Schedule for Rating Disabilities; Gynecological Conditions and Disorders of the Breast, 15068-15074 [2018-07081]
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BILLING CODE 9110–04–P
DEPARTMENT OF VETERANS
AFFAIRS
38 CFR Part 4
RIN 2900–AP13
Schedule for Rating Disabilities;
Gynecological Conditions and
Disorders of the Breast
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
rating schedule that addresses
gynecological conditions and disorders
of the breast. The effect of this action is
to ensure that this portion of the rating
schedule uses current medical
terminology and to provide detailed and
updated criteria for evaluation of
gynecological conditions and disorders
of the breast.
DATES: Effective Date: This rule is
effective on May 13, 2018.
FOR FURTHER INFORMATION CONTACT:
Ioulia Vvedenskaya, M.D., M.B.A.,
Medical Officer, Part 4 VASRD
Regulations Staff (211C), Compensation
Service, Veterans Benefits
Administration, Department of Veterans
Affairs, 810 Vermont Avenue NW,
Washington, DC 20420, (202) 461–9700.
(This is not a toll-free telephone
number.)
sradovich on DSK3GMQ082PROD with RULES
SUMMARY:
VA
published a proposed rule in the
Federal Register at 80 FR 10637 on
February 27, 2015, to amend 38 CFR
4.116, the portion of the VASRD dealing
with gynecological conditions and
SUPPLEMENTARY INFORMATION:
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disorders of the breast. VA provided a
60-day public comment period and
interested persons were invited to
submit written comments on or before
April 28, 2015. VA received 13
comments.
Several commenters expressed their
support for the proposed rule and
thanked VA for promoting gender
equality in the rating schedule.
One commenter demanded
compensation for his multiple
debilitating health issues, which he
attributed to exposure to toxic
substances at Fort McClellan. He also
urged VA to pass the Fort McClellan
Health Registry Act, H.R. 411, 113th
Cong. (2013). Several commenters stated
their belief that their multiple medical
conditions are due to exposure to toxic
substances at Fort McClellan and asked
to be considered for service connection.
Another commenter provided
information about his medical
conditions, which he stated he
developed after his reservist’s training at
Fort McClellan that involved chemical
agent training. These comments focus
on issues of service connection, rather
than the appropriate rating for already
service-connected disabilities, and
individual claims for VA benefits,
which are beyond the scope of this
rulemaking. Regarding the commenter’s
request that VA ‘‘pass’’ the Fort
McClellan Health Registry Act, VA
notes that this act is a Congressional act
and not before VA. This comment is
also beyond the scope of this
rulemaking. Therefore, VA makes no
changes to the proposed rule based on
these comments.
One commenter had a question about
the proposed note to diagnostic code
7615 ‘‘Ovary, disease, injury, or
adhesions of’’ asking if the note would
create a narrow category for disability
evaluation by identifying dysmenorrhea
and secondary amenorrhea. The
commenter’s concern is not entirely
clear. To the extent the commenter is
asking whether VA considers
dysmenorrhea and secondary
amenorrhea disabilities for rating
purposes, the note to diagnostic code
7615 provides that dysmenorrhea and
secondary amenorrhea shall be rated
under that diagnostic code. To the
extent the commenter is asking whether
identification of dysmenorrhea and
secondary amenorrhea in the note limits
the application of diagnostic code 7615
to those diseases, it does not.
Dysmenorrhea and secondary
amenorrhea are only examples of
diseases that would be rated under
diagnostic code 7615. Other
impairments associated with disease,
injury, or adhesions of the ovaries will
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continue to be rated under diagnostic
code 7615. Therefore, VA makes no
changes based on this comment.
One commenter wanted to include
premature hysterectomy secondary to
menorrhagia as an additional
gynecological disability in the rating
schedule. VA evaluates serviceconnected hysterectomy under
diagnostic codes 7617 and 7618. The
cause of the hysterectomy may be a
factor in determining service
connection, but is not important in
evaluating the condition. Therefore, VA
makes no changes based on this
comment.
One commenter suggested adding a
new diagnostic code or adjusting an
existing code for infertility due to the
loss or loss of use of other organs
besides the uterus and ovaries,
specifically fallopian tubes. The
commenter asserted that, with respect to
the uterus and ovaries, the minimum
rating for a condition that causes
infertility is 20 percent and that this
rating does not take into account
symptoms, only whether the organs are
able to function reproductively.
Therefore, the commenter asserts that
any damage to any part of the female
reproductive system that causes
infertility should result in at least a 20
percent evaluation.
While tubal damage may be
associated with infertility, infertility is
not in itself a disability for VA rating
purposes. It does not result in the loss
of average earning capacity. See 38 CFR
4.1 (stating that the purpose of the rating
schedule is to represent the average
impairment in earning capacity
resulting from diseases and injuries in
civil occupations). Diagnostic code
7614, Fallopian tube, disease, injury, or
adhesions of, provides disability ratings
for functional impairment due to
symptoms associated with fallopian
tube damage. If loss or loss of use of a
creative organ due to service-connected
fallopian tube damage is present, VA
will consider special monthly
compensation under the provisions of
38 CFR 3.350(a). VA makes no changes
based on this comment.
The same commenter proposes to add
the diagnosis of repeated miscarriages to
the list of presumptive conditions for
female veterans who have been exposed
to radiation, herbicides, or other
environmental factors that could
negatively impact the ability of a fetus
to properly develop and carry to full
term. The commenter also suggested VA
provide for an award of special monthly
compensation under the provisions of
§ 3.350(a) for repeated miscarriages of
an unknown etiology while on active
duty. Miscarriages themselves are not
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disabilities for VA rating purposes, as
they do not result in impairment of
earning capacity. See 38 CFR 4.1. The
proposed rating criteria provide for
adequate ratings based on impairment
in earning capacity due to serviceconnected damage to reproductive
organs, which may include chronic
residuals of medical or surgical
complications of pregnancy incurred
during service. Additionally, special
monthly compensation may be
warranted for loss or loss of use of a
creative organ due to service-connected
disability. See 38 CFR 3.350(a)(1).
Updating the list of presumptive
conditions for veterans who have been
exposed to radiation, herbicides, or
other environmental factors is beyond
the scope of this rulemaking, which is
about the rating of conditions which
have been service connected, not about
which diseases should be subject to
presumptive service connection.
Therefore, VA makes no changes based
on these comments.
The same commenter asked how
powerful a diagnosis of female sexual
arousal disorder would be as supporting
evidence for military sexual trauma
(MST). This rulemaking concerns the
rating schedule in part 4, specifically 38
CFR 4.116, and the evaluations that VA
assigns for physiological impairment
due to disorders of the gynecological
system and disorders of the breasts. The
evidentiary criteria for posttraumatic
stress disorder are listed in 38 CFR
3.304(f). Further, mental disabilities due
to MST are evaluated under the rating
schedule for mental disorders in § 4.130.
This comment is beyond the scope of
this rulemaking. Therefore, VA makes
no changes based on this comment.
