Schedule for Rating Disabilities: Skin, 32592-32601 [2018-14957]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 83, Number 135 (Friday, July 13, 2018)]
[Rules and Regulations]
[Pages 32592-32601]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-14957]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AP27


Schedule for Rating Disabilities: Skin

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: On August 12, 2016, VA published in the Federal Register the

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proposed rule for Schedule for Rating Disabilities: Skin. VA received 
multiple responses during the 60-day comment period. This final rule 
implements the Secretary's proposed rule with limited revisions.

DATES: This rule is effective on August 13, 2018.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Regulations Staff 
(211C), Compensation Service, Veterans Benefits Administration, 
Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 
20420, (202) 461-9700. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: 

Applicability

    In reviewing the proposed rule to prepare for publication of the 
final rule, VA determined that the statements regarding the 
applicability date in the proposed rule should be revised in order to 
avoid potential misapplication of this final rule. In the proposed 
rule, VA stated that the provisions of the new regulations would apply 
to all applications for benefits received by VA or that are pending 
before the agency of original jurisdiction on or after the effective 
date of the final rule. VA has indeed structured some regulations this 
way in the past, due to the dynamics of the regulation in question. See 
``Schedule for Rating Disabilities--Mental Disorders and Definition of 
Psychosis for Certain VA Purposes,'' 80 FR 14308 (March 19, 2015). 
However, for this final rule, VA's intent is that the claims pending 
prior to the effective date will be considered under both old and new 
rating criteria, and whatever criteria is more favorable to the veteran 
will be applied. For applications filed on or after the effective date, 
only the new criteria will be applied.

Comments Received

    Ten different commenters (including two Veterans Service 
Organizations) submitted comments in response to the proposed rule. VA 
will address their comments within the topics below.

Comments Warranting Revisions to the Proposed Rule

    VA has made five changes to the proposed rule based on comments 
received. First, two commenters noted that additional guidance 
regarding coexistent skin conditions and pyramiding might be helpful. 
VA agrees and has added a clarifying note at the start of Sec.  
4.118(b) which states: ``Two or more skin conditions may be combined in 
accordance with Sec.  4.25 only if separate areas of skin are involved. 
If two or more skin conditions involve the same area of skin, then only 
the highest evaluation shall be used.''
    Second, two commenters felt that the proposed language ``per 12-
month period'' in multiple diagnostic codes (DCs) was unclear about 
which 12-month period would be used for evaluation purposes. VA concurs 
and has revised the criteria to specify that ``over the past 12-month 
period'' is the applicable time frame for these DCs.
    Third, a commenter asserted that the evaluation criteria for eczema 
(DC 7806) should consider itching. Eczema (also known as atopic 
dermatitis) is often called ``the itch that rashes.'' The intense 
itching (without lesions at first) leads to the scratching, resulting 
in the characteristic lesions. See ``Dermatology'' 210 (Jean Bolognia 
et al. eds., 3d ed. 2012). Thus, itching is part of the pathology in 
all eczema ratings, even though only involved areas (lesions, scars) 
are considered for compensation purposes. Based on this comment, VA has 
clarified that it is the area of lesions, not the itching, that forms 
the basis of a rating, by revising in this final rule each criteria 
level in the General Rating Formula for the Skin to include the phrase 
``Characteristic lesions involving. . . .''
    Fourth, a commenter expressed concern that a long-lasting 
urticarial attack with no breaks would qualify for a 10% rating, rather 
than a 60% rating under DC 7825 (Urticaria). VA understands this 
concern and has revised the criteria in this final rule to be based on 
the condition's response to required treatment. First, VA has retitled 
the diagnostic code, ``Chronic urticaria'' and added a definition for 
chronic urticaria, which is ``continuous urticaria at least twice per 
week, off treatment, for a period of six weeks or more.'' A subset of 
patients has chronic urticaria that is unresponsive to first line 
treatment (antihistamines). If a patient is also unresponsive to second 
line treatment (e.g., epinephrine, corticosteroids, aminosalicylates), 
it is considered refractory chronic urticaria. It was, and continues to 
be, VA's intent to have evaluation levels that clearly and distinctly 
reflect increasing disability. To that end, VA has revised the 
evaluation criteria to more clearly establish three distinct levels of 
disability: (1) Chronic urticaria requiring first line treatment for 
control, (2) chronic urticaria requiring second line treatment for 
control, and (3) chronic urticaria which is refractory to both first 
line and second line treatment. A non-exhaustive list of examples for 
first line, second line, and third line treatment is given with each 
evaluation level. This should ensure, commensurate with the commenter's 
concern, that more severe and less controllable urticarial attacks 
receive higher ratings.
    Fifth, a commenter asked if active psoriatic arthritis would be 
entitled to a 60% evaluation under DC 7816 (Psoriasis) and a 100% 
evaluation under DC 5009 (Arthritis, other types), allowing for special 
monthly compensation at the ``s'' level, i.e., housebound. To clarify 
that separate ratings are permissible, VA has added the term 
``separately'' to the note in DC 7816. Special monthly compensation 
would be warranted under 38 CFR 3.350(i)(1), if the psoriasis and the 
arthritis constitute ``separate and distinct'' disabilities ``involving 
different anatomical segments or bodily systems.''
    Beyond the changes made in response to comments, this final rule 
contains several technical and non-substantive amendments to the 
proposed rule.

