Schedule for Rating Disabilities; Skin Conditions, 53353-53362 [2016-18695]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 81, Number 156 (Friday, August 12, 2016)]
[Proposed Rules]
[Pages 53353-53362]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-18695]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP27


Schedule for Rating Disabilities; Skin 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 skin conditions. 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 Skin Disorders Work Group, which is 
comprised of subject matter experts from both the Veterans Benefits 
Administration and the Veterans Health Administration, and comments 
from experts and the public gathered as part of a public forum. The 
public forum, focusing on revisions to the skin conditions section of 
the VASRD, was held in January 2012.

DATES: Comment Date: Comments must be received by VA on or before 
October 11, 2016.
    Applicability Date: The provisions of this rulemaking shall apply 
to all applications for benefits that are received by VA or that are 
pending before the agency of original jurisdiction on or after the 
effective date of the final rule. The Secretary does not intend for the 
provisions of this rulemaking to apply to claims that have been 
certified for appeal to the Board of Veterans' Appeals or are pending 
before the Board of Veterans' Appeals, the United States Court of 
Appeals for Veterans Claims, or the United States Court of Appeals for 
the Federal Circuit.

ADDRESSES: Written comments may be submitted through 
www.Regulations.gov; by mail or hand-delivery to Director, Regulation 
Policy and Management (02REG), Department of Veterans Affairs, 810 
Vermont Avenue NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. (This is not a toll free number.) Comments should indicate 
that they are submitted in response to ``RIN 2900-AP27-Schedule for 
Rating Disabilities; Skin 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: Gary Reynolds, M.D., Regulations Staff 
(211C), Compensation Service, Veterans Benefits Administration, 
Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 
20420, (202) 461-9700. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: The National Defense Authorization Act For 
Fiscal Year 2004, sec. 1501-07, Public Law 108-136, 117 Stat. 1392, 
established the Veterans' Disability Benefits Commission (Commission). 
Section 1502 of Public Law 108-136 mandated the Commission to study 
ways to improve the disability compensation system for disabled 
military veterans. The Commission consulted with the Institute of 
Medicine (IOM) to review the medical aspects of the current disability 
compensation policies for veterans. In 2007, the IOM released its 
report titled, ``A 21st Century System for Evaluating Veterans for 
Disability Benefits.''
    The IOM Report was notable in several respects. The IOM observed, 
in part, that the VASRD was inadequate at times because it contained 
obsolete information and did not sufficiently integrate current and 
accepted diagnostic procedures. In addition, the IOM observed that the 
current body system organization of the VASRD does not reflect current 
knowledge of the relationships between conditions and comorbidities. 
Institute of Medicine, Committee on Medical Evaluation of Veterans for 
Disability Compensation, ``A 21st Century System for Evaluating 
Veterans for Disability Benefits,'' 113 (Michael McGeary et al. eds. 
2007).
    Following release of the IOM report, VA created a Skin Disorders 
Work Group (Work Group). The goals adopted by the Work Group were to: 
1) improve and update the criteria that VA uses to assign levels of 
disability after service connection is granted; 2) improve the level of 
fairness in adjudication of benefits related to service connected 
disabilities of Veterans; and 3) invite public participation. The Work 
Group was led by co-chairs from the Veterans Health Administration 
(VHA) and Veterans Benefits Administration (VBA). The workgroup was 
comprised of subject matter experts (SMEs) from within VA, DoD, and 
medical academia. In addition, members from several Veterans Service 
Organizations (VSOs) were invited to participate as representatives 
from the public. The Work Group held a public forum in New York City 
during January 2012, where several SMEs gave presentations focused on 
their particular area(s) of expertise.
    After the public forum, the Work Group met periodically to continue 
the revision efforts. Participants from VBA, VHA, medical academia, and 
VSO representatives continued work within their areas of expertise. The 
regulation drafting phase began in September 2013, and continues 
through the publication of this proposed rule. The rule VA proposes is 
consistent with updating and improving criteria by using validated 
severity ratings specific to the skin for each of the disability rating 
levels. As discussed in more detail below, the newly adopted 
classifications are derived from current medical practice.

Schedule of Ratings--Skin Conditions

General Rating Formula for Skin Disorders

    Section 4.118 currently lists 30 diagnostic codes (DCs) 
encompassing conditions involving injury or disease of the skin. VA 
proposes to revise these codes, through addition, removal, or other 
revisions, to reflect current medical science, terminology, and 
functional impairment.
    VA would delete the current introductory paragraph to Sec.  4.118. 
VA added the current paragraph to explain the applicability of the 2008 
amendments to Sec.  4.118, DCs 7800, 7801, 7802, 7804, and 7805. This 
rulemaking would make further amendments and would render outdated the 
current introductory paragraph. VA would add an applicability date 
paragraph to the dates section to explain this rulemaking's 
applicability. The existing provisions in Sec.  4.118 concerning review 
of ratings and effective dates merely reflect generally applicable 
principles that need not be restated in the rating schedule.
    VA would add a new introductory paragraph to state that, for the 
purposes of Sec.  4.118, systemic therapy is treatment that is 
administered through any route (orally, injection, suppository, 
intranasally) other than the skin, and topical therapy is treatment 
that is administered through the skin. On March 1, 2016, the United 
States Court

[[Page 53354]]