One commenter was supportive of the
overall changes and additions to this
section of the rating schedule. However,
the commenter expressed concern that
the proposed rating criteria for
diagnostic code 7621 do not adequately
measure disability affecting multiple
body systems. Specifically, the
commenter stated that the proposed rule
was unclear as to whether a veteran
would obtain evaluations under other
body systems for the complications of
pelvic organ prolapse, or whether the
mild, moderate, or severe rating under
proposed amended diagnostic code
7621 is meant to encompass all
symptoms due to one or multiple pelvic
organ prolapses. The commenter stated
that, if these manifestations in different
body systems are meant to be
compensated under diagnostic code
7621, there is great potential for
undercompensating the veteran, as
separate ratings under the genitourinary
and digestive system may afford a
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higher combined evaluation. The
commenter further questioned whether
rating the manifestations separately
would constitute ‘‘pyramiding’’ under
38 CFR 4.14.
The same commenter also indicated
that the Pelvic Organ Prolapse
Quantification (POP–Q) scoring system
upon which proposed diagnostic code
7621 was based does not correlate with
the severity of symptoms affecting
multiple body systems. In addition, the
same commenter suggested that VA add
a note to diagnostic code 7621 to clarify
that functional impairment of other
body systems, including the urinary and
the digestive systems, as a result of
pelvic organ prolapse, shall be
evaluated under the appropriate
diagnostic codes.
Evaluations under proposed
diagnostic code 7621 were intended to
represent the average severity of
symptoms, including gynecological,
urinary, and digestive symptoms, and
level of impairment as contemplated by
the POP–Q system. Therefore, assigning
separate ratings under proposed
diagnostic code 7621 and the
genitourinary or digestive systems
would have violated pyramiding
principles under 38 CFR 4.14 by
allowing evaluations for urinary and/or
digestive symptoms twice. See Esteban
v. Brown, 6 Vet. App. 259, 261–262
(1994). VA acknowledges, however, that
the average may not apply to all women
and that two women with the same
degree of prolapse (as measured by
POP–Q) may experience different
disabling effects based on their
anatomical size. Therefore, in order to
more accurately evaluate functional
impairment and to ensure that the
severity of the symptoms affecting
multiple body systems are fully
captured, VA amends the proposed
rating criteria and the note under
diagnostic code 7621 to include
guidance on how to rate the residuals
and complications of pelvic organ
prolapse.
First, VA amends diagnostic code
7621 to provide a 10 percent disability
rating in all cases of complete or
incomplete pelvic organ prolapse due to
injury, disease, or surgical
complications of pregnancy. This
minimum level of compensation
recognizes the disabling effects of the
alteration to a woman’s normal
anatomy, such as a feeling of vaginal
fullness or heaviness or pressure in the
pelvis, that are not generally included in
the compensable levels of disability in
other body systems. The higher
disability ratings in originally proposed
diagnostic code 7621 took into
consideration genitourinary, digestive,
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15069
and skin symptoms, which will now be
evaluated separately as described in the
revised note to diagnostic code 7621.
Second, VA agrees with the
commenter that information should be
added to the proposed note under
diagnostic code 7621 to clarify how
rating personnel should evaluate
urinary and digestive symptoms
associated with pelvic organ prolapse.
Specifically, VA is adding information
to the note under diagnostic code 7621
to clarify that rating personnel should
separately evaluate any genitourinary,
digestive, or skin symptoms under the
appropriate diagnostic code(s) and
combine all evaluations with the 10
percent evaluation under diagnostic
code 7621. With this clarification, VA
ensures that women with pelvic organ
prolapse will receive adequate levels of
compensation based on the functional
impairment associated with their
prolapse, regardless of any anatomical
differences. The discussion by the
commenter identified another potential
approach of considering the greater
evaluation under either proposed
diagnostic code 7621 or the appropriate
system. Under that approach, however,
a veteran whose evaluation was based
on a diagnostic code under a different
body system would not be compensated
for the disabling effects of prolapse
specific to the gynecological system.
The revised rule ensures that the
disabling effects associated with
multiple body systems are fully
captured.
The same commenter also suggested
VA amend VA Form 21–0960K–2,
Gynecological Conditions Disability
Benefits Questionnaire (DBQ) to add
questions regarding the effects of any
diagnosed gynecological condition on
the digestive system and consideration
of whether the veteran has loss of use
of a creative organ. The commenter
noted that the DBQ already asks the
examiner to comment on whether the
gynecological conditions impact the
genitourinary system. Currently, VA
Form 21–0960K–2 asks an examiner to
report any complications resulting from
obstetrical or gynecological conditions
or procedures. Additionally, VA Form
21–0960K–2 asks the examiner if the
veteran has any other pertinent findings,
complications, conditions, signs and/or
symptoms related to any conditions
listed in the diagnosis section of the
form. Therefore, VA has an adequate
mechanism to capture each and every
condition related to the effects of any
diagnosed gynecological condition,
including the digestive system and loss
of use of a creative organ. VA also notes
that all affected DBQs will be updated
upon issuance of this final rule and will
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adhere to the same principles of
recording pertinent findings. Therefore,
VA makes no changes based on these
comments.
Lastly, the same commenter suggested
VA add a separate diagnostic code in
§ 4.116 for loss of coital function due to
removal of the vagina by colpectomy
and a note to consider special monthly
compensation under 38 CFR 3.350(a) to
increase rating consistency. VA
appreciates this comment, but notes that
the VASRD, in accordance with 38 CFR
4.1, is ‘‘a guide in the evaluation of
disability’’ in terms of occupational
impairment and is not an exhaustive list
of all potential diseases or conditions.
This is further reinforced by 38 CFR
4.20, which specifically provides for
analogous evaluations for unlisted
conditions according to closely related
diseases or injuries based on function
affected, anatomical location, and
symptomatology.
Colpectomy, also known as
vaginectomy, is a surgical procedure
that obliterates the vaginal canal in
order to alleviate the symptoms of
advanced pelvic organ prolapse or to
treat gynecological malignancies. Such
obliterative procedure is reserved for
women who are not candidates for more
extensive surgery or do not plan future
vaginal intercourse. Colpectomy is
generally deemed appropriate for
elderly patients with medical
comorbidities or for patients with
previous failed prolapse surgery or
pessary trials who are not sexually
active. Evans, J., Karram, M., ‘‘Step by
step: Obliterating the vaginal canal to
correct pelvic organ prolapse,’’ OBG
Manag. 2012 February;24(2):30–41
https://www.mdedge.com/sites/default/
files/Document/September-2017/0212_
OBGM_Karram.pdf. Colpectomy in
younger patients is performed to treat
advanced vaginal and/or uterine cancer.
In cases of uterine cancer, colpectomy is
used exclusively in conjunction with
total abdominal hysterectomy. In cases
of vaginal cancer, vaginectomy may be
partial, subtotal, or total, depending on
the extent of the disease. Vaginal
reconstruction is offered in order to
preserve coital function. Bardavil, T. et
al., ‘‘Vaginal Cancer’’ (updated Jan. 11,
2015), Medscape, https://
emedicine.medscape.com/article/
269188-overview#a23 (last accessed
March 8, 2018). Partial vaginectomy is
not associated with the loss of coital
function.
Accordingly, the vast majority of
colpectomy procedures involve
associated partial or complete
hysterectomy, currently addressed in
diagnostic code 7618 and a new,
separate diagnostic code for colpectomy
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is unnecessary; functional impairment
due to the colpectomy/total
vaginectomy is adequately addressed
under diagnostic code 7618 for partial
and/or total hysterectomy. In rare cases,
colpectomy is performed without any
form of hysterectomy; VA will evaluate
these circumstances analogously to
diagnostic code 7618, and, in the
absence of functional impairment or
other findings, apply the provisions of
38 CFR 4.31 to establish service
connection at a noncompensable rate.