Comments Related to Systemic and Topical Therapy and Johnson v. 
McDonald

    A total of six comments either disagreed with or questioned VA's 
proposal for defining topical and systemic therapy in light of the 
Johnson v. McDonald decision of the U.S. Court of Appeals for Veterans 
Claims (CAVC) in 2016. That decision found that any use of a topically-
applied corticosteroid constituted ``systemic therapy'' pursuant to 
diagnostic code 7806. However, in July 2017, the U.S. Court of Appeals 
for the Federal Circuit (Federal Circuit) reversed the CAVC's 
interpretation. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). 
The Federal Circuit held that the CAVC was incorrect to ``read DC 7806 
as unambiguously elevating any form of corticosteroid treatment, 
including any degree of topical corticosteroid treatment, to the level 
of `systemic therapy.''' Id. at 1354.
    Although VA's proposal for systemic and topical therapy was in part 
a reaction to the CAVC's now-reversed Johnson decision, its aim was 
also to provide clarity for raters adjudicating these claims. VA 
proposed to clarify that treatment administered through the skin is 
``topical therapy,'' while treatment administered through any route 
other than the skin (orally, injection, suppository, intranasally) is 
``systemic therapy.'' This final rule adopts VA's proposal. One theme 
of the comments was that topically-applied medications could be 
considered systemic therapy or could have systemic effects. In this 
regard, one commenter questioned why VA does not provide

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more information as to the potential systemic effects of topically-
applied corticosteroids, and another asserted that topically-applied 
medications can cause heightened effects in elderly populations.
    As noted in the supplementary information to the proposed rule, 
however, it creates a dramatic disconnect to rate a medication applied 
to the skin--affecting only the localized area to which it is applied--
as ``systemic therapy'' that affects the entire body. Rather, the 
prevailing medical understanding is that ``topical'' therapy 
``pertain[s] to a particular surface area . . . and affect[s] only the 
area to which it is applied,'' while ``systemic'' therapy ``pertain[s] 
to or affect[s] the body as a whole.'' Dorland's Illustrated Medical 
Dictionary 1865, 1940 (32d ed. 2012). VA's proposal, adopted as a final 
rule here, sets clear guidelines in accordance with this understanding: 
creams applied to the skin are ``topical therapy,'' and treatments 
applied in a way (orally, intranasally, etc.) that the medication 
circulates throughout the entire body and suppresses the immune system 
as a whole are ``systemic therapy.''
    VA also acknowledged in the supplementary information that some 
medications applied to the skin, if administered on a large enough 
scale, could have a systemic effect; but in those situations the 
veteran can obtain a higher rating due to the percentage of the body 
affected. For example, a veteran who is required to apply a cream on 
his entire body is not subject to a noncompensable rating; even though 
he is not taking systemic therapy, he would obtain a compensable rating 
under this final rule based on the percentage of his body affected by 
the condition.
    Overall, the aim of this rule is to clarify the terms used in the 
rating schedule, in order to distinguish between a condition that 
affects a large portion of the body or requires therapy affecting the 
entire body, and a condition that is localized and involves localized 
treatment. The former generally impairs earning capacity more than the 
latter. To the extent that topically-applied medications might affect 
different people (such as the elderly) in different ways, the rating 
schedule is based on the average impairment in earning capacity. 38 
U.S.C. 1155. If there is an exceptional or unusual effect of applying 
corticosteroid cream, a claimant can submit argument for an 
extraschedular rating. 38 CFR 3.321(b)(1). VA can also raise the issue 
of an extraschedular rating on its own when the evidence of record 
suggests such consideration is appropriate. This is why VA cannot 
provide more specific information on the potential systemic effects of 
topically-applied corticosteroids: the potency of the medication, the 
amount of skin affected, and the strength of the condition, will vary 
from veteran to veteran.
    One comment on this topic advocated that VA should automatically 
assume that topical corticosteroids have systemic effects based on the 
benefit-of-the-doubt standard. The benefit-of-the-doubt rule, however, 
applies to the adjudication of claims, not formulation of the rating 
schedule. 38 U.S.C. 5107(b). This commenter further stated that certain 
skin conditions cannot be cured, but only treated, and that the burden 
of applying medication with little effect is not taken into 
consideration in the proposed rule. To the contrary, frequency in 
application is a factor in the schedule for rating systemic therapy, 
but it remains VA's assessment that applying cream on the skin of less 
than 5% of the body reflects a condition that does not impair earning 
capacity at a compensable level.
    Two additional commenters viewed the proposed rule as an attempt to 
circumvent or undermine the CAVC's ruling. These comments are obviated 
by the fact that the CAVC's ruling has been reversed. See Johnson v. 
Shulkin, supra. But even if it had not been reversed, it is well 
established that a judicial interpretation of regulatory language does 
not preclude an agency from revising that language (for prospective 
application) pursuant to its rulemaking authority. See Nat'l Org. of 
Veterans Advocates Inc., v. Sec'y of Veterans Affairs, 260 F.3d 1365, 
1373 (Fed. Cir. 2001) (argument that CAVC holdings prevent revision of 
regulations ``seriously misunderstand[s] . . . the nature of the 
judicial function.''). VA may clarify the rating schedule to accord 
with its original intent in promulgating these diagnostic codes. One of 
these commenters added that skin conditions can cause real pain and 
embarrassment and should not be devalued. We understand this concern, 
but the objective criteria of (1) percentage of body affected and (2) 
mode and frequency of therapy are better suited in determining average 
impairment of earning capacity than an individual's level of 
embarrassment.
    Another commenter questioned the consistency of the proposed 
definition for systemic therapy with DC 6602 and the overall rating 
schedule. This rule is consistent with DC 6602--which defines 
``systemic'' corticosteroids as ``oral or parenteral,'' i.e., the 
corticosteroids that circulate throughout the body and affect the 
entire immune system. We are unaware, and the commenter does not 
provide further information, as to how the rule is inconsistent with 
other portions of the rating schedule.
    Finally, two commenters asserted that VA is emphasizing topical 
treatment in order to save money at the expense of quality care. This 
rule, however, should not affect how doctors treat conditions; rather, 
its aim is to clarify terms for raters adjudicating claims. We are not 
aware of any VA instruction that its doctors prescribe topical 
treatment to save money when it is not best for the patient.

