Schedule for Rating Disabilities; The Endocrine System, 50802-50807 [2017-23044]

Download as PDF 50802 Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations Section 301.75–15 issued under Sec. 204, Title II, Public Law 106–113, 113 Stat. 1501A–293; sections 301.75–15 and 301.75– 16 issued under Sec. 203, Title II, Public Law 106–224, 114 Stat. 400 (7 U.S.C. 1421 note). Done in Washington, DC, this 30th day of October 2017. Michael C. Gregoire, Acting Administrator, Animal and Plant Health Inspection Service. [FR Doc. 2017–23897 Filed 11–1–17; 8:45 am] BILLING CODE 3410–34–P DEPARTMENT OF AGRICULTURE Rural Business-Cooperative Service Rural Utilities Service 7 CFR Part 4279 Guaranteed Loanmaking CFR Correction In Title 7 of the Code of Federal Regulations, Part 2000 to End, revised as of January 1, 2017, on page 749, § 4279.162 is added to read as follows: § 4279.162 Strategic economic and community development. Applicants with projects that support the implementation of strategic economic development and community development plans are encouraged to review and consider 7 CFR part 1980, subpart K, which contains provisions for providing priority to projects that support the implementation of strategic economic development and community development plans on a Multijurisdictional basis. [81 FR 10457, Mar. 1, 2016] [FR Doc. 2017–23912 Filed 11–1–17; 8:45 am] BILLING CODE 1301–00–D DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 4 RIN 2900–AO44 Schedule for Rating Disabilities; The Endocrine System Department of Veterans Affairs. Final rule. AGENCY: ACTION: This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (VASRD) by revising the portion of the Schedule that addresses endocrine conditions and disorders of the endocrine system. The effect of this action is to ensure that the VASRD uses current medical terminology and to nlaroche on DSK9F9SC42PROD with RULES SUMMARY: VerDate Sep<11>2014 14:56 Nov 01, 2017 Jkt 244001 provide detailed and updated criteria for evaluation of endocrine disorders. DATES: This rule is effective on December 10, 2017. FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, Medical Officer, Part 4 VASRD Regulations Staff (211C), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, Ioulia.Vvedenskaya@va.gov, (202) 461– 9700 (this is not a toll-free telephone number). SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal Register at 80 FR 39011 on July 8, 2015, to amend the portion of the VASRD dealing with endocrine disorders. VA provided a 60-day public comment period, and interested persons were invited to submit written comments, suggestions, or objections on or before September 8, 2015. VA received comments from four individuals. In addition, VA received a comment from a veterans service organization. Unless otherwise indicated below, VA adopts the changes set forth in the proposed rule. Public Comments One commenter asked whether VA would recognize polycystic ovarian syndrome (PCOS) under the VA rating schedule. VA has a mechanism in place to address PCOS under 38 CFR 4.116. Specifically, the rating schedule for Gynecological Conditions and Disorders of the Breast addresses various ovarian conditions under Diagnostic Code (DC) 7615, ‘‘Ovary, disease, injury, or adhesions of’’ and allows VA to rate based on whether symptoms are controlled by or require continuous treatment. In exceptional cases where the schedular evaluation is inadequate, 38 CFR 3.321 allows for extraschedular evaluation. Therefore, VA makes no changes based on this comment. Two commenters proposed additional modifications to DC 7913, ‘‘Diabetes mellitus.’’ One commenter suggested adding a note to address the issue of regulation of activities. Another commenter suggested not changing the insulin requirements within DC 7913 without considering the other requirements in the DC such as regulation of activities. The same commenter suggested removing the insulin requirement for a 20-percent rating and the regulation of activities requirement at all disability ratings under the DC. The commenter stated that the functional impairment caused by required use of insulin is greater than impairment caused by ingestion of oral PO 00000 Frm 00002 Fmt 4700 Sfmt 4700 medication to control diabetes. As stated in the proposed rule, VA is not proposing any change to the evaluation criteria for DC 7913 at this time other than requiring ‘‘one or more daily injection’’ of insulin for a 20-, 40- or 60percent rating and instead intends to establish a work group to specifically address this condition. Therefore, these comments are beyond the scope of this rulemaking. However, VA will take these comments into consideration in connection with a possible future rulemaking. One commenter suggested changing the terminology for a 100-percent rating under DC 7903, ‘‘Hypothyroidism’’ from ‘‘myxedema’’ to ‘‘myxedema coma or crisis’’ because myxedema can be present without causing the requisite level of symptoms for a 100-percent rating. Myxedema is a term used to denote severe hypothyroidism, and myxedema coma or myxedema crisis is a medical emergency and represents a specific rare life-threatening clinical condition. Because the clinical picture of myxedema appears in the most extreme cases of hypothyroidism, we believe that this manifestation of the disability warrants a 100-percent rating (See Greenspan’s Basic & Clinical Endocrinology (D.G. Gardner et al. eds., 9th ed. 2011) available at http:// accessmedicine.mhmedical.com/ content.aspx?bookid=380& sectionid=39744047#8401831). Therefore, VA makes no changes based on this comment. The same commenter proposed that VA retain a 10-percent minimum evaluation in the DCs for endocrine disabilities because of the need for continuous medication to control the symptoms of these disabilities. VA disagrees. In the absence of symptoms, medical management of chronic endocrine disorders does not present a significant lifestyle adjustment, and it does not result in impairment of earning capacity (see 38 U.S.C. 1155). Therefore, VA makes no changes based on this comment. The same commenter noted a typographical error in the text of proposed DC 7911. The word ‘‘adrenocortical’’ was misspelled as ‘‘adrenalcortical.’’ VA has changed the spelling of the term based on this comment. One commenter was supportive of the overall changes and additions to this section of the VASRD, such as additional DCs, clarification of notes on residuals affecting other body systems, instructions to rate some residuals separately, accounting for additional symptoms, and formation of a new work group for diabetes mellitus. The E:\FR\FM\02NOR1.SGM 02NOR1 nlaroche on DSK9F9SC42PROD with RULES Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations commenter also commented that proposed DCs 7900 (Hyperthyroidism), 7903 (Hypothyroidism), and 7905 (Hypoparathyroidism) do not adequately account for disability due to uncontrolled thyroid hormone or calcium imbalance because proposed DCs 7900 and 7903 only provide a 30percent rating for symptoms existing for up to six months after diagnosis and proposed DC 7905 provides a 100percent rating for symptoms occurring for up to three months after diagnosis; thereafter, residual effects are rated under the body system affected by the endocrine disability. The commenter stated that endocrine function may still be disturbed while the correct dosage of medication is being determined and that some patients may not have received treatment. We first point out that the ratings under DC 7900 and 7903 are for ‘‘six months after initial diagnosis’’ and the rating under DC 7905 is for ‘‘three months after initial diagnosis.’’ Thus, the claimants are likely receiving treatment. In addition, as VA explained in the notice of proposed rulemaking, most symptoms of hyperthyroidism and hypothyroidism are alleviated within six months of treatment (see 80 FR 39011, 39013 (Jul. 8, 2015)). With regard to residual symptoms, the primary effect of chronic hyperthyroidism, hypothyroidism, and hypoparathyroidism is on body systems regulated by the thyroid. Therefore, in cases where veterans still have symptoms after six months for hyperthyroidism or hypothyroidism or after three months for hypoparathyroidism, VA addresses residual symptoms by rating all residuals based on the specific disability presented under the most appropriate DCs within the appropriate body system(s). The residuals of endocrine disorders such as uncontrolled thyroid hormone or calcium imbalance produce measurable disability including muscle damage, blood-clotting issues, nerve and kidney damage, depression, and many others. Therefore, VA makes no changes based on this comment. The commenter also stated that VA has not provided a reasoned argument for eliminating a 10-percent evaluation when continued medication is required under DCs 7900 and 7903. Ratings under the schedule are ‘‘based, as far as practicable, upon the average impairments of earning capacity resulting from [specific] injuries’’ or combination of injuries (see 38 U.S.C. 1155). As detailed above, VA explained in the notice of proposed rulemaking that symptoms of hyperthyroidism and VerDate Sep<11>2014 14:56 Nov 01, 2017 Jkt 244001 hypothyroidism generally resolve completely within six months after diagnosis and that symptoms of hypoparathyroidism are generally eliminated following treatment with calcium and vitamin D supplementation (see 80 FR 39011, 39012–14 (Jul. 8, 2015)). Because symptoms are generally eliminated or minimal once a patient receives appropriate medication, there is no impairment of earning capacity and therefore no need to retain the 10percent rating under DCs 7900, 7903, and 7905. As explained above, any disabling residuals may be rated under the most appropriate rating code. Further, if medication is discontinued and symptoms reappear, the disability could again be rated under the schedule for rating disabilities of the endocrine system. The same commenter suggested that proposed DC 7912 should account for residuals of common treatment procedures such as the Whipple procedure, which is also used for the treatment of pancreatic cancer. VA regulations allow for secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury (see 38 CFR 3.310(a)). Disabilities that are secondarily service connected and have distinguishable symptoms, to include disabilities that arise from the treatment of a service-connected disability, are rated separately under the VA rating schedule. Therefore, VA makes no changes based on this comment. The same commenter proposed that VA amend DCs 7901 and 7902 to account for the specific characteristics of disfigurement due to thyroid enlargement rather than rating such disfigurement under DC 7800 because the criteria in DC 7800 do not match the features of thyroid enlargement. The commenter provided two examples of this alleged inconsistency, cystic thyroid nodules requiring draining and soft swelling of the neck. If disfigurement related to thyroid enlargement does not satisfy the criteria in DC 7800, the disfigurement does not result in impairment of earning capacity and is not compensable (see 38 U.S.C. 1155). Therefore, VA makes no changes based on these comments. VA appreciates the comments submitted in response to the proposed rule. Based on the rationale stated in the proposed rule and in this document, the proposed rule is adopted with the change noted. We are additionally adding updates to 38 CFR part 4, Appendices A, B, and C, to reflect changes to the endocrine system rating criteria made by this rulemaking. The appendices are tools PO 00000 Frm 00003 Fmt 4700 Sfmt 4700 50803 for users of the VASRD and do not contain substantive content regarding evaluation of disabilities. As such, we believe it is appropriate to include these updates in this final rule. Benefits Costs The change to the proposed rule will not alter the estimated costs provided in the previous Notice of Proposed Rulemaking. Effective Date of Final Rule Veterans Benefits Administration (VBA) personnel utilize the Veterans Benefit Management System for Rating (VBMS–R) to process disability compensation claims that involve disability evaluations made under the VASRD. In order to ensure that there is no delay in processing veterans’ claims, VA must coordinate the effective date of this final rule with corresponding VBMS–R system updates. As such, this final rule will apply effective December 10, 2017, the date VBMS–R system updates related to this final rule will be complete. Executive Orders 12866 and 13563 Executive Orders 13563 and 12866 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 E:\FR\FM\02NOR1.SGM 02NOR1 50804 Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations the principles set forth in this Executive Order.’’ The economic, interagency, budgetary, legal, and policy implications of this final rule have been examined, and have 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 http:// www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of this rulemaking and its impact analysis are available on VA’s Web site at http:// 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 final rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601–612. This final rule will not directly affect any small entities. Only certain VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604. Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This final rule will have no such effect on State, local, and tribal governments, or on the private sector. Paperwork Reduction Act This final rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501–3521). Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.009, Veterans Medical Care Benefits; 64.104, Pension for Non-Service-Connected Disability for Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death. Signing Authority The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Gina S. Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, approved this document on April 19, 2017, for publication. List of Subjects in 38 CFR Part 4 Disability benefits, Pensions, Veterans. Approved: April 19, 2017. Jeffrey Martin, Office Program Manager, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs Editor’s Note: This document was received for publication at the Office of the Federal Register on October 19, 2017. For the reasons set out in the preamble, the Department of Veterans Affairs amends 38 CFR part 4 as set forth below: PART 4—SCHEDULE FOR RATING DISABILITIES 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 2. Amend § 4.104 by revising the entry for 7008 to read as follows: ■ § 4.104 Schedule of ratings-cardiovascular system. DISEASES OF THE HEART Rating * * * * 7008 Hyperthyroid heart disease. Rate under the appropriate cardiovascular diagnostic code, depending on particular findings. * * * * * * 3. Amend § 4.119 by: ■ a. Revising the entries for 7900 through 7905; ■ b. Adding in numerical order an entry for 7906; and ■ c. Revising the entries for 7907 through 7909, 7911 through 7913, and 7915 through 7919. The revisions and addition read as follows: ■ § 4.119 Schedule of ratings—endocrine system. nlaroche on DSK9F9SC42PROD with RULES Rating 7900 Hyperthyroidism, including, but not limited to, Graves’ disease: For six months after initial diagnosis .................................................................................................................................................... Thereafter, rate residuals of disease or complications of medical treatment within the appropriate diagnostic code(s) within the appropriate body system. Note (1): If hyperthyroid cardiovascular or cardiac disease is present, separately evaluate under DC 7008 (hyperthyroid heart disease). Note (2): Separately evaluate eye involvement occurring as a manifestation of Graves’ Disease as diplopia (DC 6090); impairment of central visual acuity (DCs 6061–6066); or under the most appropriate DCs in § 4.79. 7901 Thyroid enlargement, toxic: Note (1): Evaluate symptoms of hyperthyroidism under DC 7900, hyperthyroidism, including, but not limited to, Graves’ disease. Note (2): If disfigurement of the neck is present due to thyroid disease or enlargement, separately evaluate under DC 7800 (burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck). 7902 Thyroid enlargement, nontoxic: Note (1): Evaluate symptoms due to pressure on adjacent organs (such as the trachea, larynx, or esophagus) under the appropriate diagnostic code(s) within the appropriate body system. Note (2): If disfigurement of the neck is present due to thyroid disease or enlargement, separately evaluate under DC 7800 (burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck). 