This approach provides VA with
adequate criteria to evaluate functional
impairment associated with colpectomy,
with or without hysterectomy, and to
establish service connection for a
disability for purposes of an award of
special monthly compensation under 38
CFR 3.350(a). We note that while
vaginal damage due to colpectomy may
be associated with loss of coital
function, coital function is not in itself
a disability for VA rating purposes. It
does not result in the loss of earning
capacity. See 38 CFR 4.1.
Entitlement to special monthly
compensation for anatomical loss or loss
of use of a creative organ may not be
awarded more than once per creative
organ. In the case of colpectomy with
loss of coital function, the presence or
absence of partial/total hysterectomy
does not entitle a female veteran to
additional awards of special monthly
compensation based on further
anatomical loss of a creative organ; in
either scenario the veteran has met the
statutory criteria for anatomical loss or
loss of use of the female creative organ
with varying degrees of functional
disability associated with the loss/loss
of use. Accordingly, establishing a
separate diagnostic code for colpectomy
would not create entitlement to
additional special monthly
compensation under 38 CFR 3.350. For
these reasons, VA makes no changes
based on these comments at this time.
One commenter was supportive of the
proposed addition of the new diagnostic
code 7632, Female sexual arousal
disorder (FSAD). The commenter noted
that the title used, ‘‘Female sexual
arousal disorder,’’ is not the current
medical term used in The Diagnostic
and Statistical Manual of Mental
Disorders, Fifth Edition (DSM–5). In
DSM–5, gender-specific sexual
dysfunctions have been added, and, for
females, sexual desire and arousal
disorders have been combined into one
disorder: Female Sexual Interest/
Arousal Disorder.
VA’s proposed diagnostic code 7632
differs from the DSM–5 diagnosis
because it only addresses the
physiologic form of FSAD, which is
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caused in part by decreased blood flow
to the genital area and peripheral nerve
damage due to micro trauma or disease
process. This form of FSAD does not
include the psychological features of
Female Sexual Interest/Arousal Disorder
outlined in DSM–5 such as lack of, or
significantly reduced, sexual interest or
desire. If an individual is diagnosed
with Female Sexual Interest/Arousal
Disorder as outlined in DSM–5 that is
service connected, she will be rated
under the appropriate diagnostic code
under 38 CFR 4.130, which pertains to
mental disorders. Furthermore, if her
disability picture includes FSAD,
defined as the continual or recurrent
inability to accomplish or maintain an
ample lubrication-swelling reaction
during sexual intercourse, then separate
compensation under diagnostic code
7632 would be appropriate. Therefore,
VA makes no changes based on this
comment.
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 as a final rule
with the changes noted above.
Additionally, VA notes that it is making
a technical correction to its proposed
changes to Appendix B to Part 4—
Numerical Index of Disabilities.
Specifically, VA inadvertently left out
instructions to delete references to
diagnostic codes 7622 and 7623 which,
as discussed in the proposed rule, are
being removed.
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 May 13,
2018, the date VBMS–R system updates
related to this final rule will be
complete.
Executive Orders 12866, 13563, and
13771
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).
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Executive Order 13563 (Improving
Regulation and Regulatory Review)
emphasizes the importance of
quantifying both costs and benefits,
reducing costs, harmonizing rules, and
promoting flexibility. Executive Order
12866 (Regulatory Planning and
Review) defines a ‘‘significant
regulatory action,’’ which requires
review by the Office of Management and
Budget (OMB), as ‘‘any regulatory action
that is likely to result in a rule that may:
(1) Have an annual effect on the
economy of $100 million or more or
adversely affect in a material way the
economy, a sector of the economy,
productivity, competition, jobs, the
environment, public health or safety, or
State, local, or tribal governments or
communities; (2) Create a serious
inconsistency or otherwise interfere
with an action taken or planned by
another agency; (3) Materially alter the
budgetary impact of entitlements,
grants, user fees, or loan programs or the
rights and obligations of recipients
thereof; or (4) Raise novel legal or policy
issues arising out of legal mandates, the
President’s priorities, or the principles
set forth in this Executive Order.’’
The economic, interagency,
budgetary, legal, and policy
implications of this 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 website at
https://www.va.gov/orpm by following
the link for VA Regulations Published
from FY 2004 through FYTD. This rule
is not an E.O. 13771 regulatory action
because this rule is not significant under
E.O. 12866.
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 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.
List of Subjects in 38 CFR Part 4
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.
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.
Jacquelyn Hayes-Byrd, Deputy Chief of
Staff, Department of Veterans Affairs,
approved this document on April 3,
2018, for publication.
Paperwork Reduction Act
This final rule contains provisions
constituting a collection of information
under the Paperwork Reduction Act of
1995 (44 U.S.C. 3501–3521).
Specifically, this final rule is associated
with information collections related to
the filing of disability benefits claims
(VA Form 21–526EZ) as well as
Disability Benefits Questionnaires
(DBQs) which enable a claimant to
gather the necessary information from
his or her treating physician as to the
current symptoms and severity of a
disability (VA Forms 21–0960K–1,
Breast Conditions and Disorders DBQ,
and 21–0960K–2, Gynecological
Conditions DBQ). Both information
collections are currently approved by
the Office of Management and Budget
(OMB) and have been assigned OMB
control numbers 2900–0747 and 2900–
0778, respectively. VA has reviewed the
impact of this final rule on these
information collections and determined
that the information collection burden is
de minimis.
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.
Disability benefits, Pensions,
Veterans.
Signing Authority
Dated: April 3, 2018.
Jeffrey M. Martin,
Impact Analyst, Office of Regulation Policy
& Management, Office of the Secretary,
Department of Veterans Affairs.
For the reasons set out in the
preamble, VA amends 38 CFR part 4 as
follows:
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 § 4.116 as follows:
a. Revise the entry for diagnostic code
7610;
■ b. Add a note at the end of the entries
for diagnostic codes 7615 and 7619;
■ c. Revise the entry for diagnostic code
7621;
■ d. Remove the entries for diagnostic
codes 7622 and 7623;
■ e. Revise the entries for diagnostic
codes 7627 and 7628;
■ f. Add entries for diagnostic codes
7630 through 7632 in numerical order;
and
■ g. Add an authority citation at the end
of the section.
The revisions and additions read as
follows:
■
■
§ 4.116 Schedule of ratings—
gynecological conditions and disorders of
the breast.
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Rating
7610
*
*
*
Vulva or clitoris, disease or injury of (including vulvovaginitis)
*
7615 * * *
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Rating
Note: For the purpose of VA disability evaluation, a disease, injury, or adhesions of the ovaries resulting in ovarian dysfunction affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under diagnostic code 7615
*
*
*
*
*
*
7619 * * *
Note: In cases of the removal of one ovary as the result of a service-connected injury or disease, with the absence or nonfunctioning of a second ovary unrelated to service, an evaluation of 30 percent will be assigned for the service-connected
ovarian loss
*
*
*
*
*
*
*
7621 Complete or incomplete pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy ...................
Note: Pelvic organ prolapse occurs when a pelvic organ such as bladder, urethra, uterus, vagina, small bowel, or rectum
drops (prolapse) from its normal place in the abdomen. Conditions associated with pelvic organ prolapse include: uterine
or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or any combination thereof. Evaluate pelvic organ
prolapse under DC 7621. Evaluate separately any genitourinary, digestive, or skin symptoms under the appropriate diagnostic code(s) and combine all evaluations with the 10 percent evaluation under DC 7621
*
*
*
*
*
*
*
7627 Malignant neoplasms of gynecological system .......................................................................................................................
Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy
or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall
be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination
shall be subject to the provisions of § 3.105(e) of this chapter. Rate chronic residuals to include scars, lymphedema, disfigurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body system
7628 Benign neoplasms of gynecological system. Rate chronic residuals to include scars, lymphedema, disfigurement, and/or
other impairment of function under the appropriate diagnostic code(s) within the appropriate body system
*
*
*
*
*
*
*
7630 Malignant neoplasms of the breast ..........................................................................................................................................
Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy
or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall
be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination
shall be subject to the provisions of § 3.105(e) of this chapter. Rate chronic residuals according to impairment of function
due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or
loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code
7626
7631 Benign neoplasms of the breast and other injuries of the breast. Rate chronic residuals according to impairment of function due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or
loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code 7626
7632 Female sexual arousal disorder (FSAD) ..................................................................................................................................
*
1 Review
10
100
100
10
for entitlement to special monthly compensation under § 3.350 of this chapter.
(Authority: 38 U.S.C. 1155)
b. Adding, in numerical order, entries
for diagnostic codes 7630 through 7632.
The revisions and additions read as
follows:
■
3. Amend appendix A to part 4 by:
a. Revising the entries for diagnostic
codes 7610, 7615, 7619, 7621, 7622,
7623, 7627, and 7628; and
■
■
Appendix A to Part 4—Table of
Amendments and Effective Dates Since
1946
Diagnostic
code No.
Sec.
*
*
*
*
Criterion May 22, 1995; title May 13, 2018.
*
*
*
7610
*
*
*
Criterion May 22, 1995; note May 13, 2018.
*
*
*
7615
*
*
*
Criterion May 22, 1995; note May 13, 2018.
*
*
*
7619
*
*
*
Criterion May 22, 1995; evaluation May 13, 2018.
Removed May 13, 2018.
Removed May 13, 2018.
*
*
*
7621
7622
7623
*
*
*
*
Criterion March 10, 1976; criterion May 22, 1995; title, note May 13, 2018.
Added May 22, 1995; title, criterion May 13, 2018.
*
*
7627
7628
*
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*
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*
Added May 13, 2018.
Added May 13, 2018.
Added May 13, 2018.
*
*
*
*
*
7630
7631
7632
*
*
*
*
*
4. Amend appendix B to part 4 by:
a. Revising the entries for diagnostic
codes 7610 and 7621;
■ b. Removing the entries for diagnostic
codes 7622 and 7623;
■
■
c. Revising the entries for diagnostic
codes 7627 and 7628; and
■ d. Adding, in numerical order, entries
for diagnostic codes 7630 through 7632.
■
The revisions and additions read as
follows:
Appendix B to Part 4—Numerical Index
of Disabilities
Diagnostic
code No.
*
*
*
*
*
*
*
Gynecological Conditions and Disorders of the Breast
7610 .............
Vulva or clitoris, disease or injury of (including vulvovaginitis).
*
7621 .............
*
*
*
*
*
Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy.
*
*
7627 .............
7628 .............
*
*
Malignant neoplasms of gynecological system.
Benign neoplasms of gynecological system.
*
7630 .............
7631 .............
7632 .............
*
*
*
Malignant neoplasms of the breast.
Benign neoplasms of the breast and other injuries of the breast.
Female sexual arousal disorder (FSAD).
*
*
*
*
5. Amend appendix C to part 4 as
follows:
■ a. Add in alphabetical order an entry
for ‘‘Complete or incomplete pelvic
organ prolapse due to injury or disease
or surgical complications of pregnancy,
including uterine or vaginal vault
prolapse, cystocele, urethrocele,
rectocele, enterocele, or combination’’.
■ b. Add in alphabetical order an entry
for ‘‘Female sexual arousal disorder
(FSAD)’’.
■
*
*
*
*
*
*
*
*
*
*
c. Under the heading ‘‘Injury,’’ add in
alphabetical order an entry for ‘‘Breast’’.
■ d. Under the heading ‘‘Neoplasms:
Benign:’’:
■ i. Add in alphabetical order an entry
for ‘‘Breast’’.
■ ii. Remove ‘‘Gynecological or breast’’
and in its place add ‘‘Gynecological’’.
■ e. Under the heading ‘‘Neoplasms:
Malignant:’’:
■ i. Add in alphabetical order an entry
for ‘‘Breast’’.
■ ii. Remove ‘‘Gynecological or breast’’
and in its place add ‘‘Gynecological’’.
■
f. Remove the entry ‘‘Pregnancy,
surgical complications’’.
■ g. Under the heading ‘‘Uterus,’’
remove the entry ‘‘Displacement’’.
■ h. Remove ‘‘Vulva disease or injury
of’’ and add in its place ‘‘Vulva or
clitoris, disease or injury of’’.
The additions and revisions read as
follows:
■
Appendix C to Part 4—Alphabetical
Index of Disabilities
Diagnostic
code No.
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*
*
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Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy, including uterine
or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or combination ...............................................................
*
*
*
*
*
*
*
Female sexual arousal disorder (FSAD) .............................................................................................................................................
*
*
*
*
*
*
*
Injury:
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code No.
*
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Breast ...........................................................................................................................................................................................
*
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*
*
*
*
Neoplasms:
Benign:
Breast ....................................................................................................................................................................................
*
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*
*
*
*
*
Malignant:
Breast ....................................................................................................................................................................................
*
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[FR Doc. 2018–07081 Filed 4–6–18; 8:45 am]
BILLING CODE 8320–01–P
ENVIRONMENTAL PROTECTION
AGENCY
40 CFR Part 52
[EPA–R07–OAR–2015–0105; FRL–9976–48–
Region 7]
Approval and Promulgation of Air
Quality Implementation Plans;
Missouri; Update to Materials
Incorporated by Reference; Correcting
Amendments
Environmental Protection
Agency (EPA).
ACTION: Final rule; correcting
amendments.
AGENCY:
The Environmental Protection
Agency (EPA), in a final rule action
published in the Federal Register on
August 6, 2015, erroneously approved
and codified previously removed
entries; erroneously omitted the
addition of previously approved entries;
and erroneously published codification
of previously revised entries. This
technical amendment corrects the
erroneous entries.
DATES: This rule is effective on April 9,
2018.
FOR FURTHER INFORMATION CONTACT: Jan
Simpson at (913) 551–7089, or by email
at simpson.jan@epa.gov.
SUPPLEMENTARY INFORMATION: The
August 6, 2015 (80 FR 46804), Federal
Register final rule and notice of
administrative change inadvertently and
erroneously approved and codified
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SUMMARY:
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*
previously removed Missouri
regulations; omitted the addition of a
previously approved regulation; and
erroneously published incorrect state
effective dates and citation information
for previously approved entries.
On October 21, 2014 (79 FR 62844),
in a direct final rule, EPA approved a
revision to ‘‘10–6.400’’. The state
effective date is 6/27/13.
On March 3, 2015 (80 FR 11323), in
a final rule, EPA approved a revision to
remove the chapter titled ‘‘Missouri
Department of Public Safety, Division
50-State Highway Patrol, Chapter 2—
Motor Vehicle Inspection’’ and its
entries for ‘‘50–2.010 through 50–
2.420’’. This final rule also approved the
addition of ‘‘10–5.381’’.
On March 4, 2015 (80 FR 11577), EPA
approved in a direct final rule a revision
to remove the entry for ‘‘10–5.240’’ and
approved revisions to Missouri
regulations ‘‘10–6.010’’, ‘‘10–6.020’’ and
‘‘10–6.040’’. The state effective date of
‘‘10–6.010’’ is 7/30/14; the state
effective date of ‘‘10–6.020’’ is 3/30/14;
and the state effective date of ‘‘10–
6.040’’ is 11/30/14.