Comments Recommending Revisions to Evaluation Criteria

    A number of comments recommended revisions to criteria within the 
proposed rule. VA received two comments regarding DC 7806, Dermatitis 
or eczema. One comment has been addressed above and prompted a revision 
to this final rule. The other comment requested that VA include biopsy 
results in the evaluation criteria, because eczema can occur 
sporadically over the year and a doctor might only take account of what 
is observable during the examination. VA declines to make changes based 
upon this comment. The General Rating Formula for the Skin employs two 
routes to compensation, based on either the extent of skin involvement 
or the intensity of treatment. If the condition requires constant or 
near-constant systemic therapy, then, regardless of the extent of skin 
involvement at the time of examination, the veteran would be entitled 
to the highest evaluation. It is unclear how criteria based on biopsy 
results would be more favorable to veterans than this scheme. Moreover, 
obtaining a biopsy for every ratable skin condition is not necessarily 
appropriate, and a service-connected veteran is free to request an 
additional examination if a skin disorder becomes more extensive than 
what was observed during a given examination. VA received two comments 
concerning DC 7817, Erythroderma. One comment asked why the ``treatment 
failure'' language was incorporated into the proposed criteria when the 
term ``uncontrolled'' in the evaluation criteria for diabetes (DC 7913) 
``was found to be problematic.'' VA incorporated language regarding 
``treatment failure'' here because it is easily measured and can be 
applied by rating officials with consistent results. Treatment failure 
is a common occurrence with erythroderma, and we see no connection to 
the term ``uncontrolled'' in a diagnostic code for

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a different condition (diabetes) that was revised over two decades ago. 
The second comment asked whether VA would use the new DC 7817 criteria 
for pending appeals. As explained above, VA will only apply the new 
criteria to pending appeals if it is advantageous to the appellant.
    One comment addressed DC 7824, Diseases of keratinization. The 
commenter stated that we would be underrating diseases of 
keratinization by moving them to the General Rating Formula for the 
Skin, where it would not account for systemic manifestations. While VA 
concurs that the term ``systemic manifestations'' is not employed 
within the General Rating Formula for the Skin, this change does not 
adversely affect the veteran. Under the version of DC 7824 that is 
being revised by this final rule, a veteran needs both ``systemic 
manifestations'' and ``systemic medication'' for a 30% or 60% rating if 
there is not generalized cutaneous involvement. Now, under this final 
rule, a veteran with a disease of keratinization can receive such a 
rating for taking ``systemic therapy'' even without any systemic 
manifestations. This change simplifies the evaluation for veterans with 
diseases of keratinization.
    Three comments requested changes to DC 7825, Urticaria, and DC 
7826, Vasculitis, primary cutaneous. One comment has been addressed 
above, resulting in a revision to the final rule. Another comment 
asserted that the term ``documented'' in DC 7826 should not require 
evidence of a visit to a physician, clinic, or hospital, because those 
already on medication may not seek medical attention if they are used 
to managing their condition. That commenter requested that VA clarify 
that lay evidence fulfills the ``documented'' standard.
    VA understands that lay evidence must be considered when VA 
adjudicators evaluate a claim, and nothing in this final rule is meant 
to undercut that principle. On the other hand, virtually the entire VA 
ratings schedule requires some kind of documentation or objective 
testing in order to gauge the severity of a disability. In that vein, 
this final rule requires that vasculitic episodes be ``documented'' for 
a higher rating. Though the rule does not state that the only 
acceptable documentation is a doctor's contemporaneous confirmation, a 
veteran whose disease is not under control and continues to prompt 
episodes would most likely see a provider multiple times within a 12-
month period.
    The third commenter found it problematic that the criteria would 
allow mild, frequent attacks to be rated higher than more severe and 
longer attacks. This commenter also stated that a reliance on treatment 
modality is problematic, because biologics are impossible for veterans 
with weakened immune systems and others are prescribed unevenly.
    VA's change to DC 7825 in this final rule obviates this comment, as 
the urticaria criteria are no longer reliant on the number of attacks. 
VA also disagrees that basing evaluation criteria on treatment modality 
is problematic. Each line of treatment for chronic urticaria (first 
line, second line, or third line) has more than one treatment option 
available, so the fact that one particular option is poorly tolerated 
does not imply that veterans will be inaccurately rated.
    VA received three comments involving areas of affected skin, 
including requests to add forearms and lower legs as exposed areas. One 
of the commenters explained that, in summer temperatures, veterans 
cannot be expected to work with their forearms and lower legs covered. 
A second stated that there is no equitable definition of exposed skin, 
and doctors are commonly recommending more sunlight for psoriasis. The 
third suggested the work group identify which technique for measuring 
the area of involved skin would be best suited for evaluation purposes.
    VA will not make any revisions to the final rule based on the above 
comments, as VA is unaware of any occupations that require exposed 
forearms or lower legs, i.e., mandate such exposure as part of the job. 
Furthermore, dermatologists (who are the subject matter experts when it 
comes to conditions affecting the skin) have already decided how to 
calculate involved skin area and what constitutes a routinely exposed 
area; and the established medical practice in that field is to consider 
only the head, neck, and hands consistently and truly exposed, as long-
sleeved shirts and full-length pants have customarily been considered 
part of the typical clothing used in occupational settings. There is no 
justification, medical or otherwise, to change from established 
practice. Lastly, a treatment recommendation to get more sunlight for 
psoriatic skin neither precludes nor interferes with employment, and 
thus should have no bearing on the rating criteria.
    VA received two comments about alopecia, specifically DC 7830, 
Scarring alopecia, and DC 7831, Alopecia areata. One comment asserted 
that DC 7831 should provide a compensable rating for loss of scalp 
hair, since it is an exposed area. The other comment recommended a 
higher evaluation under DC 7830 for women, because this condition is 
more socially debilitating for women and, as a result, women incur a 
higher financial responsibility to deal with the condition. VA is 
sympathetic to these issues and understands the social aspects of hair 
loss. Nevertheless, the rating schedule is based on the loss of wage-
earning capacity and no reliable evidence establishes significant 
occupational impairment with loss of body hair, or that occupational 
impairment is greater in women than in men with scarring alopecia. As 
such, VA will not revise the final rule based on these two comments.
    As to the final comments, one requested a note adding consideration 
of the effect of disfigurement on the veteran's mental health. VA 
acknowledges that secondary service connection under 38 CFR 3.310 may 
be possible for a mental health disability that is found to be causally 
related to a service-connected skin disability. However, we believe 
this is clear from 38 CFR 3.310, such that a note is not necessary 
here. The second questioned why evaluation criteria do not comment on 
conditions caused by the failure of the immune system, such as 
lymphedema, which affect the skin and may require compression therapy. 
Although lymphedema may be evaluated under diagnostic codes pertaining 
to the skin if it disfigures and/or scars the skin, see 38 CFR 4.116, 
DC 7627-7628 (evaluating lymphedema ``under the appropriate diagnostic 
code(s) within the appropriate body system''), it is ultimately a 
lymphatic condition, not a skin condition, such that its consideration 
would be outside the scope of both the proposed and final rules for the 
skin.