7903 Hypothyroidism: VerDate Sep<11>2014 14:56 Nov 01, 2017 Jkt 244001 PO 00000 Frm 00004 Fmt 4700 Sfmt 4700 E:\FR\FM\02NOR1.SGM 02NOR1 30 Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations 50805 nlaroche on DSK9F9SC42PROD with RULES Rating Hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)) ................................................................................................................................................ Note (1): This evaluation shall continue for six months beyond the date that an examining physician has determined crisis stabilization. Thereafter, the residual effects of hypothyroidism shall be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). Hypothyroidism without myxedema ...................................................................................................................................................... Note (2): This evaluation shall continue for six months after initial diagnosis. Thereafter, rate residuals of disease or medical treatment under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). Note (3): If eye involvement, such as exophthalmos, corneal ulcer, blurred vision, or diplopia, is also present due to thyroid disease, also separately evaluate under the appropriate diagnostic code(s) in § 4.79, Schedule of Ratings—Eye (such as diplopia (DC 6090) or impairment of central visual acuity (DCs 6061–6066)). 7904 Hyperparathyroidism: For six months from date of discharge following surgery .................................................................................................................... Note (1): After six months, rate on residuals under the appropriate diagnostic code(s) within the appropriate body system(s) based on a VA examination. Hypercalcemia (indicated by at least one of the following: Total Ca greater than 12 mg/dL (3–3.5 mmol/L), Ionized Ca greater than 5.6 mg/dL (2–2.5 mmol/L), creatinine clearance less than 60 mL/min, bone mineral density T-score less than 2.5 SD (below mean) at any site or previous fragility fracture) .................................................................................................................... Note (2): Where surgical intervention is indicated, this evaluation shall continue until the day of surgery, at which time the provisions pertaining to a 100-percent evaluation shall apply. Note (3): Where surgical intervention is not indicated, this evaluation shall continue for six months after pharmacologic treatment begins. After six months, rate on residuals under the appropriate diagnostic code(s) within the appropriate body system(s) based on a VA examination. Symptoms such as fatigue, anorexia, nausea, or constipation that occur despite surgery; or in individuals who are not candidates for surgery but require continuous medication for control ................................................................................................... Asymptomatic ....................................................................................................................................................................................... Note (4): Following surgery or other treatment, evaluate chronic residuals, such as nephrolithiasis (kidney stones), decreased renal function, fractures, vision problems, and cardiovascular complications, under the appropriate diagnostic codes. 7905 Hypoparathyroidism: For three months after initial diagnosis ................................................................................................................................................ Thereafter, evaluate chronic residuals, such as nephrolithiasis (kidney stones), cataracts, decreased renal function, and congestive heart failure under the appropriate diagnostic codes. 7906 Thyroiditis: With normal thyroid function (euthyroid) .............................................................................................................................................. Note: Manifesting as hyperthyroidism, evaluate as hyperthyroidism, including, but not limited to, Graves’ disease (DC 7900); manifesting as hypothyroidism, evaluate as hypothyroidism (DC 7903). 7907 Cushing’s syndrome: As active, progressive disease, including areas of osteoporosis, hypertension, and proximal upper and lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, or raise arms .................................................................................................................................................................................................. Proximal upper or lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, or raise arms ................................................................................................................................... With striae, obesity, moon face, glucose intolerance, and vascular fragility ....................................................................................... Note: The evaluations specifically indicated under this diagnostic code shall continue for six months following initial diagnosis. After six months, rate on residuals under the appropriate diagnostic code(s) within the appropriate body system(s). 7908 Acromegaly: Evidence of increased intracranial pressure (such as visual field defect), arthropathy, glucose intolerance, and either hypertension or cardiomegaly .................................................................................................................................................................... Arthropathy, glucose intolerance, and hypertension ............................................................................................................................ Enlargement of acral parts or overgrowth of long bones .................................................................................................................... 7909 Diabetes insipidus: For three months after initial diagnosis ................................................................................................................................................ Note: Thereafter, if diabetes insipidus has subsided, rate residuals under the appropriate diagnostic code(s) within the appropriate body system. With persistent polyuria or requiring continuous hormonal therapy ..................................................................................................... 7911 Addison’s disease (adrenocortical insufficiency): Four or more crises during the past year ............................................................................................................................................. Three crises during the past year, or; five or more episodes during the past year ............................................................................ One or two crises during the past year, or; two to four episodes during the past year, or; weakness and fatigability, or; corticosteroid therapy required for control ........................................................................................................................................ Note (1): An Addisonian ‘‘crisis’’ consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include: anorexia; nausea; vomiting; dehydration; profound weakness; pain in abdomen, legs, and back; fever; apathy, and depressed mentation with possible progression to coma, renal shutdown, and death. Note (2): An Addisonian ‘‘episode,’’ for VA purposes, is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia, but no peripheral vascular collapse. Note (3): Tuberculous Addison’s disease will be evaluated as active or inactive tuberculosis. If inactive, these evaluations are not to be combined with the graduated ratings of 50 percent or 30 percent for non-pulmonary tuberculosis specified under § 4.88b. Assign the higher rating. 7912 Polyglandular syndrome (multiple endocrine neoplasia, autoimmune polyglandular syndrome): VerDate Sep<11>2014 14:56 Nov 01, 2017 Jkt 244001 PO 00000 Frm 00005 Fmt 4700 Sfmt 4700 E:\FR\FM\02NOR1.SGM 02NOR1 100 30 100 60 10 0 100 0 100 60 30 100 60 30 30 10 60 40 20 50806 Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations Rating Evaluate according to major manifestations to include, but not limited to, Type I diabetes mellitus, hyperthyroidism, hypothyroidism, hypoparathyroidism, or Addison’s disease. 