to intraocular lens implant, visual field 
examinations must be conducted using Goldmann's equivalent IV/4e. The 
examiner must document the results for at least 16 meridians 22\1/2\ 
degrees apart for each eye and indicate the Goldmann equivalent used. 
See Table III for the normal extent (in degrees) of the visual fields 
at the 8 principal meridians (45 degrees apart). When the examiner 
indicates that additional testing is necessary to evaluate visual 
fields, the additional testing must be conducted using either a tangent 
screen or a 30-degree threshold visual field with the Goldmann III 
stimulus size. The examination report must document the results of 
either the tangent screen or of the 30-degree threshold visual field 
with the Goldmann III stimulus size.
* * * * *
0
3. Amend Sec.  4.78 by revising paragraph (a) to read as follows:


Sec.  4.78  Muscle function.

    (a) Examination of muscle function. The examiner must use a 
Goldmann perimeter chart or the Tangent Screen method that identifies 
the four major quadrants (upward, downward, left and right lateral) and 
the central field (20 degrees or less) (see Figure 2). The examiner 
must document the results of muscle function testing by identifying the 
quadrant(s) and range(s) of degrees in which diplopia exists.
* * * * *
0
4. Amend Sec.  4.79 Schedule of ratings--eye by revising the tables 
Diseases of the Eye and Ratings for Impairment of Muscle Function to 
read as follows:

[[Page 32519]]