of Appeals for Veterans Claims (Veterans Court) found it 
``unambiguous'' that the ``use of a topical corticosteroid is systemic 
therapy within the meaning of Diagnostic Code 7806.'' Johnson v. 
McDonald, 27 Vet. App. 497, 502, 504 (2016). Under this holding, 
repeated localized application of topical corticosteroid could entitle 
a veteran to a disability rating as high as sixty percent, even if the 
affected area is very small. Johnson creates a dramatic disconnect 
between the severity of the veteran's disability and the corresponding 
rating. Therefore, VA is amending Sec.  4.118 to clearly provide that 
VA does not intend for treatment administered through the skin (topical 
therapy) to constitute systemic therapy. VA notes that it is possible 
for topical treatments to have systemic effects if administered on a 
large enough scale. However, in these situations, a veteran can obtain 
a higher rating due to the percentage of the body affected, not the 
mode of administration for his or her treatment. For example, if more 
than 40 percent of a veteran's body is covered in eczema and a veteran 
treats all affected areas with topical corticosteroid, the veteran will 
be entitled to a 60 percent rating due to the percentage of the body 
affected, not because he is taking systemic therapy.
    VA proposes a General Rating Formula to evaluate several of the 
skin disorders: dermatitis or eczema (DC 7806), discoid lupus 
erythematosus (DC 7809), dermatophytosis (DC 7813), bullous disorders 
(DC 7815), psoriasis (DC 7816), infections of the skin not listed 
elsewhere (DC 7820), cutaneous manifestations of collagen-vascular 
diseases not listed elsewhere (DC 7821), papulosquamous disorders not 
listed elsewhere (DC 7822), and diseases of keratinization (DC 7824). 
Individually, each of the above referenced conditions involves similar 
superficial components of the skin. The severity of impairment for each 
condition increases as more skin is involved. All of the conditions 
have treatments which are applied directly to the skin, as well as 
taken systemically (e.g., by mouth). There are still more similarities 
with regard to which treatments are used, treatment dosages given, 
treatment routes of administration, and treatment duration. As a 
result, VA concluded it would be more efficient to rate under the same 
formula, rather than to prescribe individual rating criteria.
    Similar to how these DCs are currently evaluated, this General 
Rating Formula accounts for percentages of areas affected, both of the 
entire body and exposed areas, as well as the level of treatment 
required. The percentage evaluations assigned under the General Rating 
Formula mirror the percentage evaluations currently assigned for these 
DCs. Specifically, VA proposes a 60 percent evaluation when at least 
one of the following is present: More than 40 percent of the entire 
body or more than 40 percent of exposed areas affected, or; Constant or 
near-constant systemic therapy including, but not limited to, 
corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, 
PUVA or other immunosuppressive drugs required per 12-month period. VA 
proposes a 30 percent evaluation when at least one of the following is 
present: 20 to 40 percent of the entire body or 20 to 40 percent of 
exposed areas affected, or; Systemic therapy including, but not limited 
to, corticosteroids, phototherapy, retinoids, biologics, 
photochemotherapy, PUVA or other immunosuppressive drugs required for a 
total duration of six weeks or more, but not constantly, per 12-month 
period. VA proposes a 10 percent evaluation when at least one of the 
following is present: At least 5 percent, but less than 20 percent of 
the entire body affected, or; At least 5 percent, but less than 20 
percent of exposed areas affected, or; Intermittent systemic therapy 
including, but not limited to, corticosteroids, phototherapy, 
retinoids, biologics, photochemotherapy, PUVA or other 
immunosuppressive drugs required for a total duration of less than six 
weeks per 12-month period. VA proposes a zero percent evaluation when 
no more than topical therapy is required per 12-month period and at 
least one of the following is present: Less than 5 percent of the 
entire body affected, or; Less than 5 percent of exposed areas 
affected.
    Additionally, VA proposes to maintain the current rating 
instruction for DCs 7806, 7809, 7813-7816, and 7820-7822 which allows 
for evaluation under disfigurement of the head, face, or neck (DC 7800) 
or scars (DCs 7801, 7802, 7804, or 7805), depending upon the 
predominant disability, in lieu of using the General Rating Formula. 
This rating instruction does not apply to current or new DC 7824, and 
therefore, VA proposes to add a clarifying sentence to that effect to 
this instruction.
    As for the expanded list of systemic therapies identified in the 
General Rating Formula, VA notes that the current VASRD lists only 
``corticosteroids or other immunosuppressive drugs'' as examples of 
systemic therapy. However, since the last review and update of the 
schedule of disability ratings for the skin, a number of new systemic 
therapies have surfaced that are used to treat the conditions covered 
under the General Rating Formula. These include phototherapy, 
retinoids, biologics, photochemotherapy, and PUVA (e.g., ultraviolet 
therapy). See, e.g., Jennifer D. Peterson, MD, et al., ``A 
Comprehensive Management Guide for Atopic Dermatitis,'' 18:6 
Dermatology Nursing, 531-42 (2006); ``Psoriasis Medications,'' WebMD, 
https://www.webmd.com/skin-problems-and-treatments/psoriasis/psoriasis-medications (last visited Aug. 25, 2015). To ensure consistent 
evaluation of these conditions, VA proposes to add these systemic 
therapies to the list of enumerated treatments.
    In addition to creating the General Rating Formula and applying it 
to DCs 7806, 7809, 7813, 7815, 7816, 7820, 7821, 7822, and 7824, VA 
proposes to amend certain individual DCs within Sec.  4.118. The 
particular changes affecting each DC immediately follow.

Diagnostic Codes 7801 and 7802

    Each of these DCs pertains to types of scars which are, in part, 
characterized as ``nonlinear.'' To broaden application of these DCs, VA 
proposes to remove the reference to ``nonlinear'' from each DC title. 
In addition, VA proposes to include a more descriptive reference to 
whether the scar involves underlying soft tissue damage in place of the 
current terms ``superficial'' and ``deep''--to assist rating personnel. 
This latter proposed change eliminates the need for current note (1) in 
each DC, as well as the last sentence in note (2) in each DC; 
therefore, VA proposes removal of those items.
    Currently, if a scar runs in two or more separate areas of the 
body, note (2) for DCs 7801 and 7802 is intended to allow for the 
assignment of a separate evaluation for each affected zone and then to 
combine those evaluations under 38 CFR 4.25. See 73 FR 54708, 54709, 
Sept. 23, 2008. Although VA has been applying note (2) in this way, VA 
finds that the note could be written more clearly. Therefore, VA 
proposes to rewrite note (2) in a clearer and more concise manner and 
to add a new note (1) to be placed under both DCs 7801 and 7802 that 
would define the zones of the body. Specifically, note (1) would define 
the six zones of the body as each extremity, the anterior trunk, and 
the posterior trunk. VA also proposes to move the statement that the 
midaxillary line is what divides the anterior and posterior trunk from 
note (2) to note (1).
    Additionally, VA proposes to add language to note (2) to allow for 
an alternative evaluation. Specifically, VA proposes to allow for a 
single evaluation