Comments Regarding Interplay of Regulations

    VA received a number of comments seeking clarification or guidance 
on the interplay between section 4.118 and other regulations.
    Three comments implicated the relationship between part 3 
regulations and section 4.118. One comment regarding multiple ratings 
for psoriatic arthritis has been addressed above, resulting in a 
revision in this final rule. Another comment asked if VA would service 
connect disabilities to other body systems resulting from the treatment 
of skin conditions. Generally, yes, VA may grant secondary service 
connection as long as the standards found in 38 CFR 3.310 are met.

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    A third comment questioned the consistency between the definition 
of chronic in 38 CFR 3.380 (diseases of allergic etiology) and the 
definition in DCs 7825 and 7826. No inconsistencies exist, as 38 CFR 
3.380 addresses service connection, while DCs 7825 and 7826 address 
evaluation, and none of these provisions address the term ``chronic.'' 
This commenter continued by stating: ``Confusion regarding `service 
connection' and evaluation criteria applies to the `continuous use' and 
`disabling effects of medication' to suggest that VA will concede 
secondary service connection [38 CFR 3.310] in cases with facts similar 
to those described (or are these functional impairments simply acute 
and transitory or will this be pyramiding?).'' VA finds this portion of 
the comment unclear and is unable to respond.
    The remaining comments covered the relationship between section 
4.118 and other part 4 regulations. One commenter assumed that combined 
ratings would result from DCs 7801 and 7802. To the contrary, the 
General Rating Formula for the Skin instructs the rater to use the 
relevant criteria or rate under DCs 7800, 7801, 7802, 7804, or 7805. 
Hence, the guidance precludes combining of disability criteria in this 
regard. Another comment asked about the difference between the six 
zones of the body in 38 CFR 4.118 and the five anatomic zones of 38 CFR 
4.55(b). VA intends that the six zones in this final rule are specific 
for the skin and not intended to reflect a global standard to be 
applied for all body systems. Yet another comment asked about the 
difference between ``anogenital region'' (noted in DC 7829) and 
``pruritus ani'' (DC 7337), and whether these ratings may be combined. 
``Anogenital region'' is an anatomic area that may be affected by 
chloracne (DC 7829), whereas ``pruritus ani'' is an itching near the 
rectum. VA may separately evaluate these conditions and combine them in 
accordance with 38 CFR 4.25.
    Still another assertion involving DC 7829 and other part 4 
regulations was that ``[i]ntertriginous areas and limitation of 
function are problematic. The axilla of the arm and the range of motion 
of the shoulder are similar to the facts in [Cullen v. Shinseki, 24 
Vet. App. 74 (2010)].'' We discern no problem in the language of DC 
7829 or conflict with Cullen. VA may separately evaluate disability 
related to acne (skin) and a disability affecting the shoulder 
(musculoskeletal). One last question presented by this commenter asked 
if the reference to ``skin folds of the breasts'' in DC 7829 could be 
used to justify a 20 percent evaluation by analogy under DC 7628, 
benign neoplasms. Because DC 7628 permits rating benign neoplasms as a 
skin condition, such a rating by analogy may be possible.

Comments Recommending Additional Diagnostic Codes

    VA received four comments recommending additional diagnostic codes: 
One comment recommending additional codes generally to reduce analogous 
coding, and three other comments recommending codes for lymphedema 
(and/or skin conditions caused by immune system failure), pressure 
ulcers, actinic keratoses, and rosacea. VA finds these additions 
unnecessary. As noted above, VA may evaluate lymphedema which 
disfigures and/or scars the skin under DCs 7801, 7802, 7804, or 7805. 
Furthermore, pressure ulcers normally are not considered a skin 
condition warranting compensation. Actinic keratoses and rosacea are 
not occupationally significant. VA is willing to consider adding 
diagnostic codes for skin conditions that are occupationally 
significant.