Therefore, we are correcting the EPA’s
regulations to remove ‘‘10–5.240’’; add
‘‘10–5.381’’; remove the chapter titled
‘‘Missouri Department of Public Safety,
Division 50-State Highway Patrol,
Chapter 2—Motor Vehicle Inspection’’
and its entries for ‘‘50–2.010 through
50–2.420’’; and revise ‘‘10–6.010’’, ‘‘10–
6.020’’ and ‘‘10–6.040’’ to reflect the
most currently approved dates and
citations.
List of Subjects in 40 CFR Part 52
Environmental protection, Air
pollution control, Carbon monoxide,
PO 00000
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7631
7631
7630
*
Incorporation by reference,
Intergovernmental relations, Lead,
Nitrogen dioxide, Ozone, Particulate
matter, Reporting and recordkeeping
requirements, Sulfur oxides, Volatile
organic compounds,
Dated: March 27, 2018.
Karen A. Flournoy,
Acting Regional Administrator, Region 7.
Accordingly, EPA amends 40 CFR
part 52 as set forth below:
PART 52—APPROVAL AND
PROMULGATION OF
IMPLEMENTATION PLANS
1. The authority citation for part 52
continues to read as follows:
■
Authority: 42 U.S.C. 7401 et seq.
Subpart AA—Missouri
2. Amend § 52.1320(c) by:
a. Removing the entry for ‘‘10–5.240’’;
■ b. Adding the entry for ‘‘10–5.381’’ in
numerical order;
■ c. Revising entries ‘‘10–6.010’’, ‘‘10–
6.020’’, ‘‘10–6.040’’, and ‘‘10–6.400’’;
and
■ d. Removing the heading ‘‘Missouri
Department of Public Safety, Division
50-State Highway Patrol, Chapter 2—
Motor Vehicle Inspection’’ and the
entries ‘‘50–2.010’’ through ‘‘50–2.420’’.
The addition and revisions read as
follows:
■
■
§ 52.1320
*
Identification of plan.
*
*
(c) * * *
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Agencies
[Federal Register Volume 83, Number 68 (Monday, April 9, 2018)]
[Rules and Regulations]
[Pages 15068-15074]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-07081]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AP13
Schedule for Rating Disabilities; Gynecological Conditions and
Disorders of the Breast
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This document amends the Department of Veterans Affairs (VA)
Schedule for Rating Disabilities (VASRD) by revising the portion of the
rating schedule that addresses gynecological conditions and disorders
of the breast. The effect of this action is to ensure that this portion
of the rating schedule uses current medical terminology and to provide
detailed and updated criteria for evaluation of gynecological
conditions and disorders of the breast.
DATES: Effective Date: This rule is effective on May 13, 2018.
FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, M.D., M.B.A.,
Medical Officer, Part 4 VASRD Regulations Staff (211C), Compensation
Service, Veterans Benefits Administration, Department of Veterans
Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 461-9700.
(This is not a toll-free telephone number.)
SUPPLEMENTARY INFORMATION: VA published a proposed rule in the Federal
Register at 80 FR 10637 on February 27, 2015, to amend 38 CFR 4.116,
the portion of the VASRD dealing with gynecological conditions and
disorders of the breast. VA provided a 60-day public comment period and
interested persons were invited to submit written comments on or before
April 28, 2015. VA received 13 comments.
Several commenters expressed their support for the proposed rule
and thanked VA for promoting gender equality in the rating schedule.
One commenter demanded compensation for his multiple debilitating
health issues, which he attributed to exposure to toxic substances at
Fort McClellan. He also urged VA to pass the Fort McClellan Health
Registry Act, H.R. 411, 113th Cong. (2013). Several commenters stated
their belief that their multiple medical conditions are due to exposure
to toxic substances at Fort McClellan and asked to be considered for
service connection. Another commenter provided information about his
medical conditions, which he stated he developed after his reservist's
training at Fort McClellan that involved chemical agent training. These
comments focus on issues of service connection, rather than the
appropriate rating for already service-connected disabilities, and
individual claims for VA benefits, which are beyond the scope of this
rulemaking. Regarding the commenter's request that VA ``pass'' the Fort
McClellan Health Registry Act, VA notes that this act is a
Congressional act and not before VA. This comment is also beyond the
scope of this rulemaking. Therefore, VA makes no changes to the
proposed rule based on these comments.
One commenter had a question about the proposed note to diagnostic
code 7615 ``Ovary, disease, injury, or adhesions of'' asking if the
note would create a narrow category for disability evaluation by
identifying dysmenorrhea and secondary amenorrhea. The commenter's
concern is not entirely clear. To the extent the commenter is asking
whether VA considers dysmenorrhea and secondary amenorrhea disabilities
for rating purposes, the note to diagnostic code 7615 provides that
dysmenorrhea and secondary amenorrhea shall be rated under that
diagnostic code. To the extent the commenter is asking whether
identification of dysmenorrhea and secondary amenorrhea in the note
limits the application of diagnostic code 7615 to those diseases, it
does not. Dysmenorrhea and secondary amenorrhea are only examples of
diseases that would be rated under diagnostic code 7615. Other
impairments associated with disease, injury, or adhesions of the
ovaries will continue to be rated under diagnostic code 7615.
Therefore, VA makes no changes based on this comment.
One commenter wanted to include premature hysterectomy secondary to
menorrhagia as an additional gynecological disability in the rating
schedule. VA evaluates service-connected hysterectomy under diagnostic
codes 7617 and 7618. The cause of the hysterectomy may be a factor in
determining service connection, but is not important in evaluating the
condition. Therefore, VA makes no changes based on this comment.
One commenter suggested adding a new diagnostic code or adjusting
an existing code for infertility due to the loss or loss of use of
other organs besides the uterus and ovaries, specifically fallopian
tubes. The commenter asserted that, with respect to the uterus and
ovaries, the minimum rating for a condition that causes infertility is
20 percent and that this rating does not take into account symptoms,
only whether the organs are able to function reproductively. Therefore,
the commenter asserts that any damage to any part of the female
reproductive system that causes infertility should result in at least a
20 percent evaluation.
While tubal damage may be associated with infertility, infertility
is not in itself a disability for VA rating purposes. It does not
result in the loss of average earning capacity. See 38 CFR 4.1 (stating
that the purpose of the rating schedule is to represent the average
impairment in earning capacity resulting from diseases and injuries in
civil occupations). Diagnostic code 7614, Fallopian tube, disease,
injury, or adhesions of, provides disability ratings for functional
impairment due to symptoms associated with fallopian tube damage. If
loss or loss of use of a creative organ due to service-connected
fallopian tube damage is present, VA will consider special monthly
compensation under the provisions of 38 CFR 3.350(a). VA makes no
changes based on this comment.
The same commenter proposes to add the diagnosis of repeated
miscarriages to the list of presumptive conditions for female veterans
who have been exposed to radiation, herbicides, or other environmental
factors that could negatively impact the ability of a fetus to properly
develop and carry to full term. The commenter also suggested VA provide
for an award of special monthly compensation under the provisions of
Sec. 3.350(a) for repeated miscarriages of an unknown etiology while
on active duty. Miscarriages themselves are not
[[Page 15069]]
disabilities for VA rating purposes, as they do not result in
impairment of earning capacity. See 38 CFR 4.1. The proposed rating
criteria provide for adequate ratings based on impairment in earning
capacity due to service-connected damage to reproductive organs, which
may include chronic residuals of medical or surgical complications of
pregnancy incurred during service. Additionally, special monthly
compensation may be warranted for loss or loss of use of a creative
organ due to service-connected disability. See 38 CFR 3.350(a)(1).