[[Page 53355]]

under DCs 7801 and 7802 if adding the entire affected zones of the body 
together would result in a higher evaluation. VA proposes this 
additional evaluation method in order to accurately reflect the level 
of disability present. In some circumstances, combining the scars from 
different zones under Sec.  4.25 results in a lower compensation level 
than if the total scar area was added together without regard to the 
zone involved. For example, under DC 7801, if there is a single scar of 
6 square inches total equally affecting both the anterior and posterior 
trunk, a compensable rating would not be warranted because the area 
affecting each zone would be less than 6 square inches total (e.g., 3 
square inches on the anterior trunk and 3 square inches on the 
posterior trunk). However, when adding these scar segments together to 
consider the total square area (6 square inches), a 10 percent 
evaluation would be warranted. Similarly, under DC 7802, there may be 
scars in separate zones that are not each 144 square inches, but which 
add up to 144 square inches total. For example, a veteran may have a 
100 square inch scar on the anterior trunk and a 100 square inch scar 
on the posterior trunk, which would not warrant a compensable rating 
under DC 7802. However, an evaluation of 10 percent would be warranted 
by adding the affected zones together for both scars, as they total to 
200 square inches together.

Diagnostic Code 7803

    This DC was deleted in October 2008. See 73 FR at 54710. However, 
several criteria reference this code. VA proposes to delete any and all 
references to DC 7803.

Diagnostic Code 7805

    VA proposes to remove the reference to ``linear'' scars from DC 
7805. The result of this change is that this DC applies to both linear 
and non-linear scars. As discussed above, VA proposes to remove the 
reference to ``nonlinear'' scars from DCs 7801 and 7802, expanding 
application of these codes to linear scars. Thus, the reference to 
linear scars should be removed from DC 7805 to avoid confusion by 
rating personnel.

Diagnostic Codes 7809 and 7821

    VA proposes to retitle both DC 7809 and DC 7821 using current 
medical terminology. Current DC 7809 refers to ``Discoid lupus 
erythematosus or subacute cutaneous lupus erythematosus.'' VA proposes 
to remove the listed condition ``subacute cutaneous lupus 
erythematosus'' from DC 7809 and add it to DC 7821. The proposed DC 
7809 will read as ``Discoid lupus erythematosus. Current DC 7809 also 
provides that a rating under DC 7809 should not be combined with a 
rating under DC 6350. In order to maintain this provision, we would add 
a note to DC 7809. The rationale for transferring subacute cutaneous 
lupus erythematosus from DC 7809 to DC 7821 is that subacute cutaneous 
lupus erythematosus is a distinctly different condition which is more 
analogous to collagen-vascular diseases not listed elsewhere (e.g., DC 
7821) than it is to discoid lupus erythematosus. See Jean L. Bolognia, 
John L. Jorrizo, et al. eds., ``Dermatology,'' 618-20 (3d ed. 2012). 
The proposed DC 7821 will read as ``Cutaneous manifestations of 
collagen-vascular diseases not listed elsewhere (including scleroderma, 
calcinosis cutis, subacute cutaneous lupus erythematosus, and 
dermatomyositis).'' There is no change in the evaluation criteria; both 
conditions would be rated under the General Rating Formula.

Diagnostic Code 7813

    Current DC 7813 describes a number of variations of 
dermatophytosis, including tinea corporis, tinea capitis, tinea pedis, 
tinea barbae, tinea unguium, and tinea cruris. To update this DC title 
with current medical terminology, VA proposes to add ``tinea 
versicolor'' to this list as well as a parenthetical for tinea 
unguium--onychomycosis as these are also common variations of 
dermatophytosis seen in the veteran population. Id. at 1251-84. As 
previously discussed above, VA intends to rate conditions covered by DC 
7813 under the General Rating Formula, which provides for similar 
evaluation criteria as are currently in effect.

Diagnostic Codes 7815 and 7816

    Current medical practice indicates conditions rated under DC 7815 
(bullous disorders) and DC 7816 (psoriasis) can affect additional areas 
beyond the skin (bullous disorders can affect mucosa of the ocular, 
oral, gastrointestinal, respiratory, and genitourinary tracts; 
psoriasis can affect oral mucosa, nails and the joints). Id. at 142, 
148-55, 472-73, 482, and 487-89. Therefore, in addition to rating these 
conditions under the General Rating Formula, VA proposes a note for 
each of these DCs. The note to DC 7815 would instruct the rater to rate 
complications and residuals of mucosal involvement (ocular, oral, 
gastrointestinal, respiratory, and genitourinary) separately under the 
appropriate diagnostic code. The note to DC 7816 would instruct the 
rater to rate complications such as psoriatic arthritis and other 
clinical manifestations (oral mucosa, nails) under the appropriate 
diagnostic code.

Diagnostic Code 7817

    VA proposes to retitle DC 7817, currently ``Exfoliative dermatitis 
(erythroderma),'' as ``Erythroderma.'' Erythroderma is the nomenclature 
being used in current medical practice. Id. at 171-81. In addition, it 
proposes to update the rating criteria to reflect up-to-date medical 
understanding of this condition. VA would also slightly reorganize the 
presentation of criteria for ease of field use. Currently, this 
condition is evaluated based upon level of involvement of the skin, 
presence of systemic manifestations, and the level of treatment 
required. VA does not propose any changes to the level of involvement 
of the skin, presence of systemic manifestations, or the level of 
treatment required. However, similar to the changes proposed in the 
General Rating Formula, the new rating criteria for DC 7817 would 
reflect additional systemic treatments appropriate for this condition. 
Currently, DC 7817 includes corticosteroids, immunosuppressive 
retinoids, PUVA (psoralen with long-wave ultraviolet-A light) or UVB 
(ultraviolet-B light) treatments, or electron beam therapy. VA proposes 
to add biologics to this list as several biological therapies have been 
approved for treatment of skin disorders in recent years. See M. 
Viguier, et al., ``Efficacy and Safety of Biologics in Erythrodermic 
Psoriasis,'' The British J. of Dermatology 167(2): 417-23 (2012). VA 
proposes that inclusion of this type of systemic therapy in the rating 
criteria would ensure consistent and accurate evaluations.
    In addition to expanding the list of systemic therapies listed, VA 
proposes to include a criterion which considers an individual's level 
of response to treatment for both the 60 percent and 100 percent 
evaluations. Under the new criteria, VA would provide a 100 percent 
rating when the veteran is not currently undergoing treatment due to a 
documented history of treatment failure with 2 or more treatment 
regimens and a 60 percent rating when the veteran is not currently 
undergoing treatment due to a documented history of treatment failure 
with 1 treatment regimen. Historically, there have been a significant 
number of veterans with this disorder who fail to respond to treatment 
(frequently, the condition is related to an underlying malignancy that 
is not treated successfully, hence the treatment failure).