7913 Diabetes mellitus: Requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated ........................................................................................................................ Requiring one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated .................................................................................................. Requiring one or more daily injection of insulin, restricted diet, and regulation of activities ............................................................... Requiring one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet ........................ Manageable by restricted diet only ...................................................................................................................................................... Note (1): Evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. Note (2): When diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. 100 60 40 20 10 * * * * * * * 7915 Neoplasm, benign, any specified part of the endocrine system: Rate as residuals of endocrine dysfunction. 7916 Hyperpituitarism (prolactin secreting pituitary dysfunction): Note: Evaluate as malignant or benign neoplasm, as appropriate. 7917 Hyperaldosteronism (benign or malignant): Note: Evaluate as malignant or benign neoplasm, as appropriate. 7918 Pheochromocytoma (benign or malignant): Note: Evaluate as malignant or benign neoplasm as appropriate. 7919 C-cell hyperplasia of the thyroid: If antineoplastic therapy is required, evaluate as a malignant neoplasm under DC 7914. If a prophylactic thyroidectomy is performed (based upon genetic testing) and antineoplastic therapy is not required, evaluate as hypothyroidism under DC 7903. * * * 4. Amend the table in appendix A to part 4 in the entries for Sec. 4.104 and Sec. 4.119 by: ■ a. Revising the entry for 7008; ■ b. Revising the entries for 7900 through 7905; ■ * c. Adding in numerical order an entry for 7906; and ■ d. Revising the entries for 7907 through 7909, 7911 through 7913, and 7915 through 7919. ■ * * The revisions and addition read as follows: Appendix A to Part 4—Table of Amendments and Effective Dates Since 1946 Diagnostic code No. Sec. * 7008 * 4.119 ....... 7900 7901 7902 7903 7904 7905 7906 7907 7908 7909 nlaroche on DSK9F9SC42PROD with RULES * 7910 7911 7912 7913 VerDate Sep<11>2014 * * * Evaluation January 12, 1998; criterion December 10, 2017. * * * * * * * * * Criterion August 13, 1981; evaluation June 9, 1996; title December 10, 2017; evaluation December 10, 2017; criterion December 10, 2017; note December 10, 2017. Criterion August 13, 1981; evaluation June 9, 1996; title December 10, 2017; evaluation December 10, 2017; criterion December 10, 2017; note December 10, 2017. Evaluation August 13, 1981; criterion June 9, 1996; title December 10, 2017; evaluation December 10, 2017; criterion December 10, 2017; note December 10, 2017. Criterion August 13, 1981; evaluation June 9, 1996; evaluation December 10, 2017; criterion December 10, 2017; note December 10, 2017. Criterion August 13, 1981; evaluation June 9, 1996; evaluation December 10, 2017; criterion December 10, 2017; note December 10, 2017. Evaluation; August 13, 1981; evaluation June 9, 1996; evaluation December 10, 2017; criterion December 10, 2017. Added December 10, 2017. Evaluation; August 13, 1981; evaluation June 9, 1996; criterion December 10, 2017; note December 10, 2017. Criterion August 13, 1981; criterion June 9, 1996; criterion December 10, 2017. Evaluation August 13, 1981; criterion June 9, 1996; evaluation June 9, 1996; criterion December 10, 2017; evaluation December 10, 2017; note December 10, 2017. Removed June 9, 1996. Evaluation March 11, 1969; evaluation August 13, 1981; criterion June 9, 1996; title December 10, 2017; note December 10, 2017. Title December 10, 2017; criterion December 10, 2017. Criterion September 9, 1975; criterion August 13, 1981; criterion June 6, 1996; evaluation June 9, 1996; criterion December 10, 2017; note December 10, 2017. 14:56 Nov 01, 2017 Jkt 244001 PO 00000 Frm 00006 Fmt 4700 Sfmt 4700 E:\FR\FM\02NOR1.SGM 02NOR1 50807 Federal Register / Vol. 82, No. 211 / Thursday, November 2, 2017 / Rules and Regulations Diagnostic code No. Sec. * 7915 7916 7917 7918 7919 * * * * * * Criterion June 9, 1996; criterion December 10, 2017. Added June 9, 1996; note December 10, 2017. Added June 9, 1996; note December 10, 2017. Added June 9, 1996; note December 10, 2017. Added June 9, 1996; evaluation June 9, 1996; criterion December 10, 2017; note December 10, 2017. * * 5. Amend Appendix B to part 4 by: a. Revising the entries for diagnostic codes 7900 through 7902; * * b. Adding, in numerical order, an entry for diagnostic code 7906; and ■ c. Revising the entries for diagnostic codes 7911 and 7912. ■ * The revisions and addition read as follows: ■ ■ * * Appendix B to Part 4—Numerical Index of Disabilities Diagnostic code No. * * * * * * * * * * THE ENDOCRINE SYSTEM 7900 .................................... 7901 .................................... 7902 .................................... Hyperthyroidism, including, but not limited to, Graves’ disease. Thyroid enlargement, toxic. Thyroid enlargement, nontoxic. * * 7906 .................................... Thyroiditis. * * * * * * * * 7911 .................................... Addison’s disease (adrenocortical insufficiency). 7912 .................................... Polyglandular syndrome (multiple endocrine neoplasia, autoimmune polyglandular syndrome). * * * 6. Amend Appendix C to Part 4 as follows: ■ a. Add, in alphabetical order, entries for ‘‘Graves’ disease’’ and ‘‘Polyglandular syndrome’’; ■ b. Revise the entry for ‘‘Thyroid gland’’; and ■ c. Add, in alphabetical order, an entry for ‘‘Thyroiditis’’. The additions and revision read as follows: ■ * * [FR Doc. 2017–23044 Filed 11–1–17; 8:45 am] BILLING CODE 8320–01–P ENVIRONMENTAL PROTECTION AGENCY 40 CFR Part 52 [EPA–R05–OAR–2016–0327; FRL–9970–14– Region 5] Air Plan Approval; Minnesota; State Board Requirements Appendix C to Part 4—Alphabetical Index of Disabilities Environmental Protection Agency (EPA). ACTION: Final rule. AGENCY: Diagnostic code No. * * * * Graves’ disease ........................ nlaroche on DSK9F9SC42PROD with RULES * * * * Polyglandular syndrome ........... * * * * Thyroid gland. Nontoxic thyroid enlargement Toxic thyroid enlargement ..... Thyroiditis ................................. * VerDate Sep<11>2014 * * 14:56 Nov 01, 2017 * The Environmental Protection Agency (EPA) is approving a state implementation plan (SIP) submission from Minnesota addressing the state * 7912 board requirements of the Clean Air Act (CAA). EPA is also approving elements of Minnesota’s submission addressing * the infrastructure requirements relating 7902 to state boards for the 1997 ozone, 1997 7901 fine particulate (PM ), 2006 PM , 2.5 2.5 7906 2008 lead (Pb), 2008 ozone, 2010 nitrogen dioxide (NO2), 2010 sulfur * dioxide (SO2), and 2012 PM2.5 National * 7900 Jkt 244001 SUMMARY: PO 00000 Frm 00007 Fmt 4700 Sfmt 4700 * * * Ambient Air Quality Standards (NAAQS). The proposed rulemaking associated with this final action was published on July 17, 2017, and EPA received no comments during the comment period, which ended on August 16, 2017. DATES: This final rule is effective on December 4, 2017. ADDRESSES: EPA has established a docket for this action under Docket ID No. EPA–R05–OAR–2016–0327. All documents in the docket are listed on the www.regulations.gov Web site. Although listed in the index, some information is not publicly available, i.e., Confidential Business Information (CBI) or other information whose disclosure is restricted by statute. Certain other material, such as copyrighted material, is not placed on the Internet and will be publicly available only in hard copy form. Publicly available docket materials are available either through www.regulations.gov or at the Environmental Protection Agency, Region 5, Air and Radiation Division, 77 West Jackson Boulevard, Chicago, Illinois 60604. This facility is open from E:\FR\FM\02NOR1.SGM 02NOR1