                           Diseases of the Eye
------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
Unless otherwise directed, evaluate diseases of the eye under
 the General Rating Formula for Diseases of the Eye.
General Rating Formula for Diseases of the Eye:
    Evaluate on the basis of either visual impairment due to
     the particular condition or on incapacitating episodes,
     whichever results in a higher evaluation.
    With documented incapacitating episodes requiring 10 or           60
     more medical visits for monitoring or treatment of an
     active eye disease or complications per year.............
    With documented incapacitating episodes requiring at least        40
     7 but no more than 9 medical visits for monitoring or
     treatment of an active eye disease or complications per
     year.....................................................
    With documented incapacitating episodes requiring at least        20
     4 but no more than 6 medical visits for monitoring or
     treatment of an active eye disease or complications per
     year.....................................................
    With documented incapacitating episodes requiring 3               10
     medical visits for monitoring or treatment of an active
     eye disease or complications per year....................
    Note (1): For the purposes of evaluation under 38 CFR
     4.79, an incapacitating episode is one which requires
     clinic visits for an active eye disease, as documented in
     the medical record by a physician or other health care
     provider, and relates to the monitoring of progress,
     administration of treatment(s), and to the development of
     complications related to the underlying active eye
     disability. Examples of treatment may include but are not
     limited to: Systemic immunosuppressants or biologic
     agents; intravitreal or periocular injections; laser
     treatments; or other surgical interventions.
    Note (2): For the purposes of evaluating visual impairment
     due to the particular condition, refer to 38 CFR 4.75-
     4.78 and to Sec.   4.79, diagnostic codes 6061-6090.
------------------------------------------------------------------------
                       Diseases of the Uveal Tract
------------------------------------------------------------------------
6000 Choroidopathy, including uveitis, iritis, cyclitis, and
 choroiditis.
6002 Scleritis.
6010 Tuberculosis of the eye:
    Active....................................................       100
    Inactive: Evaluate under Sec.   4.88c or Sec.   4.89 of
     this part, whichever is appropriate.
------------------------------------------------------------------------
              Diseases of the Retina, Macula, and Vitreous
------------------------------------------------------------------------
6006 Retinopathy or maculopathy not otherwise specified.
6008 Detachment of retina.
6011 Retinal scars, atrophy, or irregularities:
    Localized scars, atrophy, or irregularities of the retina,        10
     unilateral or bilateral, that are centrally located and
     that result in an irregular, duplicated, enlarged, or
     diminished image.........................................
    Alternatively, evaluate based on the General Rating
     Formula for Diseases of the Eye, if this would result in
     a higher evaluation.
6040 Diabetic retinopathy.
6042 Retinal dystrophy (including retinitis pigmentosa).
------------------------------------------------------------------------
                                Glaucoma
------------------------------------------------------------------------
6012 Angle-closure glaucoma.
    Evaluate under the General Rating Formula for Diseases of         10
     the Eye. Minimum evaluation if continuous medication is
     required.................................................
6013 Open-angle glaucoma.
    Evaluate under the General Rating Formula for Diseases of         10
     the Eye. Minimum evaluation if continuous medication is
     required.................................................
------------------------------------------------------------------------
                       Ocular Neoplasms and Trauma
------------------------------------------------------------------------
6007 Introacular hemorrhage.
6009 Unhealed eye injury.
    Note: This code includes orbital trauma, as well as
     penetrating and non-penetrating eye injury.
6014 Malignant neoplasms of the eye, orbit, and adnexa
 (excluding skin):
    Malignant neoplasms of the eye, orbit, and adnexa                100
     (excluding skin) that require therapy that is comparable
     to those used for systemic malignancies, i.e., systemic
     chemotherapy, X-ray therapy more extensive than to the
     area of the eye, or surgery more extensive than
     enucleation..............................................
    Note: Continue the 100-percent rating beyond the cessation
     of any surgical, X-ray, antineoplastic chemotherapy or
     other therapeutic procedure. Six months after
     discontinuance of such treatment, the appropriate
     disability rating will be determined by mandatory VA
     examination. Any change in evaluation based upon that or
     any subsequent examination will be subject to the
     provisions of Sec.   3.105(e) of this chapter. If there
     has been no local recurrence or metastasis, evaluate
     based on residuals.
    Malignant neoplasm of the eye, orbit, and adnexa
     (excluding skin) that does not require therapy comparable
     to that for systemic malignancies:
        Separately evaluate visual impairment and nonvisual
         impairment, e.g., disfigurement (diagnostic code
         7800), and combine the evaluations.
6015 Benign neoplasms of the eye, orbit, and adnexa (excluding
 skin):
    Separately evaluate visual impairment and nonvisual
     impairment, e.g., disfigurement (diagnostic code 7800),
     and combine the evaluations.
------------------------------------------------------------------------
                    Conditions of the Lacrimal System
------------------------------------------------------------------------
6025 Disorders of the lacrimal apparatus (epiphora,
 dacrocystitis, etc.):
    Bilateral.................................................        20
    Unilateral................................................        10
------------------------------------------------------------------------

[[Page 32520]]