[[Page 53356]]

    To assist rating personnel in applying the new rating criteria, VA 
proposes to add a note to DC 7817 which defines ``treatment failure.'' 
Modeled after a formula developed to study the efficacy of treatment in 
erythrodermic cutaneous T-cell lymphoma, VA proposes to define 
``treatment failure'' as either disease progression or less than a 25 
percent reduction in the extent and severity of disease after four 
weeks of prescribed therapy, as documented by medical records. See 
Zackheim HS, Kashani-Sabet M, et al., ``Low-dose methotrexate to treat 
erythrodermic cutaneous T-cell lymphoma: Results in twenty-nine 
patients,'' J. Am. Acad. of Dermatology 34(4):626-31 (1996); see also 
Bolognia, supra at 181 (erythroderma usually improves within two to six 
weeks of initiation).

Diagnostic Code 7822

    VA proposes to update the description in this code to reflect 
current medical practice. Specifically, the condition mycosis fungoides 
is added to the list of papulosquamous disorders. See Bolognia, 2019-
2027. Currently, mycosis fungoides is not listed in the rating schedule 
and has caused confusion among VA rating specialists on how to account 
for this condition, leaving VA rating specialists to invoke Sec.  4.20, 
analogous ratings. This approach could lead to inconsistent ratings for 
this condition. Therefore, adding mycosis fungoides under DC 7822 would 
eliminate the need for an analogous rating and provide a consistent 
basis for evaluating this condition.

Diagnostic Code 7825

    Chronic urticaria, also known as chronic hives, is defined as 
continuous urticaria at least twice per week off treatment for a period 
of six weeks or more. See Bolognia at 295. It can be caused by a number 
of mechanisms (physical stimulus, or touch; autoimmune causes; 
pseudoallergenic, infection-related; vasculitis-related; and, 
idiopathic, or unknown). Id. at 296. Chronic urticaria is currently 
evaluated based on the frequency of ``episodes'' or ``debilitating 
episodes'' and type of treatment. Regarding ``episodes'' or 
``debilitating episodes,'' VA believes this term is non-specific and 
not helpful to rating personnel in evaluating this condition. 
Therefore, VA proposes to replace this term with ``documented 
urticarial attacks.'' Furthermore, VA proposes to revise all of the 
rating criteria to indicate both a minimum specified frequency of 
documented urticarial attacks within a 12 month period and the type of 
treatment required. VA proposes this approach to the criteria to 
introduce greater objectivity within the evaluation criteria based on 
current medical practice. VA acknowledges that an urticarial attack 
generally results in debilitation; however, this change makes it clear 
that the acute period of debilitation must be related to the service-
connected skin disease itself rather than another condition.
    Regarding the current 30 percent and 60 percent criteria, VA 
proposes to include examples of common ``immunosuppressive therapy,'' 
to include, but not limited to, cyclosporine or steroids. See Bolognia, 
supra at 300-05. For clarity and consistency, VA would replace the 
phrase occurring ``at least four times during the past 12-month 
period'' in the 30 and 60 percent criteria with ``four or more times 
per 12-month period.''
    VA also proposes to add two new sets of criteria under the 10 
percent evaluation; the revised criteria would allow a 10 percent 
evaluation to be assigned in more circumstances based upon an 
individual's level of response to treatment. A 10 percent evaluation 
would be assigned if there are recurrent documented urticarial attacks 
occurring one to three times during the past 12-month period and 
intermittent systemic immunosuppressive therapy is required for 
control. VA would also assign a 10 percent evaluation if there are 
recurrent documented urticarial attacks occurring four or more times 
during the past 12-month period and treatment with antihistamines or 
sympathomimetics (including, but not limited to an epipen or 
intramuscular epinephrine) is required or, if there are no recurrent 
documented urticarial attacks, but continuous systemic 
immunosuppressive therapy medication is required for control 
(including, but not limited to, cyclosporine, steroids). VA also 
proposes to reorganize how the various criteria are presented for ease 
of field use.
    VA believes that a 10 percent evaluation is appropriate in each of 
these cases because the treatment measures may impose slight disability 
upon the individual. For example, long term treatment with 
antihistamines can result in drowsiness (even the non-sedating kinds) 
and autonomic nervous system dysfunction (e.g., urinary retention). Id. 
at 303. Similarly, continuous use of systemic medications may result in 
disabling effects, such as drowsiness with doxepin or weight gain, and 
increased risk of diabetes with long-term steroid use. See Manuchair 
Ebadi, ``Desk Reference of Clinical Pharmacology,'' 101, 113, 329, and 
582 (2d ed. 2008); see also ``Chronic hives (urticaria),'' Mayo Clinic 
(Sept. 17, 2011), https://www.mayoclinic.org/diseases-conditions/chronic-hives/basics/treatment/con-20031634 (last visited Apr. 23, 
2014).

