Schedule for Rating Disabilities; Dental and Oral Conditions, 44913-44921 [2015-17266]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 80, Number 144 (Tuesday, July 28, 2015)]
[Proposed Rules]
[Pages 44913-44921]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-17266]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP08


Schedule for Rating Disabilities; Dental and Oral Conditions

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 dental and oral conditions. The purpose of 
these changes is to incorporate medical advances that have occurred 
since the last amendment, update current medical terminology, and 
provide clear evaluation criteria for application of this portion of 
the rating schedule. The proposed rule reflects advances in medical 
knowledge, recommendations from the Dental and Oral Conditions 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 dental and oral conditions section of the VASRD, was held on 
January 25--26, 2011.

[[Page 44914]]


DATES: Comments must be received by VA on or before September 28, 2015.

ADDRESSES: Written comments may be submitted through 
www.regulations.gov; by mail or hand-delivery to Director, Regulations 
Management (02REG), Department of Veterans Affairs, 810 Vermont Ave. 
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-AP08--Schedule for Rating Disabilities; Dental and Oral 
Conditions.'' 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 
Ave. 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 4.150, which pertains to dental and oral 
conditions. The proposed changes will (1) update the medical 
terminology of certain dental and oral conditions, (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--Dental and Oral Conditions

    Section 4.150 currently lists 16 diagnostic codes encompassing 
conditions involving dental and oral injury or disease. VA proposes to 
revise these codes, through addition, removal, and other revisions to 
reflect current medical science, terminology, and functional 
impairment.
    VA proposes to add two notes at the beginning of Sec.  4.150 to 
clarify updated medical terminology used later in the diagnostic codes. 
The first note would provide guidance to disability rating personnel 
regarding the evidence necessary to support the objective findings 
described in various diagnostic codes. The note states that, for VA 
compensation purposes, diagnostic imaging studies include, but are not 
limited to, conventional radiography (X-ray), computed tomography (CT), 
magnetic resonance imaging (MRI), positron emission tomography (PET), 
radionuclide bone scanning, or ultrasonography. The second note regards 
rating of residuals that, though part of the disease process for a 
dental or oral condition, cause functional incapacity which cannot be 
evaluated within the dental and oral conditions system. The note 
directs disability rating personnel to evaluate the particular 
functional impairment separately (e.g., loss of vocal articulation, 
loss of smell, loss of taste, neurological impairment, respiratory 
dysfunction, and other impairments), and then apply Sec.  4.25 to 
combine the evaluation with those assigned under the schedule of 
ratings for dental and oral conditions.

Diagnostic Code 9900, ``Maxilla or Mandible, Chronic Osteomyelitis or 
Osteoradionecrosis of:''

    Current diagnostic code 9900 ``Maxilla or mandible, chronic 
osteomyelitis or osteoradionecrosis of,'' directs that such conditions 
be rated as chronic osteomyelitis under diagnostic code 5000. VA 
proposes to add osteonecrosis of the maxilla or mandible (jaw) as one 
of the diseases listed under diagnostic code 9900. Osteonecrosis of the 
jaw, commonly called ONJ, occurs when the jaw bone is exposed (not 
covered by the gums) and begins to deteriorate from a lack of 
bloodflow. Without adequate blood flow, the bone begins to weaken, 
break down, and die, which usually, causes pain. ONJ is associated with 
cancer treatments, infection, steroid use, or potent antiresorptive 
therapies that help prevent the loss of bone mass. Examples of potent 
antiresorptive therapies include bisphosphonates such as alendronate 
(Fosamax); risedronate (Actonel); and ibandronate (Boniva). While ONJ 
is linked with these conditions, it also can occur without clearly 
identifiable risk factors. Osteonecrosis of the Jaw, American College 
of Rheumatology https://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/onj.asp (last updated Sept. 2012). This 
proposed addition will facilitate assignment of appropriate disability 
evaluations to veterans who are suffering from osteonecrosis of the jaw 
(maxilla or mandible).