Comment Outside the Scope of the Proposed Rule

    VA received a comment asking why the Food and Drug Administration 
could not find another manufacturer for EpiPen[supreg]. The EpiPen 
question is well outside the scope of this rule, so VA will not respond 
to it.

Comment Regarding Public Access

    The last issue raised by a commenter dealt with public access to 
the materials developed by the Skin Disorders Work Group after a public 
forum in New York City in January 2012 but before the drafting of the 
proposed rule. Specifically, the commenter requested that the 
information developed and shared by the work group should be publicly 
available.
    In the SUPPLEMENTARY INFORMATION to the proposed rule, VA included 
information about the Skin Disorders Work Group. See 81 FR 53353, 53353 
(Aug. 12, 2016). As noted, the stated goals of the work group included 
improving and updating VA Schedule for Rating Disabilities (VASRD) 
criteria, and inviting public participation; this process included 
presentations on areas of expertise and interaction with the public at 
a public forum in January 2012. (A transcript of this public forum and 
all related materials are on file and available for public inspection 
in the Office of Regulation and Policy Management. Contact information 
for that office is noted in the ADDRESSES section of the proposed rule. 
See 81 FR at 53358.) The work group served as an initial call to 
various subject matter experts and Veterans Service Organizations to 
provide a preliminary review of the VASRD from both internal and 
external stakeholders.
    VA emphasizes that this review of the VASRD was not an opportunity 
for work group members to participate in the deliberative rulemaking 
process; the work group discussed the general topic of the VASRD body 
system and provided feedback on the areas that were subject to advances 
since the last major revision of the body system. To this end, where 
changes to the scientific and/or medical nature of a given condition 
were made in the proposed rule, VA cited the published, publicly-
available source for these changes. Not only did this provide the 
public with access to the source for a given proposed change, it also 
confirmed that VA relied upon peer-reviewed scientific and medical 
information to support a given change. While similar information may 
have been presented by a work group member, VA relied upon the 
published document(s) as the primary source for a change and included 
such sources in the administrative record for this rulemaking. VA did 
not propose scientific and/or medical changes to the VASRD in the 
absence of publicly available, peer-reviewed sources.
    Accordingly, references in the proposed rule to the work group 
serve as an explanatory background and introduction to the VASRD 
rewrite project; the changes made by this rulemaking are not a 
reflection of the work group or any work group member. All changes 
based on scientific and/or medical information are a reflection of 
cited, published materials which are available to the public. VA has 
made deliberative materials available (via citation in the rulemaking) 
and is providing access to materials from the public forum available 
for public inspection at the Office of Regulation Policy and 
Management.

Effective Date of Final Rule

    Veterans Benefits Administration personnel utilize the Veterans 
Benefits 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 August 13, 2018, the date VBMS-R system updates 
related to this final rule will be complete.

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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). 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 Fiscal Year to Date.'' This rule is not 
an Executive Order 13771 regulatory action because this rule is not 
significant under Executive Order 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 rule would directly affect only individuals and would not 
directly affect small entities. Therefore, pursuant to 5 U.S.C. 605(b), 
this rulemaking is exempt from the initial and final regulatory 
flexibility analysis requirements of sections 603 and 604.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of 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 application for disability benefits (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 21-0960F-1, Scars/Disfigurement DBQ, and 21-0960F-
2, Skin Diseases DBQ). These information collections are currently 
approved by the Office of Management and Budget (OMB) and have been 
assigned OMB control numbers 2900-0749 (for the application) and 2900-
0776 (for the DBQs). VA has reviewed the impact of this final rule on 
these information collections and determined that the incremental 
information collection burden for the first year of this rule is 
$8,828.20.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance number and title for the 
program affected by this document is 64.109, Veterans Compensation for 
Service-Connected Disability.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to submit it to the Office of 
the Federal Register for electronic publication as an official document 
of the Department of Veterans Affairs. Jacquelyn Hayes-Byrd, Acting 
Chief of Staff, Department of Veterans Affairs, approved this document 
on June 28, 2018, for publication.

List of Subjects in 38 CFR Part 4

    Disability benefits, Pensions, Veterans.

    Dated: June 28, 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, the Department of Veterans 
Affairs amends 38 CFR part 4, subpart B, as follows:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

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

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


0
2. Amend Sec.  4.118 as follows:
0
a. Remove the introductory text;
0
b. Add paragraphs (a) and (b) before the table;
0
c. Revise the entries for diagnostic codes 7801, 7802, and 7805;
0
d. Add an entry for ``GENERAL RATING FORMULA FOR THE SKIN FOR DCs 7806, 
7809, 7813-7816, 7820-7822, AND 7824'', to appear after the entry for 
diagnostic code 7805; and
0
e. Revise the entries for diagnostic codes 7806, 7809, 7813, 7815-7817, 
7820-7822, and 7824-7829.
    The revisions and additions read as follows:


Sec.  4.118  Schedule of ratings-skin.

    (a) For the purposes of this section, systemic therapy is treatment 
that is administered through any route (orally, injection, suppository, 
intranasally) other than the skin, and topical therapy is treatment 
that is administered through the skin.
    (b) Two or more skin conditions may be combined in accordance with 
Sec.  4.25 only if separate areas of skin are involved. If two or more 
skin conditions involve the same area of skin, then only the highest 
evaluation shall be used.