Diagnostic Code 7826

    Similar to DC 7825, VA proposes to update the criteria under 
current DC 7826, ``Vasculitis, primary cutaneous.'' First, VA proposes 
to replace the term ``debilitating episodes,'' which is a non-specific 
term not defined in the VASRD with the term ``documented vasculitic 
episodes.'' This change in terminology is more consistent with current 
medical practice. Next, VA proposes to modify the criteria to specify 
the minimum frequency of documented vasculitic episodes, the type of 
treatment required and the effectiveness of that treatment. In turn, 
increased disability would be reflected in objective terms (e.g., 
increased frequency of vasculitic episodes, more intensive treatment or 
lack of treatment effectiveness). VA also proposes to reorganize how 
the various criteria are presented for ease of field use. These 
modifications incorporate current medical knowledge, enhance 
objectivity and are easier for rating personnel to utilize.
    For the 60 percent level of compensation, VA proposes to remove the 
phrase ``occurring at least four times during the past 12 month 
period'' and replace the term ``recurrent'' with ``persistent'' and the 
term ``despite'' with the phrase ``refractory to.'' The phrase removal 
and term replacements are to more clearly differentiate between the 60 
percent and 30 percent compensation levels. For the 30 percent 
evaluation, VA proposes to replace the phrase ``. . . at least four 
times during the past 12-month period . . .'' with the phrase ``four or 
more times per 12-month period'' to clearly delineate the minimal 
frequency requirement and ease of field use. For the 10 percent 
evaluation, VA proposes to replace the phrase ``one to three times 
during the past 12-month period'' with ``one to three times per 12-
month period'' for ease of field use. Additionally for the 10 percent 
evaluation, VA proposes to add that the absence of recurrent documented 
vasculitic episodes but requiring continuous systemic medication for 
control would also warrant compensation. This proposed revision allows 
a 10 percent evaluation to be assigned in more circumstances, namely, 
when the disorder is controlled through the use of systemic 
medications, but there may be slight disabling effects as a result of 
such medication. See Ebadi, supra; see also

[[Page 53357]]

``Vasculitis,'' Mayo Clinic (Oct. 8, 2011), https://www.mayoclinic.org/diseases-conditions/vasculitis/basics/treatment/con-20026049 (last 
visited Apr. 23, 2014).

Diagnostic Code 7827

    VA proposes to revise and update the criteria for DC 7827, 
``Erythema multiforme; Toxic epidermal necrolysis.'' First, each 
evaluation level would reference the presence of mucosal (leading to 
impaired mastication, that is, chewing), palmar (leading to impaired 
handgrip), or plantar involvement (leading to impaired ambulation, that 
is, walking). See Bolognia, supra at 320, 322, and 326-32. The mucosal, 
palmar, and/or plantar findings would be restricted to the past 12-
month period for all evaluation levels. For clarity and consistency, VA 
would replace the phrase occurring ``at least four times during the 
past 12-month period'' in the 30 and 60 percent criteria with ``four or 
more times per 12-month period.'' For a 60 percent evaluation, 
recurrent mucosal, palmar, or plantar involvement impairing 
mastication, use of hands, or ambulation occurring four or more times 
per 12-month period despite ongoing immunosuppresive therapy would be 
required. For a 30 percent evaluation, recurrent mucosal, palmar, or 
plantar involvement not impairing mastication, use of hands, or 
ambulation occurring four or more times per 12-month period, and 
requiring intermittent systemic therapy would be required.
    A 10 percent evaluation would be assigned for the following 
circumstances: (1) One to three episodes of mucosal, palmar, or plantar 
involvement not impairing mastication, use of hands, or ambulation 
occurring per 12-month period AND requiring intermittent systemic 
therapy, or (2) without recurrent episodes, but requiring continuous 
systemic medication for control. This allows a 10 percent evaluation to 
be assigned in more circumstances, based upon the level of response to 
treatment. Lastly, VA proposes to add a note at the end of DC 7827 
defining, for the purposes of DC 7827 only, that systemic therapy may 
consist of one or more of the following treatment agents: 
Immunosuppressives, antihistamines, or sympathomimetics. See Ebadi, 
supra; see also Victor Cohen, PharmD, et al., ``Toxic Epidermal 
Necrolysis Treatment & Management,'' MEDSCAPE REFERENCE (Mar. 3, 2014), 
https://emedicine.medscape.com/article/229698-treatment#a1156 (last 
visited Apr. 23, 2014).

Diagnostic Code 7828

    VA proposes to update DC 7828, ``Acne,'' by removing the reference 
to ``superficial cysts'' in the zero percent rating criteria. This 
update is proposed based upon current medical terminology as the term 
``superficial cysts'' is no longer used in the medical community. See 
Bolognia, supra at 547-50 and 555-58.

Diagnostic Code 7829

    Current DC 7829 instructs rating personnel to evaluate chloracne 
based, in part, on either the presence of deep or superficial acne. The 
current evaluation criteria instructs that either a 10 or 30 percent 
evaluation should be assigned depending upon whether more or less than 
40 percent of the face and neck are involved; VA does not propose 
changes to these criteria. However, a 10 percent evaluation is also 
assigned when there is ``deep acne other than on the face and neck.'' 
VA proposes to clarify that a 10 percent evaluation should only be 
assigned when deep acne affects non-intertriginous areas of the body 
other than the face and neck or less than 40 percent of the face and 
neck. Intertriginous areas of the body include the axilla of the arm, 
the anogenital region, and skin folds of the breast or between digits. 
Samuel T. Selden, MD, ``Intertrigo,''Medscape Reference (Mar. 27, 
2012), https://emedicine.medscape.com/article/1087691-overview (last 
visited Apr. 23, 2014). Deep acne affecting these areas of the body 
results in greater functional impairment to the individual because 
these represent more sensitive areas of the body. Therefore, VA 
proposes to assign a higher 20 percent evaluation when deep acne 
affects the intertriginous areas of the body.
    Additionally, for reasons previously discussed in DC 7828, VA 
proposes to remove the term ``superficial cysts'' from the rating 
criteria under the zero percent evaluation. See Bolognia, supra at 547-
50 and 555-58.

Technical Amendments

    VA also proposes several technical amendments. We would update 
Appendix A, B, and C of part 4 to reflect the above noted proposed 
amendments.

Executive Orders 12866 and 13563

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

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 directly affect only 
individuals and would not directly affect small entities. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of sections 603 
and 604.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of

[[Page 53358]]

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 numbers and titles for 
the programs affected by this document are 64.104, Pension for Non-
Service-Connected Disability for Veterans; 64.109, Veterans 
Compensation for Service-Connected Disability; and 64.110, Veterans 
Dependency and Indemnity Compensation for Service-Connected Death.

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. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on August 1, 2016, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Dated: August 1, 2016.
Jeffrey Martin,
Office Program Manager, Office of Regulation Policy & Management, 
Office of the Secretary, Department of Veterans Affairs.