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[Federal Register Volume 82, Number 211 (Thursday, November 2, 2017)]
[Rules and Regulations]
[Pages 50802-50807]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-23044]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AO44


Schedule for Rating Disabilities; The Endocrine System

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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

SUMMARY: This document amends the Department of Veterans Affairs (VA) 
Schedule for Rating Disabilities (VASRD) by revising the portion of the 
Schedule that addresses endocrine conditions and disorders of the 
endocrine system. The effect of this action is to ensure that the VASRD 
uses current medical terminology and to provide detailed and updated 
criteria for evaluation of endocrine disorders.

DATES: This rule is effective on December 10, 2017.

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

SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal 
Register at 80 FR 39011 on July 8, 2015, to amend the portion of the 
VASRD dealing with endocrine disorders. VA provided a 60-day public 
comment period, and interested persons were invited to submit written 
comments, suggestions, or objections on or before September 8, 2015. VA 
received comments from four individuals. In addition, VA received a 
comment from a veterans service organization. Unless otherwise 
indicated below, VA adopts the changes set forth in the proposed rule.

Public Comments

    One commenter asked whether VA would recognize polycystic ovarian 
syndrome (PCOS) under the VA rating schedule. VA has a mechanism in 
place to address PCOS under 38 CFR 4.116. Specifically, the rating 
schedule for Gynecological Conditions and Disorders of the Breast 
addresses various ovarian conditions under Diagnostic Code (DC) 7615, 
``Ovary, disease, injury, or adhesions of'' and allows VA to rate based 
on whether symptoms are controlled by or require continuous treatment. 
In exceptional cases where the schedular evaluation is inadequate, 38 
CFR 3.321 allows for extraschedular evaluation. Therefore, VA makes no 
changes based on this comment.
    Two commenters proposed additional modifications to DC 7913, 
``Diabetes mellitus.'' One commenter suggested adding a note to address 
the issue of regulation of activities. Another commenter suggested not 
changing the insulin requirements within DC 7913 without considering 
the other requirements in the DC such as regulation of activities. The 
same commenter suggested removing the insulin requirement for a 20-
percent rating and the regulation of activities requirement at all 
disability ratings under the DC. The commenter stated that the 
functional impairment caused by required use of insulin is greater than 
impairment caused by ingestion of oral medication to control diabetes. 
As stated in the proposed rule, VA is not proposing any change to the 
evaluation criteria for DC 7913 at this time other than requiring ``one 
or more daily injection'' of insulin for a 20-, 40- or 60-percent 
rating and instead intends to establish a work group to specifically 
address this condition. Therefore, these comments are beyond the scope 
of this rulemaking. However, VA will take these comments into 
consideration in connection with a possible future rulemaking.
    One commenter suggested changing the terminology for a 100-percent 
rating under DC 7903, ``Hypothyroidism'' from ``myxedema'' to 
``myxedema coma or crisis'' because myxedema can be present without 
causing the requisite level of symptoms for a 100-percent rating. 
Myxedema is a term used to denote severe hypothyroidism, and myxedema 
coma or myxedema crisis is a medical emergency and represents a 
specific rare life-threatening clinical condition. Because the clinical 
picture of myxedema appears in the most extreme cases of 
hypothyroidism, we believe that this manifestation of the disability 
warrants a 100-percent rating (See Greenspan's Basic & Clinical 
Endocrinology (D.G. Gardner et al. eds., 9th ed. 2011) available at 
http://accessmedicine.mhmedical.com/content.aspx?bookid=380§ionid=39744047#8401831). Therefore, VA 
makes no changes based on this comment.
    The same commenter proposed that VA retain a 10-percent minimum 
evaluation in the DCs for endocrine disabilities because of the need 
for continuous medication to control the symptoms of these 
disabilities. VA disagrees. In the absence of symptoms, medical 
management of chronic endocrine disorders does not present a 
significant lifestyle adjustment, and it does not result in impairment 
of earning capacity (see 38 U.S.C. 1155). Therefore, VA makes no 
changes based on this comment.
    The same commenter noted a typographical error in the text of 
proposed DC 7911. The word ``adrenocortical'' was misspelled as 
``adrenalcortical.'' VA has changed the spelling of the term based on 
this comment.
    One commenter was supportive of the overall changes and additions 
to this section of the VASRD, such as additional DCs, clarification of 
notes on residuals affecting other body systems, instructions to rate 
some residuals separately, accounting for additional symptoms, and 
formation of a new work group for diabetes mellitus. The

[[Page 50803]]