Updating the list of presumptive conditions for veterans who have been
exposed to radiation, herbicides, or other environmental factors is
beyond the scope of this rulemaking, which is about the rating of
conditions which have been service connected, not about which diseases
should be subject to presumptive service connection. Therefore, VA
makes no changes based on these comments.
The same commenter asked how powerful a diagnosis of female sexual
arousal disorder would be as supporting evidence for military sexual
trauma (MST). This rulemaking concerns the rating schedule in part 4,
specifically 38 CFR 4.116, and the evaluations that VA assigns for
physiological impairment due to disorders of the gynecological system
and disorders of the breasts. The evidentiary criteria for
posttraumatic stress disorder are listed in 38 CFR 3.304(f). Further,
mental disabilities due to MST are evaluated under the rating schedule
for mental disorders in Sec. 4.130. This comment is beyond the scope
of this rulemaking. Therefore, VA makes no changes based on this
comment.
One commenter was supportive of the overall changes and additions
to this section of the rating schedule. However, the commenter
expressed concern that the proposed rating criteria for diagnostic code
7621 do not adequately measure disability affecting multiple body
systems. Specifically, the commenter stated that the proposed rule was
unclear as to whether a veteran would obtain evaluations under other
body systems for the complications of pelvic organ prolapse, or whether
the mild, moderate, or severe rating under proposed amended diagnostic
code 7621 is meant to encompass all symptoms due to one or multiple
pelvic organ prolapses. The commenter stated that, if these
manifestations in different body systems are meant to be compensated
under diagnostic code 7621, there is great potential for
undercompensating the veteran, as separate ratings under the
genitourinary and digestive system may afford a higher combined
evaluation. The commenter further questioned whether rating the
manifestations separately would constitute ``pyramiding'' under 38 CFR
4.14.
The same commenter also indicated that the Pelvic Organ Prolapse
Quantification (POP-Q) scoring system upon which proposed diagnostic
code 7621 was based does not correlate with the severity of symptoms
affecting multiple body systems. In addition, the same commenter
suggested that VA add a note to diagnostic code 7621 to clarify that
functional impairment of other body systems, including the urinary and
the digestive systems, as a result of pelvic organ prolapse, shall be
evaluated under the appropriate diagnostic codes.
Evaluations under proposed diagnostic code 7621 were intended to
represent the average severity of symptoms, including gynecological,
urinary, and digestive symptoms, and level of impairment as
contemplated by the POP-Q system. Therefore, assigning separate ratings
under proposed diagnostic code 7621 and the genitourinary or digestive
systems would have violated pyramiding principles under 38 CFR 4.14 by
allowing evaluations for urinary and/or digestive symptoms twice. See
Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). VA acknowledges,
however, that the average may not apply to all women and that two women
with the same degree of prolapse (as measured by POP-Q) may experience
different disabling effects based on their anatomical size. Therefore,
in order to more accurately evaluate functional impairment and to
ensure that the severity of the symptoms affecting multiple body
systems are fully captured, VA amends the proposed rating criteria and
the note under diagnostic code 7621 to include guidance on how to rate
the residuals and complications of pelvic organ prolapse.
First, VA amends diagnostic code 7621 to provide a 10 percent
disability rating in all cases of complete or incomplete pelvic organ
prolapse due to injury, disease, or surgical complications of
pregnancy. This minimum level of compensation recognizes the disabling
effects of the alteration to a woman's normal anatomy, such as a
feeling of vaginal fullness or heaviness or pressure in the pelvis,
that are not generally included in the compensable levels of disability
in other body systems. The higher disability ratings in originally
proposed diagnostic code 7621 took into consideration genitourinary,
digestive, and skin symptoms, which will now be evaluated separately as
described in the revised note to diagnostic code 7621.
Second, VA agrees with the commenter that information should be
added to the proposed note under diagnostic code 7621 to clarify how
rating personnel should evaluate urinary and digestive symptoms
associated with pelvic organ prolapse. Specifically, VA is adding
information to the note under diagnostic code 7621 to clarify that
rating personnel should separately evaluate any genitourinary,
digestive, or skin symptoms under the appropriate diagnostic code(s)
and combine all evaluations with the 10 percent evaluation under
diagnostic code 7621. With this clarification, VA ensures that women
with pelvic organ prolapse will receive adequate levels of compensation
based on the functional impairment associated with their prolapse,
regardless of any anatomical differences. The discussion by the
commenter identified another potential approach of considering the
greater evaluation under either proposed diagnostic code 7621 or the
appropriate system. Under that approach, however, a veteran whose
evaluation was based on a diagnostic code under a different body system
would not be compensated for the disabling effects of prolapse specific
to the gynecological system. The revised rule ensures that the
disabling effects associated with multiple body systems are fully
captured.
The same commenter also suggested VA amend VA Form 21-0960K-2,
Gynecological Conditions Disability Benefits Questionnaire (DBQ) to add
questions regarding the effects of any diagnosed gynecological
condition on the digestive system and consideration of whether the
veteran has loss of use of a creative organ. The commenter noted that
the DBQ already asks the examiner to comment on whether the
gynecological conditions impact the genitourinary system. Currently, VA
Form 21-0960K-2 asks an examiner to report any complications resulting
from obstetrical or gynecological conditions or procedures.
Additionally, VA Form 21-0960K-2 asks the examiner if the veteran has
any other pertinent findings, complications, conditions, signs and/or
symptoms related to any conditions listed in the diagnosis section of
the form. Therefore, VA has an adequate mechanism to capture each and
every condition related to the effects of any diagnosed gynecological
condition, including the digestive system and loss of use of a creative
organ. VA also notes that all affected DBQs will be updated upon
issuance of this final rule and will
[[Page 15070]]
adhere to the same principles of recording pertinent findings.
Therefore, VA makes no changes based on these comments.
Lastly, the same commenter suggested VA add a separate diagnostic
code in Sec. 4.116 for loss of coital function due to removal of the
vagina by colpectomy and a note to consider special monthly
compensation under 38 CFR 3.350(a) to increase rating consistency. VA
appreciates this comment, but notes that the VASRD, in accordance with
38 CFR 4.1, is ``a guide in the evaluation of disability'' in terms of
occupational impairment and is not an exhaustive list of all potential
diseases or conditions. This is further reinforced by 38 CFR 4.20,
which specifically provides for analogous evaluations for unlisted
conditions according to closely related diseases or injuries based on
function affected, anatomical location, and symptomatology.
Colpectomy, also known as vaginectomy, is a surgical procedure that
obliterates the vaginal canal in order to alleviate the symptoms of
advanced pelvic organ prolapse or to treat gynecological malignancies.
Such obliterative procedure is reserved for women who are not
candidates for more extensive surgery or do not plan future vaginal
intercourse. Colpectomy is generally deemed appropriate for elderly
patients with medical comorbidities or for patients with previous
failed prolapse surgery or pessary trials who are not sexually active.