Diagnostic Codes 9902 ``Mandible, Loss of Approximately One-Half,'' 
9906 ``Ramus, Loss of Whole or Part of,'' and 9907 ``Ramus, Loss of 
Less Than One-Half the Substance of, Not Involving Loss of Continuity''

    Current diagnostic codes 9902 ``Mandible, loss of approximately 
one-half''; 9906 ``Ramus, loss of whole or part of''; and 9907 ``Ramus, 
loss of less than one-half the substance of, not involving loss of 
continuity'' address impairments associated with various degrees of 
mandible loss. Loss of approximately one-half of the mandible, 
involving temporomandibular articulation, is currently evaluated at 50 
percent; if temporomandibular articulation is not involved, it is 
evaluated at 30 percent. Loss of whole or part of the ramus, involving 
loss of temporomandibular articulation bilaterally, is currently 
evaluated at 50 percent; the same disability presented unilaterally is 
currently evaluated at 30 percent. Without loss of temporomandibular 
articulation, loss of whole or part of the ramus is evaluated at 30 
percent bilaterally and 20 percent unilaterally. Loss of less than one-
half the substance of the ramus, not involving loss of continuity, is 
currently evaluated at 20 percent bilaterally and 10 percent 
unilaterally.
    The mandible is viewed as a single functional unit that consists of 
the mandibular body and the mandibular rami. The anterior portion of 
the mandible, called the body, is horseshoe-shaped and runs 
horizontally. At the posterior ends of the body are two vertical 
extensions called rami (singular, ramus). The Work Group recognized 
that, because the ramus is a portion of the mandible, impairments of 
the ramus should be rated as impairments of the mandible as a whole. 
Therefore, proposed diagnostic code 9902, ``Mandible, loss of, 
including ramus, unilaterally or bilaterally,'' combines evaluations 
currently done under diagnostic codes 9902, 9906, and 9907 to better 
reflect the current understanding of anatomy, physiology, and 
disability due to the disease or injury of the mandible, including the 
rami. Furthermore, the disabling effect of the loss of different 
portions of the mandible has been combined in light of its anatomy and 
the usual reconstruction goals. The proposed rating criteria also 
reflect the function of the portions of the mandible, providing higher 
evaluations for the loss of the joint than for areas that do not 
disrupt continuity. Mehta R.P. et al., Mandibular Reconstruction in 
2004: An Analysis of Different Techniques,

[[Page 44915]]

https://www.ncbi.nlm.nih.gov/pubmed/15252248.
    The reconstruction of oromandibular defects (mandibular 
reconstruction) presents a significant surgical challenge. Mandibular 
deformities and defects may result from trauma, infections, prior 
radiation exposure, and neoplasms (tumors); most mandibular deformities 
result from surgical excision of tumors. The mandible plays a major 
role in airway protection and support of the tongue, lower dentition 
(teeth), and the muscles of the floor of the mouth permitting chewing, 
swallowing, speaking, and respiration. It also defines the contour of 
the lower third of the face. Interruption of mandibular continuity, 
therefore, produces both a cosmetic and functional deformity. The 
resulting dysfunction after loss of part of the mandible varies from 
minimal to major. In order to achieve successful mandibular 
reconstruction, the reconstructive surgeon must attempt to restore bony 
continuity and facial contour, maintain tongue mobility, and attempt to 
restore sensation to the affected areas. In addition, oral and dental 
rehabilitation postoperatively is important to improve the patient's 
ability to manipulate the food bolus, swallow, and articulate speech. 
Jesse E. Smith et al., Mandibular Plating, Medscape, https://emedicine.medscape.com/article/881542-overview (last updated Dec. 19, 
2014).
    In light of these disabling effects of mandibular loss and advances 
in reconstruction of the oral cavity, VA proposes additional levels of 
disability to recognize greater functional impairment where mandibular 
loss cannot be replaced by prostheses. VA proposes a 70 percent 
evaluation for the loss of one-half or more of the mandible, involving 
temporomandibular articulation, where the loss is not replaceable by 
prosthesis. VA proposes a 50 percent evaluation for the same anatomical 
loss, where it is replaceable by prosthesis. VA proposes a 40 percent 
evaluation for the loss of one-half or more of mandible, not involving 
temporomandibular articulation, where the loss is not replaceable by 
prosthesis, and a 30 percent evaluation for the same anatomical loss, 
where it is replaceable by prosthesis. VA differentiates the 
evaluations involving one-half or more of the mandible, whether or not 
involving temporomandibular articulation, on the basis of whether or 
not they are replaceable by prosthesis because large, complex defects 
where a prosthesis is not suitable present greater functional and 
cosmetic impairments.
    VA proposes a 70 percent evaluation for the loss of less than one-
half of the mandible, involving temporomandibular articulation, where 
the loss is not replaceable by prosthesis. VA proposes a 50 percent 
evaluation for the same anatomical loss, where it is replaceable by 
prosthesis. VA proposes a 20 percent evaluation for the loss of less 
than one-half of mandible, not involving temporomandibular 
articulation, where the loss is not replaceable by prosthesis, and a 10 
percent evaluation for the same anatomical loss, where it is 
replaceable by prosthesis. VA differentiates the evaluations involving 
less than one-half of the mandible, whether or not involving 
temporomandibular articulation, on the basis of whether or not they are 
replaceable by prosthesis because large, complex defects where a 
prosthesis is not suitable present greater functional and cosmetic 
impairments.
    Consequently, VA proposes to delete existing diagnostic codes 9906 
``Ramus, loss of whole or part of:'' and 9907 ``Ramus, loss of less 
than one-half the substance of, not involving loss of continuity:'' 
while incorporating relevant evaluation criteria into revised 
diagnostic code 9902 ``Mandible, loss of, including ramus, unilaterally 
or bilaterally.''