    For the reasons set out in the preamble, the Department of Veterans 
Affairs proposes to amend 38 CFR part 4, subpart B as follows:

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.  4.118 by:
0
a. Revising the introductory paragraph;
0
b. Revising the entries for diagnostic codes 7801, 7802, and 7805;
0
c. Adding an entry for ``General Rating Formula For The Skin For DCs 
7806, 7809, 7813-7816, 7820-7822, And 7824'', to appear after the entry 
for diagnostic code 7805;
0
d. Revising entries for diagnostic codes 7806, 7809, 7813, 7815, 7816, 
7817, 7820, 7821, 7822, 7824, 7825, 7826, 7827, 7828, and 7829.
    The revisions and additions read as follows:


Sec.  4.118  Schedule of ratings-skin.

    For the purposes of this section, systemic therapy is treatment 
that is administered through any route (orally, injection, suppository, 
intranasally) other than the skin. For the purposes of this section, 
topical therapy is treatment that is administered through the skin.

------------------------------------------------------------------------
                                                                Rating
------------------------------------------------------------------------
 
                              * * * * * * *
7801 Burn scar(s) or scar(s) due to other causes, not of
 the head, face, or neck, that are associated with
 underlying soft tissue damage:
    Area or areas of 144 square inches (929 sq. cm.) or               40
     greater...............................................
    Area or areas of at least 72 square inches (465 sq.               30
     cm.) but less than 144 square inches (929 sq. cm.)....
    Area or areas of at least 12 square inches (77 sq. cm.)           20
     but less than 72 square inches (465 sq. cm.)..........
    Area or areas of at least 6 square inches (39 sq. cm.)            10
     but less than 12 square inches (77 sq. cm.)...........
    Note (1): For the purposes of DCs 7801 and 7802, the
     six (6) zones of the body are defined as each
     extremity, anterior trunk and posterior trunk. The
     midaxillary line divides the anterior trunk from the
     posterior trunk.......................................
    Note (2): A separate evaluation may be assigned for
     each affected zone of the body under this diagnostic
     code if there are multiple scars, or a single scar,
     affecting multiple zones of the body. Combine the
     separate evaluations under Sec.   4.25. Alternatively,
     if a higher evaluation would result from adding the
     areas affected from multiple zones of the body, a
     single evaluation may also be assigned under this
     diagnostic code.......................................
7802 Burn scar(s) or scar(s) due to other causes, not of
 the head, face, or neck, that are not associated with
 underlying soft tissue damage:
    Area or areas of 144 square inches (929 sq. cm.) or               10
     greater...............................................
    Note (1): For the purposes of DCs 7801 and 7802, the
     six (6) zones of the body are defined as each
     extremity, anterior trunk and posterior trunk. The
     midaxillary line divides the anterior trunk from the
     posterior trunk.......................................
    Note (2): A separate evaluation may be assigned for
     each affected zone of the body under this diagnostic
     code if there are multiple scars, or a single scar,
     affecting multiple zones of the body. Combine the
     separate evaluations under Sec.   4.25. Alternatively,
     if a higher evaluation would result from adding the
     areas affected from multiple zones of the body, a
     single evaluation may also be assigned under this
     diagnostic code.......................................
 
                              * * * * * * *
7805 Scars, other; and other effects of scars evaluated
 under diagnostic codes 7800, 7801, 7802, and 7804:
    Evaluate any disabling effect(s) not considered in a
     rating provided under diagnostic codes 7800-04 under
     an appropriate diagnostic code........................
General Rating Formula For The Skin For DCs 7806, 7809,
 7813-7816, 7820-7822, And 7824:
    At least one of the following
        More than 40 percent of the entire body or more               60
         than 40 percent of exposed areas affected, or;....
        Constant or near-constant systemic therapy
         including, but not limited to, corticosteroids,
         phototherapy, retinoids, biologics,
         photochemotherapy, PUVA or other immunosuppressive
         drugs required per 12-month period................
    At least one of the following..........................           30
        20 to 40 percent of the entire body or 20 to 40
         percent of exposed areas affected, or;

[[Page 53359]]

 
        Systemic therapy including, but not limited to,
         corticosteroids, phototherapy, retinoids,
         biologics, photochemotherapy, PUVA or other
         immunosuppressive drugs required for a total
         duration of six weeks or more, but not constantly,
         per 12-month period...............................
    At least one of the following..........................           10
        At least 5 percent, but less than 20 percent of the
         entire body affected, or;
        At least 5 percent, but less than 20 percent of
         exposed areas affected, or;
        Intermittent systemic therapy including, but not
         limited to, corticosteroids, phototherapy,
         retinoids, biologics, photochemotherapy, PUVA or
         other immunosuppressive drugs required for a total
         duration of less than six weeks per 12-month
         period............................................
    No more than topical therapy required per 12-month                 0
     period and at least one of the following..............
        Less than 5 percent of the entire body affected,
         or;
        Less than 5 percent of exposed areas affected......
    Or rate as disfigurement of the head, face or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability. This rating
     instruction does not apply to DC 7824.................
7806 Dermatitis or eczema.
Evaluate under the General Rating Formula for the Skin.
 
                              * * * * * * *
7809 Discoid lupus erythematosus.
    Evaluate under the General Rating Formula for the Skin.
    Note: Do not combine with ratings under DC 6350........
 