[[Page 32598]]



------------------------------------------------------------------------
                                                                 Rating
------------------------------------------------------------------------
 
                              * * * * * * *
7801 Burn scar(s) or scar(s) due to other causes, not of the
 head, face, or neck, that are associated with underlying
 soft tissue damage:
    Area or areas of 144 square inches (929 sq. cm.) or               40
     greater.................................................
    Area or areas of at least 72 square inches (465 sq. cm.)          30
     but less than 144 square inches (929 sq. cm.)...........
    Area or areas of at least 12 square inches (77 sq. cm.)           20
     but less than 72 square inches (465 sq. cm.)............
    Area or areas of at least 6 square inches (39 sq. cm.)            10
     but less than 12 square inches (77 sq. cm.).............
    Note (1): For the purposes of DCs 7801 and 7802, the six
     (6) zones of the body are defined as each extremity,
     anterior trunk, and posterior trunk. The midaxillary
     line divides the anterior trunk from the posterior trunk
    Note (2): A separate evaluation may be assigned for each
     affected zone of the body under this diagnostic code if
     there are multiple scars, or a single scar, affecting
     multiple zones of the body. Combine the separate
     evaluations under Sec.   4.25. Alternatively, if a
     higher evaluation would result from adding the areas
     affected from multiple zones of the body, a single
     evaluation may also be assigned under this diagnostic
     code....................................................
7802 Burn scar(s) or scar(s) due to other causes, not of the
 head, face, or neck, that are not associated with underlying
 soft tissue damage:
    Area or areas of 144 square inches (929 sq. cm.) or               10
     greater.................................................
    Note (1): For the purposes of DCs 7801 and 7802, the six
     (6) zones of the body are defined as each extremity,
     anterior trunk, and posterior trunk. The midaxillary
     line divides the anterior trunk from the posterior trunk
    Note (2): A separate evaluation may be assigned for each
     affected zone of the body under this diagnostic code if
     there are multiple scars, or a single scar, affecting
     multiple zones of the body. Combine the separate
     evaluations under Sec.   4.25. Alternatively, if a
     higher evaluation would result from adding the areas
     affected from multiple zones of the body, a single
     evaluation may also be assigned under this diagnostic
     code....................................................
 
                              * * * * * * *
7805 Scars, other; and other effects of scars evaluated under
 diagnostic codes 7800, 7801, 7802, or 7804:
    Evaluate any disabling effect(s) not considered in a
     rating provided under diagnostic codes 7800-04 under an
     appropriate diagnostic code.............................
General Rating Formula For The Skin For DCs 7806, 7809, 7813-
 7816, 7820-7822, and 7824:
    At least one of the following............................         60
    Characteristic lesions involving more than 40 percent of
     the entire body or more than 40 percent of exposed areas
     affected; or
    Constant or near-constant systemic therapy including, but         60
     not limited to, corticosteroids, phototherapy,
     retinoids, biologics, photochemotherapy, psoralen with
     long-wave ultraviolet-A light (PUVA), or other
     immunosuppressive drugs required over the past 12-month
     period..................................................
    At least one of the following............................         30
    Characteristic lesions involving more than 20 to 40
     percent of the entire body or 20 to 40 percent of
     exposed areas affected; or
    Systemic therapy including, but not limited to,
     corticosteroids, phototherapy, retinoids, biologics,
     photochemotherapy, PUVA, or other immunosuppressive
     drugs required for a total duration of 6 weeks or more,
     but not constantly, over the past 12-month period.......
    At least one of the following............................         10
    Characteristic lesions involving at least 5 percent, but
     less than 20 percent, of the entire body affected; or
    At least 5 percent, but less than 20 percent, of exposed
     areas affected; or
    Intermittent systemic therapy including, but not limited
     to, corticosteroids, phototherapy, retinoids, biologics,
     photochemotherapy, PUVA, or other immunosuppressive
     drugs required for a total duration of less than 6 weeks
     over the past 12-month period...........................
    No more than topical therapy required over the past 12-            0
     month period and at least one of the following..........
    Characteristic lesions involving less than 5 percent of
     the entire body affected; or
    Characteristic lesions involving less than 5 percent of
     exposed areas affected..................................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability. This rating
     instruction does not apply to DC 7824...................
7806 Dermatitis or eczema.
    Evaluate under the General Rating Formula for the Skin...
 
                              * * * * * * *
7809 Discoid lupus erythematosus.
    Evaluate under the General Rating Formula for the Skin...
    Note: Do not combine with ratings under DC 6350..........
 
                              * * * * * * *
7813 Dermatophytosis (ringworm: Of body, tinea corporis; of
 head, tinea capitis; of feet, tinea pedis; of beard area,
 tinea barbae; of nails, tinea unguium (onychomycosis); of
 inguinal area (jock itch), tinea cruris; tinea versicolor).
    Evaluate under the General Rating Formula for the Skin...
7815 Bullous disorders (including pemphigus vulgaris,
 pemphigus foliaceous, bullous pemphigoid, dermatitis
 herpetiformis, epidermolysis bullosa acquisita, benign
 chronic familial pemphigus (Hailey-Hailey), and porphyria
 cutanea tarda).
    Evaluate under the General Rating Formula for the Skin...
    Note: Rate complications and residuals of mucosal
     involvement (ocular, oral, gastrointestinal,
     respiratory, or genitourinary) separately under the
     appropriate diagnostic code.............................
7816 Psoriasis.
    Evaluate under the General Rating Formula for the Skin...
    Note: Rate complications such as psoriatic arthritis and
     other clinical manifestations (e.g., oral mucosa, nails)
     separately under the appropriate diagnostic code........
7817 Erythroderma:
    Generalized involvement of the skin with systemic                100
     manifestations (such as fever, weight loss, or
     hypoproteinemia) AND one of the following...............