Diagnostic Code 9903 ``Mandible, Nonunion of, Confirmed by Diagnostic 
Imaging Studies:''

    Current diagnostic code 9903 addresses impairments associated with 
nonunion of the mandible. Severe and moderate nonunion of the mandible 
are currently rated at 30 percent and 10 percent, respectively, and 
evaluation is dependent upon the degree of motion and relative loss of 
masticatory function. However, the current rating criteria do not 
reflect modern medical terminology because a nonunion occurs when the 
mandible does not heal in an appropriate time frame and the result is 
mobility of the fracture segments present after an adequate healing 
phase. In addition, if the mandibular fragments are not immobilized 
properly immediately after fracture, or treatment is delayed, a fibrous 
union (i.e., nonunion) is formed and radiographic evidence is often 
needed to make this determination. Edward W. Chang et al., General 
Principles of Mandible Fracture and Occlusion, Medscape, https://emedicine.medscape.com/article/868375-overview (last updated Mar. 28, 
2014).
    Therefore, VA proposes to re-title diagnostic code 9903 as 
``Mandible, nonunion of, confirmed by diagnostic imaging studies:'' and 
base newly developed rating criteria on a better understanding of 
anatomy, physiology, and functional impairment of the mandibular 
nonunion. Under proposed diagnostic code 9903, mandibular nonunion 
would warrant a 30 percent evaluation with the presence of false 
motion, which is considered severe, or a 10 percent evaluation if there 
is no false motion, which is considered moderate. In addition, VA 
proposes to delete the note under current diagnostic code 9903.

Diagnostic Code 9904 ``Mandible, Malunion of:''

    Currently, malunion of mandible where severe, moderate, and slight 
displacement is present is rated at 20, 10, and 0 percent, 
respectively, and is dependent upon degree of motion and relative loss 
of masticatory function. However, the current rating criteria do not 
reflect modern medical terminology because malunion refers to improper 
alignment of the healed bony segments where the normal anatomic 
structure is not restored because of unsatisfactory reduction and the 
result is abnormal occlusion (i.e., open bite) and joint function. 
Edward W. Chang et al., General Principles of Mandible Fracture and 
Occlusion, Medscape, https://emedicine.medscape.com/article/868375-overview (last updated Mar. 28, 2014).
    Therefore, VA proposes to base newly developed rating criteria on a 
better understanding of anatomy, physiology, and functional impairment 
of the mandibular malunion. Under proposed diagnostic code 9904, 
mandibular malunion with displacement causing severe or moderate 
anterior or posterior open bite resulting in displacement would warrant 
20 and 10 percent evaluations respectively. A 0 percent evaluation 
would be assigned for mandibular malunion resulting in displacement 
that does not cause anterior or posterior open bite. In addition, VA 
proposes to delete the note under diagnostic code 9904. The proposed 
rating criteria are based on measurable signs of functional impairment 
and incorporate all elements of disability evaluation in cases of 
mandibular malunion.

Diagnostic Code 9905 ``Temporomandibular Disorder.''