                              * * * * * * *
7813 Dermatophytosis (ringworm: of body, tinea corporis; of
 head, tinea capitis; of feet, tinea pedis; of beard area,
 tinea barbae; of nails, tinea unguium (onychomycosis); of
 inguinal area (jock itch), tinea cruris; tinea versicolor)
    Evaluate under the General Rating Formula for the Skin.
7815 Bullous disorders (including pemphigus vulgaris,
 pemphigus foliaceous, bullous pemphigoid, dermatitis
 herpetiformis, epidermolysis bullosa acquisita, benign
 chronic familial pemphigus (Hailey-Hailey), and porphyria
 cutanea tarda)............................................
    Evaluate under the General Rating Formula for the Skin.
    Note: Rate complications and residuals of mucosal
     involvement (ocular, oral, gastrointestinal,
     respiratory, and genitourinary) separately under the
     appropriate diagnostic code...........................
7816 Psoriasis.............................................
    Evaluate under the General Rating Formula for the Skin.
    Note: Rate complications such as psoriatic arthritis
     and other clinical manifestations (oral mucosa, nails)
     under the appropriate diagnostic code.................
7817 Erythroderma:
    Generalized involvement of the skin with systemic
     manifestations (such as fever, weight loss, and
     hypoproteinemia) AND one of the following:
        Constant or near-constant systemic therapy such as
         therapeutic doses of corticosteroids,
         immunosuppressive retinoids, PUVA (psoralen with
         long-wave ultraviolet-A light); UVB (ultraviolet-B
         light) treatments, biologics, or electron beam
         therapy required per 12-month period, or
        No current treatment due to a documented history of          100
         treatment failure with 2 or more treatment
         regimens..........................................
    Generalized involvement of the skin without systemic
     manifestations and one of the following:..............
        Constant or near-constant systemic therapy such as
         therapeutic doses of corticosteroids,
         immunosuppressive retinoids, PUVA (psoralen with
         long-wave ultraviolet-A light); UVB (ultraviolet-B
         light) treatments, biologics, or electron beam
         therapy required per 12-month period, or
        No current treatment due to a documented history of           60
         treatment failure with 1 treatment regimen........
    Any extent of involvement of the skin, and any of the             30
     following therapies required for a total duration of
     six weeks or more, but not constantly, per 12-month
     period: Systemic therapy such as therapeutic doses of
     corticosteroids, immunosuppressive retinoids, PUVA
     (psoralen with long-wave ultraviolet-A light) or UVB
     (ultraviolet-B light) treatments, biologics, or
     electron beam therapy.................................
    Any extent of involvement of the skin, and any of the             10
     following therapies required for a total duration of
     less than six weeks per 12-month period: Systemic
     therapy such as therapeutic doses of corticosteroids,
     immunosuppressive retinoids, PUVA (psoralen with long-
     wave ultraviolet-A light) or UVB (ultraviolet-B light)
     treatments, biologics, or electron beam therapy.......
    Any extent of involvement of the skin, and; no more                0
     than topical therapy required per 12-month period.....
    Note: Treatment failure is defined as either disease
     progression, or less than a 25 percent reduction in
     the extent and severity of disease after four weeks of
     prescribed therapy, as documented by medical records..
 
                              * * * * * * *
7820 Infections of the skin not listed elsewhere (including
 bacterial, fungal, viral, treponemal and parasitic
 diseases).
    Evaluate under the General Rating Formula for the Skin.
7821 Cutaneous manifestations of collagen-vascular diseases
 not listed elsewhere (including scleroderma, calcinosis
 cutis, subacute cutaneous lupus erythematosus, and
 dermatomyositis)..........................................
    Evaluate under the General Rating Formula for the Skin.
7822 Papulosquamous disorders not listed elsewhere
 (including lichen planus, large or small plaque
 parapsoriasis, pityriasis lichenoides et varioliformis
 acuta (PLEVA), lymphomatoid papulosus, mycosis fungoides,
 and pityriasis rubra pilaris (PRP)).......................
    Evaluate under the General Rating Formula for the Skin.
 
                              * * * * * * *
7824 Diseases of keratinization (including icthyoses,
 Darier's disease, and palmoplantar keratoderma).
    Evaluate under the General Rating Formula for the Skin.
7825 Urticaria:
    Recurrent documented urticarial attacks occurring four            60
     or more times per 12-month period despite continuous
     immunosuppressive therapy (including, but not limited
     to, cyclosporine and steroids)........................

[[Page 53360]]

 
    Recurrent documented urticarial attacks occurring four            30
     or more times per 12-month period and requiring
     intermittent systemic immunosuppressive therapy
     (including, but not limited to, cyclosporine and
     steroids) for control.................................
    At least one of the following..........................           10
        Recurrent documented urticarial attacks occurring
         one to three times per 12-month period, and
         requiring intermittent systemic immunosuppressive
         therapy for control, or
        Recurrent documented urticarial attacks occurring
         four or more times per 12-month period, and
         requiring treatment with antihistamines or
         sympathomimetics (including, but not limited to an
         epipen or intramuscular epinephrine), or
        Without recurrent documented urticarial attacks,
         but requiring continuous systemic
         immunosuppressive therapy medication (including,
         but not limited to, cyclosporine and steroids) for
         control...........................................
7826 Vasculitis, primary cutaneous:
    Persistent documented vasculitis episodes refractory to           60
     continuous immunosuppressive therapy..................
    All of the following...................................           30
        Recurrent documented vasculitic episodes occurring
         four or more times per 12-month period, and
        Requiring intermittent systemic immunosuppressive
         therapy for control...............................
    At least one of the following..........................           10
        Recurrent documented vasculitic episodes occurring
         one to three times per 12-month period, and
         requiring intermittent systemic immunosuppressive
         therapy for control, or
        Without recurrent documented vasculitic episodes
         but requiring continuous systemic medication for
         control...........................................
        Or rate as disfigurement of the head, face, or neck
         (DC 7800) or scars (DC's 7801, 7802, 7804, or
         7805), depending upon the predominant disability..
7827 Erythema multiforme; Toxic epidermal necrolysis:
    Recurrent mucosal, palmar, or plantar involvement                 60
     impairing mastication, use of hands, or ambulation
     occurring four or more times per 12-month period
     despite ongoing immunosuppresive therapy..............
    All of the following...................................           30
        Recurrent mucosal, palmar, or plantar involvement
         not impairing mastication, use of hands, or
         ambulation occurring four or more times per 12-
         month period, and
        Requiring intermittent systemic therapy............
    At least one of the following..........................           10
        One to three episodes of mucosal, palmar, or
         plantar involvement not impairing mastication, use
         of hands, or ambulation occurring per 12-month
         period AND requiring intermittent systemic
         therapy, or
        Without recurrent episodes, but requiring
         continuous systemic medication for control........
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7804, or 7805),
     depending upon the predominant disability.............
    Note: For the purposes of this DC only, systemic
     therapy may consist of one or more of the following
     treatment agents: Immunosuppressives, antihistamines,
     or sympathomimetics...................................
7828 Acne:
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.....
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck,
     or; deep acne other than on the face and neck.........
    Superficial acne (comedones, papules, pustules) of any             0
     extent................................................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7804, or 7805),
     depending upon the predominant disability.............
7829 Chloracne:
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.....
    Deep acne (deep inflamed nodules and pus-filled cysts)            20
     affecting the intertriginous areas (the axilla of the
     arm, the anogenital region, skin folds of the breasts
     or between digits)....................................
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck;
     or, deep acne affecting non-intertriginous areas of
     the body (other than the face and neck)...............
    Superficial acne (comedones, papules, pustules) of any             0
     extent................................................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DC's 7801, 7802, 7804, or 7805),
     depending upon the predominant disability.............
 