commenter also commented that proposed DCs 7900 (Hyperthyroidism), 7903 
(Hypothyroidism), and 7905 (Hypoparathyroidism) do not adequately 
account for disability due to uncontrolled thyroid hormone or calcium 
imbalance because proposed DCs 7900 and 7903 only provide a 30-percent 
rating for symptoms existing for up to six months after diagnosis and 
proposed DC 7905 provides a 100-percent rating for symptoms occurring 
for up to three months after diagnosis; thereafter, residual effects 
are rated under the body system affected by the endocrine disability. 
The commenter stated that endocrine function may still be disturbed 
while the correct dosage of medication is being determined and that 
some patients may not have received treatment.
    We first point out that the ratings under DC 7900 and 7903 are for 
``six months after initial diagnosis'' and the rating under DC 7905 is 
for ``three months after initial diagnosis.'' Thus, the claimants are 
likely receiving treatment. In addition, as VA explained in the notice 
of proposed rulemaking, most symptoms of hyperthyroidism and 
hypothyroidism are alleviated within six months of treatment (see 80 FR 
39011, 39013 (Jul. 8, 2015)).
    With regard to residual symptoms, the primary effect of chronic 
hyperthyroidism, hypothyroidism, and hypoparathyroidism is on body 
systems regulated by the thyroid. Therefore, in cases where veterans 
still have symptoms after six months for hyperthyroidism or 
hypothyroidism or after three months for hypoparathyroidism, VA 
addresses residual symptoms by rating all residuals based on the 
specific disability presented under the most appropriate DCs within the 
appropriate body system(s).
    The residuals of endocrine disorders such as uncontrolled thyroid 
hormone or calcium imbalance produce measurable disability including 
muscle damage, blood-clotting issues, nerve and kidney damage, 
depression, and many others. Therefore, VA makes no changes based on 
this comment.
    The commenter also stated that VA has not provided a reasoned 
argument for eliminating a 10-percent evaluation when continued 
medication is required under DCs 7900 and 7903. Ratings under the 
schedule are ``based, as far as practicable, upon the average 
impairments of earning capacity resulting from [specific] injuries'' or 
combination of injuries (see 38 U.S.C. 1155). As detailed above, VA 
explained in the notice of proposed rulemaking that symptoms of 
hyperthyroidism and hypothyroidism generally resolve completely within 
six months after diagnosis and that symptoms of hypoparathyroidism are 
generally eliminated following treatment with calcium and vitamin D 
supplementation (see 80 FR 39011, 39012-14 (Jul. 8, 2015)). Because 
symptoms are generally eliminated or minimal once a patient receives 
appropriate medication, there is no impairment of earning capacity and 
therefore no need to retain the 10-percent rating under DCs 7900, 7903, 
and 7905. As explained above, any disabling residuals may be rated 
under the most appropriate rating code. Further, if medication is 
discontinued and symptoms reappear, the disability could again be rated 
under the schedule for rating disabilities of the endocrine system.
    The same commenter suggested that proposed DC 7912 should account 
for residuals of common treatment procedures such as the Whipple 
procedure, which is also used for the treatment of pancreatic cancer. 
VA regulations allow for secondary service connection for disabilities 
that are proximately due to or the result of a service-connected 
disease or injury (see 38 CFR 3.310(a)). Disabilities that are 
secondarily service connected and have distinguishable symptoms, to 
include disabilities that arise from the treatment of a service-
connected disability, are rated separately under the VA rating 
schedule. Therefore, VA makes no changes based on this comment.
    The same commenter proposed that VA amend DCs 7901 and 7902 to 
account for the specific characteristics of disfigurement due to 
thyroid enlargement rather than rating such disfigurement under DC 7800 
because the criteria in DC 7800 do not match the features of thyroid 
enlargement. The commenter provided two examples of this alleged 
inconsistency, cystic thyroid nodules requiring draining and soft 
swelling of the neck. If disfigurement related to thyroid enlargement 
does not satisfy the criteria in DC 7800, the disfigurement does not 
result in impairment of earning capacity and is not compensable (see 38 
U.S.C. 1155). Therefore, VA makes no changes based on these comments.
    VA appreciates the comments submitted in response to the proposed 
rule. Based on the rationale stated in the proposed rule and in this 
document, the proposed rule is adopted with the change noted.
    We are additionally adding updates to 38 CFR part 4, Appendices A, 
B, and C, to reflect changes to the endocrine system rating criteria 
made by this rulemaking. The appendices are tools for users of the 
VASRD and do not contain substantive content regarding evaluation of 
disabilities. As such, we believe it is appropriate to include these 
updates in this final rule.

Benefits Costs

    The change to the proposed rule will not alter the estimated costs 
provided in the previous Notice of Proposed Rulemaking.

Effective Date of Final Rule

    Veterans Benefits Administration (VBA) personnel utilize the 
Veterans Benefit Management System for Rating (VBMS-R) to process 
disability compensation claims that involve disability evaluations made 
under the VASRD. In order to ensure that there is no delay in 
processing veterans' claims, VA must coordinate the effective date of 
this final rule with corresponding VBMS-R system updates. As such, this 
final rule will apply effective December 10, 2017, the date VBMS-R 
system updates related to this final rule will be complete.

Executive Orders 12866 and 13563

    Executive Orders 13563 and 12866 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

[[Page 50804]]

the principles set forth in this Executive Order.''
    The economic, interagency, budgetary, legal, and policy 
implications of this final rule have been examined, and have 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 http://www.regulations.gov, usually within 48 hours after the 
rulemaking document is published. Additionally, a copy of this 
rulemaking and its impact analysis are available on VA's Web site at 
http://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 final rule will not have a 
significant economic impact on a substantial number of small entities 
as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
612. This final rule will not directly affect any small entities. Only 
certain VA beneficiaries could be directly affected. Therefore, 
pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial 
and final regulatory flexibility analysis requirements of sections 603 
and 604.

Unfunded Mandates

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

Paperwork Reduction Act

    This final rule contains no provisions constituting a collection of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521).

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance program numbers and 
titles for this rule are 64.009, Veterans Medical Care Benefits; 
64.104, Pension for Non-Service-Connected Disability for Veterans; 
64.109, Veterans Compensation for Service-Connected Disability; and 
64.110, Veterans Dependency and Indemnity Compensation for Service-
Connected Death.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. Gina S. 
Farrisee, Deputy Chief of Staff, Department of Veterans Affairs, 
approved this document on April 19, 2017, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Approved: April 19, 2017.
Jeffrey Martin,
Office Program Manager, Office of Regulation Policy & Management, 
Office of the Secretary, Department of Veterans Affairs

    Editor's Note:  This document was received for publication at 
the Office of the Federal Register on October 19, 2017.

    For the reasons set out in the preamble, the Department of Veterans 
Affairs amends 38 CFR part 4 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.  4.104 by revising the entry for 7008 to read as follows:


Sec.  4.104  Schedule of ratings-cardiovascular system.

                          Diseases of the Heart
------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
 
                                * * * * *
7008 Hyperthyroid heart disease.
  Rate under the appropriate cardiovascular diagnostic code,
   depending on particular findings.
 
                                * * * * *
------------------------------------------------------------------------


0
3. Amend Sec.  4.119 by:
0
a. Revising the entries for 7900 through 7905;
0
b. Adding in numerical order an entry for 7906; and
0
c. Revising the entries for 7907 through 7909, 7911 through 7913, and 
7915 through 7919.
    The revisions and addition read as follows:


Sec.  4.119  Schedule of ratings--endocrine system.

------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
7900 Hyperthyroidism, including, but not limited to, Graves'
 disease:
    For six months after initial diagnosis...................         30
    Thereafter, rate residuals of disease or complications of
     medical treatment within the appropriate diagnostic
     code(s) within the appropriate body system.
    Note (1): If hyperthyroid cardiovascular or cardiac
     disease is present, separately evaluate under DC 7008
     (hyperthyroid heart disease).
    Note (2): Separately evaluate eye involvement occurring
     as a manifestation of Graves' Disease as diplopia (DC
     6090); impairment of central visual acuity (DCs 6061-
     6066); or under the most appropriate DCs in Sec.   4.79.
7901 Thyroid enlargement, toxic:
    Note (1): Evaluate symptoms of hyperthyroidism under DC
     7900, hyperthyroidism, including, but not limited to,
     Graves' disease.
    Note (2): If disfigurement of the neck is present due to
     thyroid disease or enlargement, separately evaluate
     under DC 7800 (burn scar(s) of the head, face, or neck;
     scar(s) of the head, face, or neck due to other causes;
     or other disfigurement of the head, face, or neck).
7902 Thyroid enlargement, nontoxic:
    Note (1): Evaluate symptoms due to pressure on adjacent
     organs (such as the trachea, larynx, or esophagus) under
     the appropriate diagnostic code(s) within the
     appropriate body system.
    Note (2): If disfigurement of the neck is present due to
     thyroid disease or enlargement, separately evaluate
     under DC 7800 (burn scar(s) of the head, face, or neck;
     scar(s) of the head, face, or neck due to other causes;
     or other disfigurement of the head, face, or neck).
7903 Hypothyroidism:

[[Page 50805]]

 
    Hypothyroidism manifesting as myxedema (cold intolerance,        100
     muscular weakness, cardiovascular involvement
     (including, but not limited to hypotension, bradycardia,
     and pericardial effusion), and mental disturbance
     (including, but not limited to dementia, slowing of
     thought and depression))................................
    Note (1): This evaluation shall continue for six months
     beyond the date that an examining physician has
     determined crisis stabilization. Thereafter, the
     residual effects of hypothyroidism shall be rated under
     the appropriate diagnostic code(s) within the
     appropriate body system(s) (e.g., eye, digestive, and
     mental disorders).
    Hypothyroidism without myxedema..........................         30
    Note (2): This evaluation shall continue for six months
     after initial diagnosis. Thereafter, rate residuals of
     disease or medical treatment under the most appropriate
     diagnostic code(s) under the appropriate body system
     (e.g., eye, digestive, mental disorders).
    Note (3): If eye involvement, such as exophthalmos,
     corneal ulcer, blurred vision, or diplopia, is also
     present due to thyroid disease, also separately evaluate
     under the appropriate diagnostic code(s) in Sec.   4.79,
     Schedule of Ratings--Eye (such as diplopia (DC 6090) or
     impairment of central visual acuity (DCs 6061-6066)).
7904 Hyperparathyroidism:
    For six months from date of discharge following surgery..        100
    Note (1): After six months, rate on residuals under the
     appropriate diagnostic code(s) within the appropriate
     body system(s) based on a VA examination.
    Hypercalcemia (indicated by at least one of the                   60
     following: Total Ca greater than 12 mg/dL (3-3.5 mmol/
     L), Ionized Ca greater than 5.6 mg/dL (2-2.5 mmol/L),
     creatinine clearance less than 60 mL/min, bone mineral
     density T-score less than 2.5 SD (below mean) at any
     site or previous fragility fracture)....................
    Note (2): Where surgical intervention is indicated, this
     evaluation shall continue until the day of surgery, at
     which time the provisions pertaining to a 100-percent
     evaluation shall apply.
    Note (3): Where surgical intervention is not indicated,
     this evaluation shall continue for six months after
     pharmacologic treatment begins. After six months, rate
     on residuals under the appropriate diagnostic code(s)
     within the appropriate body system(s) based on a VA
     examination.
    Symptoms such as fatigue, anorexia, nausea, or                    10
     constipation that occur despite surgery; or in
     individuals who are not candidates for surgery but
     require continuous medication for control...............
    Asymptomatic.............................................          0
    Note (4): Following surgery or other treatment, evaluate
     chronic residuals, such as nephrolithiasis (kidney
     stones), decreased renal function, fractures, vision
     problems, and cardiovascular complications, under the
     appropriate diagnostic codes.
7905 Hypoparathyroidism:
    For three months after initial diagnosis.................        100
    Thereafter, evaluate chronic residuals, such as
     nephrolithiasis (kidney stones), cataracts, decreased
     renal function, and congestive heart failure under the
     appropriate diagnostic codes.
7906 Thyroiditis:
    With normal thyroid function (euthyroid).................          0
    Note: Manifesting as hyperthyroidism, evaluate as
     hyperthyroidism, including, but not limited to, Graves'
     disease (DC 7900); manifesting as hypothyroidism,
     evaluate as hypothyroidism (DC 7903).
7907 Cushing's syndrome:
    As active, progressive disease, including areas of               100
     osteoporosis, hypertension, and proximal upper and lower
     extremity muscle wasting that results in inability to
     rise from squatting position, climb stairs, rise from a
     deep chair without assistance, or raise arms............
    Proximal upper or lower extremity muscle wasting that             60
     results in inability to rise from squatting position,
     climb stairs, rise from a deep chair without assistance,
     or raise arms...........................................
    With striae, obesity, moon face, glucose intolerance, and         30
     vascular fragility......................................
    Note: The evaluations specifically indicated under this
     diagnostic code shall continue for six months following
     initial diagnosis. After six months, rate on residuals
     under the appropriate diagnostic code(s) within the
     appropriate body system(s).
7908 Acromegaly:
    Evidence of increased intracranial pressure (such as             100
     visual field defect), arthropathy, glucose intolerance,
     and either hypertension or cardiomegaly.................
    Arthropathy, glucose intolerance, and hypertension.......         60
    Enlargement of acral parts or overgrowth of long bones...         30
7909 Diabetes insipidus:
    For three months after initial diagnosis.................         30
    Note: Thereafter, if diabetes insipidus has subsided,
     rate residuals under the appropriate diagnostic code(s)
     within the appropriate body system.
    With persistent polyuria or requiring continuous hormonal         10
     therapy.................................................
7911 Addison's disease (adrenocortical insufficiency):
    Four or more crises during the past year.................         60
    Three crises during the past year, or; five or more               40
     episodes during the past year...........................
    One or two crises during the past year, or; two to four           20
     episodes during the past year, or; weakness and
     fatigability, or; corticosteroid therapy required for
     control.................................................
    Note (1): An Addisonian ``crisis'' consists of the rapid
     onset of peripheral vascular collapse (with acute
     hypotension and shock), with findings that may include:
     anorexia; nausea; vomiting; dehydration; profound
     weakness; pain in abdomen, legs, and back; fever;
     apathy, and depressed mentation with possible
     progression to coma, renal shutdown, and death.
    Note (2): An Addisonian ``episode,'' for VA purposes, is
     a less acute and less severe event than an Addisonian
     crisis and may consist of anorexia, nausea, vomiting,
     diarrhea, dehydration, weakness, malaise, orthostatic
     hypotension, or hypoglycemia, but no peripheral vascular
     collapse.
    Note (3): Tuberculous Addison's disease will be evaluated
     as active or inactive tuberculosis. If inactive, these
     evaluations are not to be combined with the graduated
     ratings of 50 percent or 30 percent for non-pulmonary
     tuberculosis specified under Sec.   4.88b. Assign the
     higher rating.
7912 Polyglandular syndrome (multiple endocrine neoplasia,
 autoimmune polyglandular syndrome):

[[Page 50806]]