    Diagnostic code 9905 is currently titled ``Temporomandibular 
articulation, limited motion of,'' which represents outdated medical 
terminology. The term TMJ is actually an abbreviation for the longer 
anatomical term--temporomandibular joint. Unfortunately, over the 
years, the term

[[Page 44916]]

TMJ has developed into a long misunderstood and yet commonly used 
acronym in the vocabulary of both doctors and patients alike. As a 
result of this common misappropriation of terminology, in the last 
several years there has been a concerted effort on the part of the 
medical profession to change the acronym to TMD (temporomandibular 
disorder) in an effort to more accurately reflect that which is more 
often being discussed. The American Association of Oral and 
Maxillofacial Surgeons (AAOMS) has recognized TMD as appropriate 
terminology for the group of disorders affecting the temporomandibular 
joint.
    VA proposes to retitle diagnostic code 9905 as ``Temporomandibular 
disorder (TMD),'' which is consistent with current medical terminology. 
TMD refers to a collection of medical and dental conditions affecting 
the temporomandibular joint and/or the muscles of mastication, as well 
as contiguous tissue components. Although specific etiologies such as 
degenerative arthritis and trauma underlie some TMD, as a group these 
conditions have no common etiology or biological explanation and 
comprise a diverse group of health problems whose signs and symptoms 
are overlapping, but not necessarily identical. Temporomandibular 
Disorders (TMD), American Academy of Orofacial Pain, https://s3.amazonaws.com/ClubExpressClubFiles/508439/documents/AAOP_Brochure_-_TMD_Revision_3-27-2014.pdf?AWSAccessKeyId=AKIAIB6I23VLJX7E4J7Q&Expires=1435244199&response-content-disposition=inline%3B%20filename%3DAAOP_Brochure_-_TMD_Revision_3-27-2014.pdf&Signature=Jb117XxOWMO%2FT5tFkXgZ9MobBG0%3D 
(last visited Jun. 25, 2015).
    Under current diagnostic code 9905, motion limitation for 
temporomandibular articulation is measured solely as loss of 
interincisal opening and lateral excursive distance, where ratings for 
limited interincisal movement are not combined with ratings for limited 
lateral excursion. Current diagnostic code 9905 provides for the 
following evaluations: A 40 percent evaluation with interincisal range 
from 0 to 10 mm (millimeters); a 30 percent evaluation with 
interincisal range from 11 to 20 mm; a 20 percent evaluation with 
interincisal range from 21 to 30 mm; a 10 percent evaluation with 
interincisal range from 31 to 40 mm; and a 10 percent evaluation with 
lateral excursion of 0 to 4 mm.
    The understanding of what constitutes disability due to TMD and how 
to quantify the contributory components has evolved. Charles F. Guardia 
et al., Temporomandibular Disorders, Medscape, https://emedicine.medscape.com/article/1143410-overview#showall (last updated 
Jan. 7, 2014). The Work Group developed rating criteria that takes into 
account restriction of diet and limitation of mouth opening in the 
evaluation of functional impairment due to TMD.
    In addition, VA proposes to revise the rating criteria according to 
the current indicators of normal range of mouth opening measured by 
vertical (inter-incisal) opening. Guidelines to the Evaluation of 
Impairment of the Oral and Maxillofacial Region, American Association 
of Oral and Maxillofacial Surgeons, https://www.astmjs.org/impairment.html. Under proposed diagnostic code 9905, 10 mm of maximum 
unassisted vertical opening with dietary restrictions to all 
mechanically altered foods would warrant a 50 percent evaluation; 10 mm 