Evans, J., Karram, M., ``Step by step: Obliterating the vaginal canal
to correct pelvic organ prolapse,'' OBG Manag. 2012 February;24(2):30-
41 https://www.mdedge.com/sites/default/files/Document/September-2017/0212_OBGM_Karram.pdf. Colpectomy in younger patients is performed to
treat advanced vaginal and/or uterine cancer. In cases of uterine
cancer, colpectomy is used exclusively in conjunction with total
abdominal hysterectomy. In cases of vaginal cancer, vaginectomy may be
partial, subtotal, or total, depending on the extent of the disease.
Vaginal reconstruction is offered in order to preserve coital function.
Bardavil, T. et al., ``Vaginal Cancer'' (updated Jan. 11, 2015),
Medscape, https://emedicine.medscape.com/article/269188-overview#a23
(last accessed March 8, 2018). Partial vaginectomy is not associated
with the loss of coital function.
Accordingly, the vast majority of colpectomy procedures involve
associated partial or complete hysterectomy, currently addressed in
diagnostic code 7618 and a new, separate diagnostic code for colpectomy
is unnecessary; functional impairment due to the colpectomy/total
vaginectomy is adequately addressed under diagnostic code 7618 for
partial and/or total hysterectomy. In rare cases, colpectomy is
performed without any form of hysterectomy; VA will evaluate these
circumstances analogously to diagnostic code 7618, and, in the absence
of functional impairment or other findings, apply the provisions of 38
CFR 4.31 to establish service connection at a noncompensable rate. This
approach provides VA with adequate criteria to evaluate functional
impairment associated with colpectomy, with or without hysterectomy,
and to establish service connection for a disability for purposes of an
award of special monthly compensation under 38 CFR 3.350(a). We note
that while vaginal damage due to colpectomy may be associated with loss
of coital function, coital function is not in itself a disability for
VA rating purposes. It does not result in the loss of earning capacity.
See 38 CFR 4.1.
Entitlement to special monthly compensation for anatomical loss or
loss of use of a creative organ may not be awarded more than once per
creative organ. In the case of colpectomy with loss of coital function,
the presence or absence of partial/total hysterectomy does not entitle
a female veteran to additional awards of special monthly compensation
based on further anatomical loss of a creative organ; in either
scenario the veteran has met the statutory criteria for anatomical loss
or loss of use of the female creative organ with varying degrees of
functional disability associated with the loss/loss of use.
Accordingly, establishing a separate diagnostic code for colpectomy
would not create entitlement to additional special monthly compensation
under 38 CFR 3.350. For these reasons, VA makes no changes based on
these comments at this time.
One commenter was supportive of the proposed addition of the new
diagnostic code 7632, Female sexual arousal disorder (FSAD). The
commenter noted that the title used, ``Female sexual arousal
disorder,'' is not the current medical term used in The Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In DSM-
5, gender-specific sexual dysfunctions have been added, and, for
females, sexual desire and arousal disorders have been combined into
one disorder: Female Sexual Interest/Arousal Disorder.
VA's proposed diagnostic code 7632 differs from the DSM-5 diagnosis
because it only addresses the physiologic form of FSAD, which is caused
in part by decreased blood flow to the genital area and peripheral
nerve damage due to micro trauma or disease process. This form of FSAD
does not include the psychological features of Female Sexual Interest/
Arousal Disorder outlined in DSM-5 such as lack of, or significantly
reduced, sexual interest or desire. If an individual is diagnosed with
Female Sexual Interest/Arousal Disorder as outlined in DSM-5 that is
service connected, she will be rated under the appropriate diagnostic
code under 38 CFR 4.130, which pertains to mental disorders.
Furthermore, if her disability picture includes FSAD, defined as the
continual or recurrent inability to accomplish or maintain an ample
lubrication-swelling reaction during sexual intercourse, then separate
compensation under diagnostic code 7632 would be appropriate.
Therefore, VA makes no changes based on this comment.
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 as a final rule with the changes
noted above. Additionally, VA notes that it is making a technical
correction to its proposed changes to Appendix B to Part 4--Numerical
Index of Disabilities. Specifically, VA inadvertently left out
instructions to delete references to diagnostic codes 7622 and 7623
which, as discussed in the proposed rule, are being removed.
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 May 13, 2018, the date VBMS-R system
updates related to this final rule will be complete.
Executive Orders 12866, 13563, and 13771
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).
[[Page 15071]]
Executive Order 13563 (Improving Regulation and Regulatory Review)
emphasizes the importance of quantifying both costs and benefits,
reducing costs, harmonizing rules, and promoting flexibility. Executive
Order 12866 (Regulatory Planning and Review) defines a ``significant
regulatory action,'' which requires review by the Office of Management
and Budget (OMB), as ``any regulatory action that is likely to result
in a rule that may: (1) Have an annual effect on the economy of $100
million or more or adversely affect in a material way the economy, a
sector of the economy, productivity, competition, jobs, the
environment, public health or safety, or State, local, or tribal
governments or communities; (2) Create a serious inconsistency or
otherwise interfere with an action taken or planned by another agency;
(3) Materially alter the budgetary impact of entitlements, grants, user
fees, or loan programs or the rights and obligations of recipients
thereof; or (4) Raise novel legal or policy issues arising out of legal
mandates, the President's priorities, or the principles set forth in
this Executive Order.''
The economic, interagency, budgetary, legal, and policy
implications of this 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 website
at https://www.va.gov/orpm by following the link for VA Regulations
Published from FY 2004 through FYTD. This rule is not an E.O. 13771
regulatory action because this rule is not significant under E.O.
12866.
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 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 provisions constituting a collection of
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521). Specifically, this final rule is associated with information
collections related to the filing of disability benefits claims (VA
Form 21-526EZ) as well as Disability Benefits Questionnaires (DBQs)
which enable a claimant to gather the necessary information from his or
her treating physician as to the current symptoms and severity of a
disability (VA Forms 21-0960K-1, Breast Conditions and Disorders DBQ,
and 21-0960K-2, Gynecological Conditions DBQ). Both information
collections are currently approved by the Office of Management and
Budget (OMB) and have been assigned OMB control numbers 2900-0747 and
2900-0778, respectively. VA has reviewed the impact of this final rule
on these information collections and determined that the information
collection burden is de minimis.
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.
List of Subjects in 38 CFR Part 4
Disability benefits, Pensions, Veterans.
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. Jacquelyn
Hayes-Byrd, Deputy Chief of Staff, Department of Veterans Affairs,
approved this document on April 3, 2018, for publication.
Dated: April 3, 2018.
Jeffrey M. Martin,
Impact Analyst, Office of Regulation Policy & Management, Office of the
Secretary, Department of Veterans Affairs.
For the reasons set out in the preamble, VA amends 38 CFR part 4 as
follows:
PART 4--SCHEDULE FOR RATING DISABILITIES
0
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
Subpart B--Disability Ratings
0
2. Amend Sec. 4.116 as follows:
0
a. Revise the entry for diagnostic code 7610;
0
b. Add a note at the end of the entries for diagnostic codes 7615 and
7619;
0
c. Revise the entry for diagnostic code 7621;
0
d. Remove the entries for diagnostic codes 7622 and 7623;
0
e. Revise the entries for diagnostic codes 7627 and 7628;
0
f. Add entries for diagnostic codes 7630 through 7632 in numerical
order; and
0
g. Add an authority citation at the end of the section.
The revisions and additions read as follows:
Sec. 4.116 Schedule of ratings--gynecological conditions and
disorders of the breast.