 
                            Corneal Diseases
------------------------------------------------------------------------
6001 Keratopathy.
6017 Trachomatous conjunctivitis:
    Active: Evaluate under the General Rating Formula for             30
     Diseases of the Eye, minimum rating......................
    Inactive: Evaluate based on residuals, such as visual
     impairment and disfigurement (diagnostic code 7800).
6018 Chronic conjunctivitis (nontrachomatous):
    Active: Evaluate under the General Rating Formula for             10
     Diseases of the Eye, minimum rating......................
    Inactive: Evaluate based on residuals, such as visual
     impairment and disfigurement (diagnostic code 7800).
6035 Keratoconus.
6036 Status post corneal transplant:
    Rate under the General Rating Formula for Diseases of the
     Eye.
        Minimum, if there is pain, photophobia, and glare             10
         sensitivity..........................................
------------------------------------------------------------------------
    External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow
------------------------------------------------------------------------
6020 Ectropion:
    Bilateral.................................................        20
    Unilateral................................................        10
6021 Entropion:
    Bilateral.................................................        20
    Unilateral................................................        10
6022 Lagophthalmos:
    Bilateral.................................................        20
    Unilateral................................................        10
6023 Loss of eyebrows, complete, unilateral or bilateral......        10
6024 Loss of eyelashes, complete, unilateral or bilateral.....        10
6032 Loss of eyelids, partial or complete:
    Separately evaluate both visual impairment due to eyelid
     loss and nonvisual impairment, e.g., disfigurement
     (diagnostic code 7800), and combine the evaluations.
6034 Pterygium:
    Evaluate under the General Rating Formula for Diseases of
     the Eye, disfigurement (diagnostic code 7800),
     conjunctivitis (diagnostic code 6018), etc., depending on
     the particular findings, and combine in accordance with
     Sec.   4.25.
6037 Pinguecula:
    Evaluate based on disfigurement (diagnostic code 7800).
6091 Symblepharon:
    Evaluate under the General Rating Formula for Diseases of
     the Eye, lagophthalmos (diagnostic code 6022),
     disfigurement (diagnostic code 7800), etc., depending on
     the particular findings, and combine in accordance with
     Sec.   4.25.
------------------------------------------------------------------------
                           Disease of the Lens
------------------------------------------------------------------------
6027 Cataract:
    Preoperative: Evaluate under the General Rating Formula
     for Diseases of the Eye.
    Postoperative: If a replacement lens is present
     (pseudophakia), evaluate under the General Rating Formula
     for Diseases of the Eye. If there is no replacement lens,
     evaluate based on aphakia (diagnostic code 6029).
6029 Aphakia or dislocation of crystalline lens:
    Evaluate based on visual impairment, and elevate the
     resulting level of visual impairment one step.
    Minimum (unilateral or bilateral).........................        30
------------------------------------------------------------------------
                       Neuro-Ophthalmic Conditions
------------------------------------------------------------------------
6016 Nystagmus, central.......................................        10
6019 Ptosis, unilateral or bilateral:
    Evaluate based on visual impairment or, in the absence of
     visual impairment, on disfigurement (diagnostic code
     7800).
6026 Optic neuropathy: Evaluate under the General Rating
 Formula for Diseases of the Eye.
6030 Paralysis of accommodation (due to neuropathy of the             20
 Oculomotor Nerve (cranial nerve III))........................
6046 Post-chiasmal disorders: Evaluate under the General
 Rating Formula for Diseases of the Eye.
------------------------------------------------------------------------


                Ratings for Impairment of Muscle Function
------------------------------------------------------------------------
                                                       Equivalent visual
                  Degree of diplopia                         acuity
------------------------------------------------------------------------
6090 Diplopia (double vision):
    (a) Central 20 degrees...........................              5/200
    (b) 21 degrees to 30 degrees.....................           (1.5/60)
        (1) Down
        (2) Lateral..................................             15/200
        (3) Up.......................................           (4.5/60)
    (c) 31 degrees to 40 degrees.....................             20/100
        (1) Down.....................................             (6/30)
        (2) Lateral..................................       20/70 (6/21)

[[Page 32521]]

 
        (3) Up
    Note: In accordance with 38 CFR 4.31, diplopia         20/200 (6/60)
     that is occasional or that is correctable with         20/70 (6/21)
     spectacles is evaluated at 0 percent............       20/40 (6/12)
------------------------------------------------------------------------
(Authority: 38 U.S.C. 1155).