of maximum unassisted vertical opening without dietary restrictions to 
mechanically altered foods would warrant a 40 percent evaluation; 20 mm 
of maximum unassisted vertical opening with dietary restrictions to all 
mechanically altered foods would warrant a 40 percent evaluation; 20 mm 
of maximum unassisted vertical opening without dietary restrictions to 
mechanically altered foods would warrant a 30 percent evaluation; 29 mm 
of maximum unassisted vertical opening with dietary restrictions to 
full liquid and pureed foods would warrant a 40 percent evaluation; 29 
mm of maximum unassisted vertical opening with dietary restrictions to 
soft and semi-solid foods would warrant a 30 percent evaluation; 29 mm 
of maximum unassisted vertical opening without dietary restrictions to 
mechanically altered foods would warrant a 20 percent evaluation; 34 mm 
of maximum unassisted vertical opening with dietary restrictions to 
full liquid and pureed foods would warrant a 30 percent evaluation; 34 
mm of maximum unassisted vertical opening with dietary restrictions to 
soft and semi-solid foods would warrant a 20 percent evaluation; 34 mm 
of maximum unassisted vertical opening without dietary restrictions to 
mechanically altered foods would warrant a 10 percent evaluation. VA 
proposes retaining the current criteria at 10 percent for lateral 
excursion limited to 0 to 4 mm, in addition to adding the 10 percent 
evaluation for 34 mm of maximum unassisted vertical opening without 
dietary restrictions to mechanically altered foods.
    The additional criteria were added to integrate the use of 
mechanically altered foods that allows for more accurate assessment of 
functional capacity in cases of temporomandibular disorder that 
requires texture-modified diets. Furthermore, properly prepared 
texture-modified diets can help improve or maintain the nutritional 
status of a patient who requires a texture-modified diet. Evidence-
Based Nutrition Practice Guidelines and Evidence-Based Toolkits 
developed by the Academy of Nutrition and Dietics (formerly American 
Dietetic Association) defines mechanically altered foods as altered by 
blending, chopping, grinding or mashing so that they are easy to chew 
and swallow (i.e., full liquid, puree, soft and semisolid foods). 
Academy of Nutrition and Dietics, Level 2 Nutrition Therapy for 
Dysphagia: Mechanically Altered Foods, https://nutritioncaremanual.org/vault/editor/Docs/Level%202%20NT%20for%20Dysphagia_MechAltered.pdf 
(last visited Jun. 3, 2015).
    In addition to the existing note, VA proposes to add two notes 
under diagnostic code 9905 to provide comprehensive guidance to 
disability rating personnel. The existing note would be redesignated as 
Note (1). Note (2) would provide that the normal maximum unassisted 
range of vertical jaw opening is from 35 to 50 mm, which is based on 
current guidelines to the evaluation of impairment of the oral and 
maxillofacial region. Guidelines to the Evaluation of Impairment of the 
Oral and Maxillofacial Region, American Association of Oral and 
Maxillofacial Surgeons, https://www.astmjs.org/impairment.html (last 
visited Jun. 3, 2015). The guidance on consideration of texture-
modified diets is provided in proposed note (3). Proposed note (3) 
would define ``mechanically altered foods'' as altered by blending, 
chopping, grinding or mashing so that they are easy to chew and 
swallow, specifically full liquid, puree, soft and semisolid foods. 
Finally, proposed note (3) instructs disability rating specialists 
that, in order to warrant a rating elevation based on mechanically 
altered foods, a physician must record or verify the use of texture-
modified diets.