                              * * * * * * *
------------------------------------------------------------------------


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

0
3. Amend appendix A to part 4, under the entry Sec. 4.118, by:
0
a. Revising the entries for diagnostic codes 7801, 7802, 7805, 7806, 
7809, 7813, 7815, 7816, and 7817;
0
b. Removing the entry for 7820-7833;
0
c. Adding entries for diagnostic codes 7820, 7821, 7822, 7823, 7824, 
7825, 7826, 7827, 7828, 7829, 7830, 7831, 7832, and 7833.
    The revisions and additions read as follows:

Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                               Diagnostic
          Section               Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.118
                                       7801  Criterion July 6, 1950;
                                              criterion August 30, 2002;
                                              criterion October 23,
                                              2008; title, note 1, note
                                              2 [effective date of final
                                              rule].

[[Page 53361]]

 
                                       7802  Criterion September 22,
                                              1978; criterion August 30,
                                              2002; criterion October
                                              23, 2008; title, note 1,
                                              note 2 [effective date of
                                              final rule].
 
                              * * * * * * *
                                       7805  Criterion October 23, 2008;
                                              title [effective date of
                                              final rule].
                                             General Rating Formula for
                                              DCs 7806, 7809, 7813--
                                              7816, 7820--7822, and 7824
                                              added [effective date of
                                              final rule].
                                       7806  Criterion September 9,
                                              1975; evaluation August
                                              30, 2002; criterion
                                              [effective date of final
                                              rule].
 
                              * * * * * * *
                                       7809  Criterion August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
 
                              * * * * * * *
                                       7813  Criterion August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
 
                              * * * * * * *
                                       7815  Evaluation August 30, 2002;
                                              criterion, note [effective
                                              date of final rule].
                                       7816  Evaluation August 30, 2002;
                                              criterion, note [effective
                                              date of final rule].
                                       7817  Evaluation August 30, 2002;
                                              title, criterion, note
                                              [effective date of final
                                              rule].
 
                              * * * * * * *
                                       7820  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7821  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7822  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7823  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7824  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7825  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7826  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7827  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7828  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7829  Added August 30, 2002;
                                              criterion [effective date
                                              of final rule].
                                       7830  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7831  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7832  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
                                       7833  Added August 30, 2002;
                                              title, criterion
                                              [effective date of final
                                              rule].
 
                              * * * * * * *
------------------------------------------------------------------------

0
4. Amend appendix B to part 4, under the center heading The Skin,, by 
revising the entries for diagnostic codes 7801, 7802, 7805, 7809, 7813, 
7817, 7821, and 7822 to read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
     Diagnostic  Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                                THE SKIN
------------------------------------------------------------------------
 
                              * * * * * * *
7801..........................  Burn scar(s) or scar(s) due to other
                                 causes, not of the head, face, or neck
                                 that are associated with underlying
                                 soft tissue damage.
7802..........................  Burn scar(s) or scar(s) due to other
                                 causes, not of the head, face, or neck
                                 that are not associated with underlying
                                 soft tissue damage.
 
                              * * * * * * *
7805..........................  Scars, other; and other effects of scars
                                 evaluated under diagnostic codes 7800,
                                 7801, 7802, and 7804.
 
                              * * * * * * *
7809..........................  Discoid lupus erythematosus.
 
                              * * * * * * *
7813..........................  Dermatophytosis.
 

[[Page 53362]]

 
                              * * * * * * *
7817..........................  Erythroderma.
 
                              * * * * * * *
7821..........................  Cutaneous manifestations of collagen-
                                 vascular diseases not listed elsewhere
                                 (including scleroderma, calcinosis
                                 cutis, subacute cutaneous lupus
                                 erythematosus, and dermatomyositis).
7822..........................  Papulosquamous disorders not listed
                                 elsewhere.
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Amend appendix C to part 4 by:
0
a. Removing the entry ``Cutaneous manifestations of collagen-vascular 
diseases'' and add in its place an entry for ``Cutaneous manifestations 
of collagen-vascular diseases not listed elsewhere (including 
scleroderma, calcinosis cutis, subacute cutaneous lupus erythematosus, 
and dermatomyositis)'';
0
b. Adding in alphabetical order entries for ``Discoid lupus 
erythematosus'', and ``Erythroderma''; and
0
c. Revising the entries under ``Scars.''
    The additions and revisions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Cutaneous manifestations of collagen-vascular diseases              7821
 not listed elsewhere (including scleroderma, calcinosis
 cutis, subacute cutaneous lupus erythematosus, and
 dermatomyositis).......................................
 
                              * * * * * * *
Discoid lupus erythematosus.............................            7809
 
                              * * * * * * *
Erythroderma............................................            7817
 
                              * * * * * * *
Scars:
    Burn scar(s) of the head, face, or neck; scar(s) of             7800
     the head, face, or neck due to other causes; or
     other disfigurement of the head, face, or neck.....
    Burn scar(s) or scar(s) due to other causes, not of             7801
     the head, face, or neck that are associated with
     underlying soft tissue damage......................
    Burn scar(s) or scar(s) due to other causes, not of             7802
     the head, face, or neck that are not associated
     with underlying soft tissue damage.................
    Retina..............................................            6011
    Scars, other; and other effects of scars evaluated              7805
     under diagnostic codes 7800, 7801, 7802, and 7804..
    Unstable or painful.................................            7804
 
                              * * * * * * *
------------------------------------------------------------------------


[FR Doc. 2016-18695 Filed 8-11-16; 8:45 am]
 BILLING CODE 8320-01-P