[[Page 32599]]

 
    Constant or near-constant systemic therapy such as
     therapeutic doses of corticosteroids, other
     immunosuppressive drugs, retinoids, PUVA (psoralen with
     long-wave ultraviolet-A light), UVB (ultraviolet-B
     light) treatments, biologics, or electron beam therapy
     required over the past 12 month period; or
    No current treatment due to a documented history of              100
     treatment failure with 2 or more treatment regimens.....
    Generalized involvement of the skin without systemic
     manifestations and one of the following.................
    Constant or near-constant systemic therapy such as
     therapeutic doses of corticosteroids, other
     immunosuppressive drugs, retinoids, PUVA, UVB
     treatments, biologics, or electron beam therapy required
     over the past 12-month period; or.......................
    No current treatment due to a documented history of               60
     treatment failure with 1 treatment regimen..............
    Any extent of involvement of the skin, and any of the             30
     following therapies required for a total duration of 6
     weeks or more, but not constantly, over the past 12-
     month period: systemic therapy such as therapeutic doses
     of corticosteroids, other immunosuppressive drugs,
     retinoids, PUVA, UVB treatments, biologics, or electron
     beam therapy............................................
    Any extent of involvement of the skin, and any of the             10
     following therapies required for a total duration of
     less than 6 weeks over the past 12-month period:
     systemic therapy such as therapeutic doses of
     corticosteroids, other immunosuppressive drugs,
     retinoids, PUVA, UVB treatments, biologics, or electron
     beam therapy............................................
    Any extent of involvement of the skin, and no more than            0
     topical therapy required over the past 12-month period..
    Note: Treatment failure is defined as either disease
     progression, or less than a 25 percent reduction in the
     extent and severity of disease after four weeks of
     prescribed therapy, as documented by medical records....
 
                              * * * * * * *
7820 Infections of the skin not listed elsewhere (including
 bacterial, fungal, viral, treponemal, and parasitic
 diseases).
    Evaluate under the General Rating Formula for the Skin...
7821 Cutaneous manifestations of collagen-vascular diseases
 not listed elsewhere (including scleroderma, calcinosis
 cutis, subacute cutaneous lupus erythematosus, and
 dermatomyositis).
    Evaluate under the General Rating Formula for the Skin...
 
                              * * * * * * *
7822 Papulosquamous disorders not listed elsewhere (including
 lichen planus, large or small plaque parapsoriasis,
 pityriasis lichenoides et varioliformis acuta (PLEVA),
 lymphomatoid papulosus, mycosis fungoides, and pityriasis
 rubra pilaris (PRP)).
    Evaluate under the General Rating Formula for the Skin...
 
                              * * * * * * *
7824 Diseases of keratinization (including icthyoses,
 Darier's disease, and palmoplantar keratoderma).
    Evaluate under the General Rating Formula for the Skin...
7825 Chronic urticaria:
    For the purposes of this diagnostic code, chronic
     urticaria is defined as continuous urticaria at least
     twice per week, off treatment, for a period of six weeks
     or more.................................................
    Chronic refractory urticaria that requires third line             60
     treatment for control (e.g., plasmapheresis,
     immunotherapy, immunosuppressives) due to
     ineffectiveness with first and second line treatments...
    Chronic urticaria that requires second line treatment             30
     (e.g., corticosteroids, sympathomimetics, leukotriene
     inhibitors, neutrophil inhibitors, thyroid hormone) for
     control.................................................
    Chronic urticaria that requires first line treatment              10
     (antihistamines) for control............................
7826 Vasculitis, primary cutaneous:
    Persistent documented vasculitis episodes refractory to           60
     continuous immunosuppressive therapy....................
    All of the following.....................................         30
    Recurrent documented vasculitic episodes occurring four
     or more times over the past 12-month period; and
    Requiring intermittent systemic immunosuppressive therapy         30
     for control.............................................
    At least one of the following............................         10
    Recurrent documented vasculitic episodes occurring one to
     three times over the past 12-month period, and requiring
     intermittent systemic immunosuppressive therapy for
     control; or
    Without recurrent documented vasculitic episodes but
     requiring continuous systemic medication for control....
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability...............
7827 Erythema multiforme; Toxic epidermal necrolysis:
    Recurrent mucosal, palmar, or plantar involvement                 60
     impairing mastication, use of hands, or ambulation
     occurring four or more times over the past 12-month
     period despite ongoing immunosuppressive therapy........
    All of the following.....................................         30
    Recurrent mucosal, palmar, or plantar involvement not
     impairing mastication, use of hands, or ambulation,
     occurring four or more times over the past 12-month
     period; and requiring intermittent systemic therapy.....
    At least one of the following............................         10
    One to three episodes of mucosal, palmar, or plantar
     involvement not impairing mastication, use of hands, or
     ambulation, occurring over the past 12-month period AND
     requiring intermittent systemic therapy; or
    Without recurrent episodes, but requiring continuous
     systemic medication for control.........................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability...............
    Note: For the purposes of this DC only, systemic therapy
     may consist of one or more of the following treatment
     agents: immunosuppressives, antihistamines, or
     sympathomimetics........................................
7828 Acne:
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.......
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck, or
     deep acne other than on the face and neck...............
Superficial acne (comedones, papules, pustules) of any extent          0
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability...............
7829 Chloracne:

[[Page 32600]]

 
    Deep acne (deep inflamed nodules and pus-filled cysts)            30
     affecting 40 percent or more of the face and neck.......
    Deep acne (deep inflamed nodules and pus-filled cysts)            20
     affecting the intertriginous areas (the axilla of the
     arm, the anogenital region, skin folds of the breasts,
     or between digits)......................................
    Deep acne (deep inflamed nodules and pus-filled cysts)            10
     affecting less than 40 percent of the face and neck; or
     deep acne affecting non-intertriginous areas of the body
     (other than the face and neck)..........................
    Superficial acne (comedones, papules, pustules) of any             0
     extent..................................................
    Or rate as disfigurement of the head, face, or neck (DC
     7800) or scars (DCs 7801, 7802, 7804, or 7805),
     depending upon the predominant disability...............
 