Diagnostic Code 9911 ``Hard Palate, Loss of:''

    Current diagnostic codes 9911 ``Hard palate, loss of half or 
more:'' and 9912 ``Hard palate, loss of less than half of:'' address 
loss of the hard palate. VA proposes to restructure the current rating 
criteria and combine evaluations presently done under these two codes

[[Page 44917]]

into proposed diagnostic code 9911, titled ``Hard palate, loss of:'' 
for ease of use. No change to the evaluation criteria is proposed.

Diagnostic Code 9916 ``Maxilla, Malunion or Nonunion of:''

    Current diagnostic code 9916 addresses impairments associated with 
malunion or nonunion of maxilla. Currently, severe displacement due to 
malunion or nonunion of maxilla warrants a 30 percent evaluation, while 
moderate and slight displacement warrant 10 and 0 percent evaluations, 
respectively. However, the current criteria do not reflect modern 
medical terminology and do not take into account advances in the 
understanding of anatomy and physiology of maxillary fractures and its 
residuals. Kris S. Moe et al., Maxillary and Le Fort Fractures, 
Medscape, https://emedicine.medscape.com/article/1283568-overview (last 
updated Dec. 3, 2013).
    Therefore, VA proposes to restructure the rating criteria to 
recognize the various aspects of maxillary fractures and their 
functional outcomes. Specifically, in cases of nonunion, the mobility 
of the maxillary fracture segments is the key sign of nonunion; 
therefore, disability evaluations would be based on the presence or 
absence of false motion. In cases of malunion, improper alignment of 
the healed bony segments, which result in abnormal occlusion (i.e., 
open bite) and joint function, is the principal component of functional 
impairment due to maxillary malunion; therefore, disability evaluations 
would be based on the degree of displacement of bony segments, which 
cause various degrees of open bite.
    Under proposed diagnostic code 9916, maxillary nonunion with false 
motion present would warrant a 30 percent evaluation. A 10 percent 
evaluation would be assigned for maxillary nonunion without false 
motion.
    Under proposed diagnostic code 9916, maxillary malunion with 
displacement that causes severe or moderate anterior or posterior open 
bite would warrant 30 and 10 percent evaluations, respectively. A 0 
percent evaluation would be assigned for maxillary malunion with 
displacement that causes mild anterior or posterior open bite. For the 
sake of clarity for disability rating personnel, VA proposes to insert 
a new note stating that, for VA compensation purposes, the severity of 
maxillary nonunion is dependent upon the degree of abnormal mobility of 
maxilla fragments following treatment (i.e., presence or absence of 
false motion), and that maxillary nonunion has to be confirmed by 
diagnostic imaging studies. Maxillary nonunion is difficult to diagnose 
without diagnostic imaging studies because fibrosis makes nonunions 
semi-stable and mimic healed bone upon physical examination. Thus, 
diagnostic imaging is necessary for a diagnosis of nonunion.

New Diagnostic Codes

    VA also proposes to add two new diagnostic codes in order to 
account for impairment due to benign and malignant oral lesions 
(neoplasms). Nader Sadeghi et al., Malignant Tumors of the Palate, 
Medscape, https://emedicine.medscape.com/article/847807-overview (last 
updated Apr. 22, 2015). Surgical resections of benign and malignant 
tumors often create large defects accompanied by dysfunction and 
disfigurement, and radiation therapy produces significant morbidity and 
unique tissue-management problems. Therefore, disabilities resulting 
from various treatments for benign and malignant neoplasms shall be 
rated based on residuals such as loss of supporting structures (bone or 
teeth) and/or functional impairment due to scarring.
    Proposed diagnostic code 9917, titled ``Neoplasm, hard and soft 
tissue, benign,'' directs that such conditions be rated as loss of 
supporting structures (bone or teeth) and/or functional impairment due 
to scarring. Proposed diagnostic code 9918, titled ``Neoplasm, hard and 
soft tissue, malignant,'' directs that such conditions be rated at 100 
percent. The note following diagnostic code 9918 would state that the 
rating of 100 percent shall continue beyond the cessation of any 
surgical, radiation, antineoplastic chemotherapy or other therapeutic 
procedure and that, six months after discontinuance of such treatment, 
the appropriate disability rating shall be determined by mandatory VA 
examination. The note would also state that any change in evaluation 
based upon that or any subsequent examination shall be subject to the 
provisions of 38 CFR 3.105(e). Lastly, the note would direct rating 
personnel to evaluate based on residuals, such as loss of supporting 
structures and/or functional impairment due to scarring, if there has 
been no local recurrence or metastasis.

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).

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.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) defines a 
``significant regulatory action,'' which requires review by the Office 
of Management and Budget (OMB), 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 regulatory action 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

[[Page 44918]]

document is published. Additionally, a copy of the 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.

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.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.011, Veterans Dental 
Care, and 64.109, Veterans Compensation for Service-Connected 
Disability.

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 L. 
Nabors, II, Chief of Staff, approved this document on June 30, 2015, 
for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Dated: July 9, 2015.
William F. Russo,
Acting Director, Office of Regulation Policy & Management, Office of 
the General Counsel, Department of Veterans Affairs.
    For the reasons stated in the preamble, VA proposes to amend 38 CFR 
part 4, subpart B as set forth below:

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.  4.150 by revising the entries for diagnostic codes 9900, 
9902-9905, 9911, 9916; adding Notes 1 and 2, diagnostic codes 9917 and 
9918; and removing diagnostic codes 9906, 9907, and 9912.
    The revisions and addtions read as follows:


Sec.  4.150  Schedule of ratings--dental and oral conditions.