 
    Evaluate according to major manifestations to include,
     but not limited to, Type I diabetes mellitus,
     hyperthyroidism, hypothyroidism, hypoparathyroidism, or
     Addison's disease.
7913 Diabetes mellitus:
    Requiring more than one daily injection of insulin,              100
     restricted diet, and regulation of activities (avoidance
     of strenuous occupational and recreational activities)
     with episodes of ketoacidosis or hypoglycemic reactions
     requiring at least three hospitalizations per year or
     weekly visits to a diabetic care provider, plus either
     progressive loss of weight and strength or complications
     that would be compensable if separately evaluated.......
    Requiring one or more daily injection of insulin,                 60
     restricted diet, and regulation of activities with
     episodes of ketoacidosis or hypoglycemic reactions
     requiring one or two hospitalizations per year or twice
     a month visits to a diabetic care provider, plus
     complications that would not be compensable if
     separately evaluated....................................
    Requiring one or more daily injection of insulin,                 40
     restricted diet, and regulation of activities...........
    Requiring one or more daily injection of insulin and              20
     restricted diet, or; oral hypoglycemic agent and
     restricted diet.........................................
    Manageable by restricted diet only.......................         10
    Note (1): Evaluate compensable complications of diabetes
     separately unless they are part of the criteria used to
     support a 100-percent evaluation. Noncompensable
     complications are considered part of the diabetic
     process under DC 7913.
    Note (2): When diabetes mellitus has been conclusively
     diagnosed, do not request a glucose tolerance test
     solely for rating purposes.
 
                              * * * * * * *
7915 Neoplasm, benign, any specified part of the endocrine
 system:
    Rate as residuals of endocrine dysfunction.
7916 Hyperpituitarism (prolactin secreting pituitary
 dysfunction):
    Note: Evaluate as malignant or benign neoplasm, as
     appropriate.
7917 Hyperaldosteronism (benign or malignant):
    Note: Evaluate as malignant or benign neoplasm, as
     appropriate.
7918 Pheochromocytoma (benign or malignant):
    Note: Evaluate as malignant or benign neoplasm as
     appropriate.
7919 C-cell hyperplasia of the thyroid:
    If antineoplastic therapy is required, evaluate as a
     malignant neoplasm under DC 7914. If a prophylactic
     thyroidectomy is performed (based upon genetic testing)
     and antineoplastic therapy is not required, evaluate as
     hypothyroidism under DC 7903.
 
                              * * * * * * *
------------------------------------------------------------------------


0
4. Amend the table in appendix A to part 4 in the entries for Sec. 
4.104 and Sec. 4.119 by:
0
a. Revising the entry for 7008;
0
b. Revising the entries for 7900 through 7905;
0
c. Adding in numerical order an entry for 7906; and
0
d. Revising the entries for 7907 through 7909, 7911 through 7913, and 
7915 through 7919.
    The revisions and addition read as follows:

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

------------------------------------------------------------------------
                  Diagnostic
      Sec.         code No.
------------------------------------------------------------------------
 
                              * * * * * * *
                        7008  Evaluation January 12, 1998; criterion
                               December 10, 2017.
 
                              * * * * * * *
4.119..........         7900  Criterion August 13, 1981; evaluation June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7901  Criterion August 13, 1981; evaluation June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7902  Evaluation August 13, 1981; criterion June
                               9, 1996; title December 10, 2017;
                               evaluation December 10, 2017; criterion
                               December 10, 2017; note December 10,
                               2017.
                        7903  Criterion August 13, 1981; evaluation June
                               9, 1996; evaluation December 10, 2017;
                               criterion December 10, 2017; note
                               December 10, 2017.
                        7904  Criterion August 13, 1981; evaluation June
                               9, 1996; evaluation December 10, 2017;
                               criterion December 10, 2017; note
                               December 10, 2017.
                        7905  Evaluation; August 13, 1981; evaluation
                               June 9, 1996; evaluation December 10,
                               2017; criterion December 10, 2017.
                        7906  Added December 10, 2017.
                        7907  Evaluation; August 13, 1981; evaluation
                               June 9, 1996; criterion December 10,
                               2017; note December 10, 2017.
                        7908  Criterion August 13, 1981; criterion June
                               9, 1996; criterion December 10, 2017.
                        7909  Evaluation August 13, 1981; criterion June
                               9, 1996; evaluation June 9, 1996;
                               criterion December 10, 2017; evaluation
                               December 10, 2017; note December 10,
                               2017.
                        7910  Removed June 9, 1996.
                        7911  Evaluation March 11, 1969; evaluation
                               August 13, 1981; criterion June 9, 1996;
                               title December 10, 2017; note December
                               10, 2017.
                        7912  Title December 10, 2017; criterion
                               December 10, 2017.
                        7913  Criterion September 9, 1975; criterion
                               August 13, 1981; criterion June 6, 1996;
                               evaluation June 9, 1996; criterion
                               December 10, 2017; note December 10,
                               2017.
 

[[Page 50807]]

 
                              * * * * * * *
                        7915  Criterion June 9, 1996; criterion December
                               10, 2017.
                        7916  Added June 9, 1996; note December 10,
                               2017.
                        7917  Added June 9, 1996; note December 10,
                               2017.
                        7918  Added June 9, 1996; note December 10,
                               2017.
                        7919  Added June 9, 1996; evaluation June 9,
                               1996; criterion December 10, 2017; note
                               December 10, 2017.
 
                              * * * * * * *
------------------------------------------------------------------------


0
5. Amend Appendix B to part 4 by:
0
a. Revising the entries for diagnostic codes 7900 through 7902;
0
b. Adding, in numerical order, an entry for diagnostic code 7906; and
0
c. Revising the entries for diagnostic codes 7911 and 7912.
    The revisions and addition read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

------------------------------------------------------------------------
     Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                          THE ENDOCRINE SYSTEM
------------------------------------------------------------------------
7900.........................  Hyperthyroidism, including, but not
                                limited to, Graves' disease.
7901.........................  Thyroid enlargement, toxic.
7902.........................  Thyroid enlargement, nontoxic.
 
                              * * * * * * *
7906.........................  Thyroiditis.
 
                              * * * * * * *
7911.........................  Addison's disease (adrenocortical
                                insufficiency).
7912.........................  Polyglandular syndrome (multiple
                                endocrine neoplasia, autoimmune
                                polyglandular syndrome).
 
                              * * * * * * *
------------------------------------------------------------------------


0
6. Amend Appendix C to Part 4 as follows:
0
a. Add, in alphabetical order, entries for ``Graves' disease'' and 
``Polyglandular syndrome'';
0
b. Revise the entry for ``Thyroid gland''; and
0
c. Add, in alphabetical order, an entry for ``Thyroiditis''.
    The additions and revision read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
                                                              Diagnostic
                                                               code No.
------------------------------------------------------------------------
 
                                * * * * *
Graves' disease............................................         7900
 
                                * * * * *
Polyglandular syndrome.....................................         7912
 
                                * * * * *
Thyroid gland..............................................
  Nontoxic thyroid enlargement.............................         7902
  Toxic thyroid enlargement................................         7901
Thyroiditis................................................         7906
 
                                * * * * *
------------------------------------------------------------------------

[FR Doc. 2017-23044 Filed 11-1-17; 8:45 am]
 BILLING CODE 8320-01-P