0
5. In Appendix A to Part 4, add Sec. Sec.  4.77, 4.78, and 4.79 to read 
as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                               Diagnostic
            Sec.                code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.77.......................  ..............  Revised [insert effective
                                              date of final rule].
4.78.......................  ..............  Revised [insert effective
                                              date of final rule].
4.79.......................  ..............  Introduction criterion
                                              [insert effective date of
                                              final rule]; Revised
                                              General Rating Formula for
                                              Diseases of the Eye
                                              [insert effective date of
                                              final rule]; General
                                              Rating Formula for
                                              Diseases of the Eye NOTE
                                              revised [insert effective
                                              date of final rule];
                                              Organizational categories
                                              added [insert effective
                                              date of final rule].
                                       6000  Criterion [insert effective
                                              date of final rule].
                                       6001  Criterion [insert effective
                                              date of final rule].
                                       6002  Criterion [insert effective
                                              date of final rule].
                                       6006  Title [insert effective
                                              date of final rule];
                                              criterion [insert
                                              effective date of final
                                              rule].
                                       6007  Criterion [insert effective
                                              date of final rule].
                                       6008  Criterion [insert effective
                                              date of final rule].
                                       6009  Criterion [insert effective
                                              date of final rule].
                                       6011  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6012  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6013  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6014  Title [insert effective
                                              date of final rule].
                                       6015  Title [insert effective
                                              date of final rule].
                                       6017  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6018  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6019  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6026  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6027  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6034  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6035  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6036  Evaluation [insert
                                              effective date of final
                                              rule].
                                       6040  Added [insert effective
                                              date of final rule].
                                       6042  Added [insert effective
                                              date of final rule].
                                       6046  Added [insert effective
                                              date of final rule].
                                       6091  Evaluation [insert
                                              effective date of final
                                              rule].
 
                              * * * * * * *
------------------------------------------------------------------------

0
6. In Appendix B to Part 4, The Eye, Diseases of the Eye, revise 
diagnostic codes 6000, 6003-6005, 6006-6009, 6011-15, 6017-6018, 6026-
6027, 6034-6036, and add diagnostic codes 6040, 6042, and 6046 to read 
as follows:

[[Page 32522]]



          Appendix A to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
         Diagnostic code No.
------------------------------------------------------------------------
 
                                * * * * *
                                 THE EYE
                           Diseases of the Eye
------------------------------------------------------------------------
 
                                * * * * *
6000................................  Choroidopathy, including uveitis,
                                       iritis, cyclitis, and
                                       choroiditis.
6001................................  Keratopathy.
6002................................  Scleritis.
6006................................  Retinopathy or maculopathy not
                                       otherwise specified.
6007................................  Intraocular hemorrhage.
6008................................  Detachment of retina.
6009................................  Unhealed eye injury.
6010................................  Tuberculosis of eye.
6011................................  Retinal scars, atrophy, or
                                       irregularities.
6012................................  Angle-closure glaucoma.
6013................................  Open-angle glaucoma.
6014................................  Malignant neoplasms of the eye,
                                       orbit, and adnexa (excluding
                                       skin).
6015................................  Benign neoplasms of the eye,
                                       orbit, and adnexa (excluding
                                       skin).
 
                                * * * * *
6025................................  Disorders of the lacrimal
                                       apparatus (epiphora,
                                       dacrocystitis, etc.)
6026................................  Optic neuropathy.
6027................................  Cataract.
 
                                * * * * *
6034................................  Pterygium.
6035................................  Keratoconus.
6036................................  Status post corneal transplant.
 
                                * * * * *
6040................................  Diabetic retinopathy.
6042................................  Retinal dystrophy (including
                                       retinitis pigmentosa).
6046................................  Post-chiasmal disorders.
 
                                * * * * *
------------------------------------------------------------------------

0
7. In Appendix C to Part 4, revise the disability entries for 
diagnostic codes 6006, 6014, and 6015, and add disability entries for 
Retinopathy, diabetic; Retinal dystrophy (including retinitis 
pigmentosa); and Post-chiasmal disorders to read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                                * * * * *
New growths:
    Benign
 
                                * * * * *
        Eye, orbit, and adnexa..........................            6015
 
                                * * * * *
        Eye, orbit, and adnexa..........................            6014
 
                                * * * * *
Post-chiasmal disorders.................................            6046
 
                                * * * * *
Retinal dystrophy (including retinitis pigmentosa)......            6042
Retinopathy, diabetic...................................            6040
Retinopathy or maculopathy not otherwise specified......            6006
 
                                * * * * *
------------------------------------------------------------------------

[FR Doc. 2015-13788 Filed 6-8-15; 8:45 am]
 BILLING CODE 8320-01-P