Note (1): For VA compensation purposes, diagnostic
 imaging studies include, but are not limited to,
 conventional radiography (X-ray), computed tomography
 (CT), magnetic resonance imaging (MRI), positron
 emission tomography (PET), radionuclide bone scanning,
 or ultrasonography.....................................
Note (2): Separately evaluate loss of vocal
 articulation, loss of smell, loss of taste,
 neurological impairment, respiratory dysfunction, and
 other impairments under the appropriate diagnostic code
 and combine under Sec.   4.25 for each separately rated
 condition..............................................
9900 Maxilla or mandible, chronic osteomyelitis,
 osteonecrosis or osteoradionecrosis of:
    Rate as osteomyelitis, chronic under diagnostic code
     5000...............................................
 
                              * * * * * * *
9902 Mandible loss of, including ramus, unilaterally or
 bilaterally:
    Loss of one-half or more,
        Involving temporomandibular articulation........
            Not replaceable by prosthesis...............              70
            Replaceable by prosthesis...................              50
        Not involving temporomandibular articulation....
            Not replaceable by prosthesis...............              40
            Replaceable by prosthesis...................              30
    Loss of less than one-half,
        Involving temporomandibular articulation........
            Not replaceable by prosthesis...............              70
            Replaceable by prosthesis...................              50
        Not involving temporomandibular articulation....
            Not replaceable by prosthesis...............              20
            Replaceable by prosthesis...................              10
9903 Mandible, nonunion of, confirmed by diagnostic
 imaging studies:
    Severe, with false motion...........................              30
    Moderate, without false motion......................              10
9904 Mandible, malunion of:
    Displacement, causing severe anterior or posterior                20
     open bite..........................................
    Displacement, causing moderate anterior or posterior              10
     open bite..........................................
    Displacement, not causing anterior or posterior open               0
     bite...............................................
9905 Temporomandibular disorder (TMD).
    Interincisal range:
        10 millimeters (mm) of maximum unassisted
         vertical opening...............................
            With dietary restrictions to all                          50
             mechanically altered food..................
            Without dietary restrictions to mechanically              40
             altered foods..............................
        20 mm of maximum unassisted vertical opening....
            With dietary restrictions to all                          40
             mechanically altered foods.................
            Without dietary restrictions to mechanically              30
             altered foods..............................
        29 mm of maximum unassisted vertical opening....
            With dietary restrictions to full liquid and              40
             pureed foods...............................
            With dietary restrictions to soft and semi-               30
             solid foods................................
            Without dietary restrictions to mechanically              20
             altered foods..............................
        34 mm of maximum unassisted vertical opening....
            With dietary restrictions to full liquid and              30
             pureed foods...............................

[[Page 44919]]

 
            With dietary restrictions to soft and semi-               20
             solid foods................................
            Without dietary restrictions to mechanically              10
             altered foods..............................
    Lateral excursion range of motion:
        0 to 4 mm.......................................              10
Note (1): Ratings for limited interincisal movement
 shall not be combined with ratings for limited lateral
 excursion.
Note (2): For VA compensation purposes, the normal
 maximum unassisted range of vertical jaw opening is
 from 35 to 50 mm.
Note (3): For VA compensation purposes, mechanically
 altered foods are defined as altered by blending,
 chopping, grinding or mashing so that they are easy to
 chew and swallow. There are four levels of mechanically
 altered foods: full liquid, puree, soft, and semisolid
 foods. To warrant elevation based on mechanically
 altered foods, the use of texture-modified diets must
 be recorded or verified by a physician.
 
                              * * * * * * *
9911 Hard palate, loss of:
    Loss of half or more, not replaceable by prosthesis.              30
    Loss of less than half, not replaceable by                        20
     prosthesis.........................................
    Loss of half or more, replaceable by prosthesis.....              10
    Loss of less than half, replaceable by prosthesis...               0
 
                              * * * * * * *
9916 Maxilla, malunion or nonunion of:
    Nonunion,
        with false motion...............................              30
        without false motion............................              10
    Malunion,
        with displacement, causing severe anterior or                 30
         posterior open bite............................
        with displacement, causing moderate anterior or               10
         posterior open bite............................
        with displacement, causing mild anterior or                    0
         posterior open bite............................
Note: For VA compensation purposes, the severity of
 maxillary nonunion is dependent upon the degree of
 abnormal mobility of maxilla fragments (i.e., presence
 or absence of false motion), and maxillary nonunion
 must be confirmed by diagnostic imaging studies.
9917 Neoplasm, hard and soft tissue, benign.
    Rate as loss of supporting structures (bone or
     teeth) and/or functional impairment due to
     scarring.
9918 Neoplasm, hard and soft tissue, malignant..........             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. If
     there has been no local recurrence or metastasis,
     rate on residuals such as loss of supporting
     structures (bone or teeth) and/or functional
     impairment due to scarring.
------------------------------------------------------------------------