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
* * * * * * *
7610 Vulva or clitoris, disease or injury of (including
vulvovaginitis)
* * * * * * *
7615 * * *
[[Page 15072]]
Note: For the purpose of VA disability evaluation, a ..............
disease, injury, or adhesions of the ovaries
resulting in ovarian dysfunction affecting the
menstrual cycle, such as dysmenorrhea and secondary
amenorrhea, shall be rated under diagnostic code
7615
* * * * * * *
7619 * * *
Note: In cases of the removal of one ovary as the
result of a service-connected injury or disease,
with the absence or nonfunctioning of a second
ovary unrelated to service, an evaluation of 30
percent will be assigned for the service-connected
ovarian loss
* * * * * * *
7621 Complete or incomplete pelvic organ prolapse due to 10
injury, disease, or surgical complications of pregnancy
Note: Pelvic organ prolapse occurs when a pelvic
organ such as bladder, urethra, uterus, vagina,
small bowel, or rectum drops (prolapse) from its
normal place in the abdomen. Conditions associated
with pelvic organ prolapse include: uterine or
vaginal vault prolapse, cystocele, urethrocele,
rectocele, enterocele, or any combination thereof.
Evaluate pelvic organ prolapse under DC 7621.
Evaluate separately any genitourinary, digestive,
or skin symptoms under the appropriate diagnostic
code(s) and combine all evaluations with the 10
percent evaluation under DC 7621
* * * * * * *
7627 Malignant neoplasms of gynecological system........ 100
Note: A rating of 100 percent shall continue beyond
the cessation of any surgical, radiation,
antineoplastic chemotherapy or other therapeutic
procedures. Six months after discontinuance of such
treatment, the appropriate disability rating shall
be determined by mandatory VA examination. Any
change in evaluation based upon that or any
subsequent examination shall be subject to the
provisions of Sec. 3.105(e) of this chapter. Rate
chronic residuals to include scars, lymphedema,
disfigurement, and/or other impairment of function
under the appropriate diagnostic code(s) within the
appropriate body system
7628 Benign neoplasms of gynecological system. Rate
chronic residuals to include scars, lymphedema,
disfigurement, and/or other impairment of function
under the appropriate diagnostic code(s) within the
appropriate body system
* * * * * * *
7630 Malignant neoplasms of the breast.................. 100
Note: A rating of 100 percent shall continue beyond
the cessation of any surgical, radiation,
antineoplastic chemotherapy or other therapeutic
procedure. Six months after discontinuance of such
treatment, the appropriate disability rating shall
be determined by mandatory VA examination. Any
change in evaluation based upon that or any
subsequent examination shall be subject to the
provisions of Sec. 3.105(e) of this chapter. Rate
chronic residuals according to impairment of
function due to scars, lymphedema, or disfigurement
(e.g., limitation of arm, shoulder, and wrist
motion, or loss of grip strength, or loss of
sensation, or residuals from harvesting of muscles
for reconstructive purposes), and/or under
diagnostic code 7626
7631 Benign neoplasms of the breast and other injuries
of the breast. Rate chronic residuals according to
impairment of function due to scars, lymphedema, or
disfigurement (e.g., limitation of arm, shoulder, and
wrist motion, or loss of grip strength, or loss of
sensation, or residuals from harvesting of muscles for
reconstructive purposes), and/or under diagnostic code
7626
7632 Female sexual arousal disorder (FSAD).............. \1\ 0
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation under Sec.
3.350 of this chapter.
(Authority: 38 U.S.C. 1155)
0
3. Amend appendix A to part 4 by:
0
a. Revising the entries for diagnostic codes 7610, 7615, 7619, 7621,
7622, 7623, 7627, and 7628; and
0
b. Adding, in numerical order, entries for diagnostic codes 7630
through 7632.
The revisions and additions read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------
* * * * * * *
7610 Criterion May 22, 1995; title
May 13, 2018.
* * * * * * *
7615 Criterion May 22, 1995; note
May 13, 2018.
* * * * * * *
7619 Criterion May 22, 1995; note
May 13, 2018.
* * * * * * *
7621 Criterion May 22, 1995;
evaluation May 13, 2018.
7622 Removed May 13, 2018.
7623 Removed May 13, 2018.
* * * * * * *
7627 Criterion March 10, 1976;
criterion May 22, 1995;
title, note May 13, 2018.
7628 Added May 22, 1995; title,
criterion May 13, 2018.
[[Page 15073]]
* * * * * * *
7630 Added May 13, 2018.
7631 Added May 13, 2018.
7632 Added May 13, 2018.
* * * * * * *
------------------------------------------------------------------------
0
4. Amend appendix B to part 4 by:
0
a. Revising the entries for diagnostic codes 7610 and 7621;
0
b. Removing the entries for diagnostic codes 7622 and 7623;
0
c. Revising the entries for diagnostic codes 7627 and 7628; and
0
d. Adding, in numerical order, entries for diagnostic codes 7630
through 7632.
The revisions and additions read as follows:
Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
Gynecological Conditions and Disorders of the Breast
------------------------------------------------------------------------
7610........................ Vulva or clitoris, disease or injury of
(including vulvovaginitis).
* * * * * * *
7621........................ Complete or incomplete pelvic organ
prolapse due to injury or disease or
surgical complications of pregnancy.
* * * * * * *
7627........................ Malignant neoplasms of gynecological
system.
7628........................ Benign neoplasms of gynecological system.
* * * * * * *
7630........................ Malignant neoplasms of the breast.
7631........................ Benign neoplasms of the breast and other
injuries of the breast.
7632........................ Female sexual arousal disorder (FSAD).
* * * * * * *
------------------------------------------------------------------------
0
5. Amend appendix C to part 4 as follows:
0
a. Add in alphabetical order an entry for ``Complete or incomplete
pelvic organ prolapse due to injury or disease or surgical
complications of pregnancy, including uterine or vaginal vault
prolapse, cystocele, urethrocele, rectocele, enterocele, or
combination''.
0
b. Add in alphabetical order an entry for ``Female sexual arousal
disorder (FSAD)''.
0
c. Under the heading ``Injury,'' add in alphabetical order an entry for
``Breast''.
0
d. Under the heading ``Neoplasms: Benign:'':
0
i. Add in alphabetical order an entry for ``Breast''.
0
ii. Remove ``Gynecological or breast'' and in its place add
``Gynecological''.
0
e. Under the heading ``Neoplasms: Malignant:'':
0
i. Add in alphabetical order an entry for ``Breast''.
0
ii. Remove ``Gynecological or breast'' and in its place add
``Gynecological''.
0
f. Remove the entry ``Pregnancy, surgical complications''.
0
g. Under the heading ``Uterus,'' remove the entry ``Displacement''.
0
h. Remove ``Vulva disease or injury of'' and add in its place ``Vulva
or clitoris, disease or injury of''.
The additions and revisions read as follows:
Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
Diagnostic
code No.
------------------------------------------------------------------------
* * * * * * *
Complete or incomplete pelvic organ prolapse due to 7621
injury or disease or surgical complications of
pregnancy, including uterine or vaginal vault prolapse,
cystocele, urethrocele, rectocele, enterocele, or
combination............................................
* * * * * * *
Female sexual arousal disorder (FSAD)................... 7632
* * * * * * *
Injury:
[[Page 15074]]
* * * * * * *
Breast.............................................. 7631
* * * * * * *
Neoplasms:
Benign:
Breast.......................................... 7631
* * * * * * *
Malignant:
Breast.......................................... 7630
* * * * * * *
------------------------------------------------------------------------
[FR Doc. 2018-07081 Filed 4-6-18; 8:45 am]
BILLING CODE 8320-01-P