                              * * * * * * *
------------------------------------------------------------------------


0
 3. Amend appendix A to part 4 in the table under Sec. 4.118 by 
revising the entries for diagnostic codes 7801, 7802, 7805, 7806, 7809, 
7813, 7815 through 7817, and 7820-7833 to read as follows:

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

------------------------------------------------------------------------
                            Diagnostic
         Section             Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.118...................            7800  Evaluation August 30, 2002;
                                           criterion October 23, 2008.
                                    7801  Criterion July 6, 1950;
                                           criterion August 30, 2002;
                                           criterion October 23, 2008;
                                           title, note 1, note 2 August
                                           13, 2018.
                                    7802  Criterion September 22, 1978;
                                           criterion August 30, 2002;
                                           criterion October 23, 2008;
                                           title, note 1, note 2 August
                                           13, 2018.
 
                              * * * * * * *
                                    7805  Criterion October 23, 2008;
                                           title August 13, 2018.
                                          General Rating Formula for DCs
                                           7806, 7809, 7813-7816, 7820-
                                           7822, and 7824 added August
                                           13, 2018.
                                    7806  Criterion September 9, 1975;
                                           evaluation August 30, 2002;
                                           criterion August 13, 2018.
 
                              * * * * * * *
                                    7809  Criterion August 30, 2002;
                                           title, criterion August 13,
                                           2018.
 
                              * * * * * * *
                                    7813  Criterion August 30, 2002;
                                           title, criterion August 13,
                                           2018.
 
                              * * * * * * *
                                    7815  Evaluation August 30, 2002;
                                           criterion, note August 13,
                                           2018.
                                    7816  Evaluation August 30, 2002;
                                           criterion, note August 13,
                                           2018.
                                    7817  Evaluation August 30, 2002;
                                           title, criterion, note August
                                           13, 2018.
 
                              * * * * * * *
                                    7820  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7821  Added August 30, 2002; title,
                                           criterion August 13, 2018.
                                    7822  Added August 30, 2002; title,
                                           criterion August 13, 2018.
                                    7823  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7824  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7825  Added August 30, 2002; title,
                                           criterion August 13, 2018.
                                    7826  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7827  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7828  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7829  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7830  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7831  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7832  Added August 30, 2002;
                                           criterion August 13, 2018.
                                    7833  Added August 30, 2002;
                                           criterion August 13, 2018.
 
                              * * * * * * *
------------------------------------------------------------------------


0
 4. Amend appendix B to part 4 under the heading ``THE SKIN'' by 
revising the entries for diagnostic codes 7801, 7802, 7805, 7809, 7813, 
7817, 7821, 7822, and 7825 to read as follows:

Appendix B to Part 4--Numerical Index of Disabilities

[[Page 32601]]



------------------------------------------------------------------------
  Diagnostic Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
                                THE SKIN
------------------------------------------------------------------------
 
                              * * * * * * *
7801..................  Burn scar(s) or scar(s) due to other causes, not
                         of the head, face, or neck that are associated
                         with underlying soft tissue damage.
7802..................  Burn scar(s) or scar(s) due to other causes, not
                         of the head, face, or neck that are not
                         associated with underlying soft tissue damage.
 
                              * * * * * * *
7805..................  Scars, other; and other effects of scars
                         evaluated under diagnostic codes 7800, 7801,
                         7802, or 7804.
 
                              * * * * * * *
7809..................  Discoid lupus erythematosus.
 
                              * * * * * * *
7813..................  Dermatophytosis.
 
                              * * * * * * *
7817..................  Erythroderma.
 
                              * * * * * * *
7821..................  Cutaneous manifestations of collagen-vascular
                         diseases not listed elsewhere.
7822..................  Papulosquamous disorders not listed elsewhere.
 
                              * * * * * * *
7825..................  Chronic urticaria.
 
                              * * * * * * *
------------------------------------------------------------------------


0
5. Amend appendix C to part 4 as follows:
0
a. Revise the entry for ``Cutaneous manifestations of collagen-vascular 
diseases'' (diagnostic code 7821);
0
b. Add in alphabetical order an entry for ``Erythroderma'';
0
c. Remove the entry for ``Exfoliative dermatitis'';
0
d. Revise the entry for ``Scars''; and
0
e. Revise the entry for ``Urticaria'' (diagnostic code 7825).
    The revisions and addition read as follows:

Appendix C to Part 4--Alphabetical Index of Disabilities

------------------------------------------------------------------------
                                                            Diagnostic
                                                             Code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Cutaneous manifestations of collagen-vascular diseases              7821
 not listed elsewhere...................................
 
                              * * * * * * *
Erythroderma............................................            7817
 
                              * * * * * * *
Scars:
    Burn scar(s) of the head, face, or neck; scar(s) of             7800
     the head, face, or neck due to other causes; or
     other disfigurement of the head, face, or neck.....
    Burn scar(s) or scar(s) due to other causes, not of             7801
     the head, face, or neck that are associated with
     underlying soft tissue damage......................
    Burn scar(s) or scar(s) due to other causes, not of             7802
     the head, face, or neck that are not associated
     with underlying soft tissue damage.................
    Retina..............................................            6011
    Scars, other; and other effects of scars evaluated              7805
     under diagnostic codes 7800, 7801, 7802, or 7804...
    Unstable or painful.................................            7804
 
                              * * * * * * *
    Urticaria, chronic..................................            7825
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2018-14957 Filed 7-12-18; 8:45 am]
 BILLING CODE 8320-01-P