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

0
3. Amend Appendix A to Part 4 by revising the entries for diagnostic 
codes 9900, 9902, 9903, 9905, 9911, 9916; adding diagnostic codes 9904, 
9917 and 9918; and removing diagnostic codes 9906, 9907, and 9912 to 
read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                                   Diagnostic
              Sec.                  Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
 
                              * * * * * * *
                                           9900  Criterion September 22,
                                                  1978; criterion
                                                  February 17, 1994;
                                                  title [effective date
                                                  of final rule].
 
                              * * * * * * *
                                           9902  Criterion February 17,
                                                  1994; evaluation
                                                  [effective date of
                                                  final rule]; title
                                                  [effective date of
                                                  final rule].
                                           9903  Criterion February 17,
                                                  1994; evaluation
                                                  [effective date of
                                                  final rule]; title
                                                  [effective date of
                                                  final rule].
                                           9904  Criterion [effective
                                                  date of final rule].
                                           9905  Criterion September 22,
                                                  1978; evaluation
                                                  February 17, 1994;
                                                  evaluation [effective
                                                  date of final rule];
                                                  title [effective date
                                                  of final rule].
                                           9906  Removed [effective date
                                                  of final rule].
                                           9907  Removed [effective date
                                                  of final rule].
 
                              * * * * * * *
                                           9911  Criterion and title
                                                  [effective date of
                                                  final rule].
                                           9912  Removed [effective date
                                                  of final rule].
 
                              * * * * * * *
                                           9916  Added February 17,
                                                  1994; criterion
                                                  [effective date of
                                                  final rule].
                                           9917  Added [effective date
                                                  of final rule].
                                           9918  Added [effective date
                                                  of final rule].

[[Page 44920]]

 
 
                              * * * * * * *
------------------------------------------------------------------------

0
4. Amend Appendix B to Part 4 by revising the entries for diagnostic 
codes 9900, 9902, 9903, 9905, and 9911; adding 9917 and 9918; and 
removing 9906, 9907, and 9912.
    The revisions read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
        Diagnostic Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                       DENTAL AND ORAL CONDITIONS
------------------------------------------------------------------------
9900..............................  Maxilla or mandible, chronic
                                     osteomyelitis, osteonecrosis or
                                     osteoradionecrosis of.
 
                              * * * * * * *
9902..............................  Mandible loss of, including ramus,
                                     unilaterally or bilaterally.
9903..............................  Mandible, nonunion of, confirmed by
                                     diagnostic imaging studies.
 
                              * * * * * * *
9905..............................  Temporomandibular disorder (TMD).
 
                              * * * * * * *
9911..............................  Hard palate, loss of.
 
                              * * * * * * *
9917..............................  Neoplasm, hard and soft tissue,
                                     benign.
9918..............................  Neoplasm, hard and soft tissue,
                                     malignant.
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Amend Appendix C to Part 4 by revising the entries for diagnostic 
codes 9900, 9902, 9903, 9905, and 9911; adding 9917 and 9918; and 
removing 9906, 9907, and 9912.
    The revisions and additions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Limitation of motion:
    Temporomandibular...................................            9905
 
                              * * * * * * *
Mandible:
    Including ramus, unilaterally or bilaterally........            9902
 
                              * * * * * * *
Loss of:
    Palate, hard........................................            9911
 
                              * * * * * * *
    Maxilla or mandible, chronic osteomyelitis,                     9900
     osteonecrosis or osteoradionecrosis of.............
 
                              * * * * * * *
Neoplasms:
    Benign:
 
                              * * * * * * *
        Hard and soft tissue............................            9917
 

[[Page 44921]]

 
                              * * * * * * *
    Malignant:
 
                              * * * * * * *
        Hard and soft tissue............................            9918
 
                              * * * * * * *
Nonunion:
    Mandible, confirmed by diagnostic imaging studies...            9903
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2015-17266 Filed 7-27-15; 8:45 am]
 BILLING CODE 8320-01-P