Schedule for Rating Disabilities: The Cardiovascular System, 37594-37607 [2019-15904]

Download as PDF 37594 Proposed Rules Federal Register Vol. 84, No. 148 Thursday, August 1, 2019 This section of the FEDERAL REGISTER contains notices to the public of the proposed issuance of rules and regulations. The purpose of these notices is to give interested persons an opportunity to participate in the rule making prior to the adoption of the final rules. DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 4 RIN 2900–AQ67 Schedule for Rating Disabilities: The Cardiovascular System Department of Veterans Affairs. Proposed rule. AGENCY: ACTION: The Department of Veterans Affairs (VA) proposes to amend the section of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule) that addresses the cardiovascular system. The proposed changes incorporate medical advances that have occurred since the last review, update medical terminology, and clarify evaluation criteria where necessary. Where changes to the scientific and/ or medical nature of a given condition have been proposed, VA has cited the published, publicly-available sources for these changes. The proposed changes are not a reflection of any particular expert’s comments or recommendations, but were based on published, peer-reviewed materials. Materials from the public forum, held in 2011, are available for public inspection at the Office of Regulation Policy and Management (see the ADDRESSES section of this rulemaking), and other deliberative materials are cited herein. DATES: VA must receive comments on or before September 30, 2019. ADDRESSES: Submit written comments through www.Regulations.gov; by mail or hand-delivery to the Director, Office of Regulations Policy and Management (00REG), Department of Veterans Affairs, 810 Vermont Ave. NW, Room 1064, Washington, DC 20420; or by fax to (202) 273–9026. Comments should indicate that they are submitted in response to RIN 2900–AQ67—Schedule for Rating Disabilities: The Cardiovascular System. Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, jspears on DSK3GMQ082PROD with PROPOSALS SUMMARY: VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 Room 1068, between the hours of 8:00 a.m. and 4:30 p.m. Monday through Friday (except holidays). Please call (202) 461–4902 for an appointment. (This is not a toll-free number.) In addition, during the comment period, please view comments online through the Federal Docket Management System (FDMS) at www.Regulations.gov. FOR FURTHER INFORMATION CONTACT: Gary Reynolds, MD, Medical Officer, Regulations Staff (211D), 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: As part of VA’s ongoing revision of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule), VA proposes changes to 38 Code of Federal Regulations (CFR) §§ 4.100 and 4.104, which pertain to the cardiovascular system. The proposed changes will: (1) Update the medical terminology of certain conditions; (2) add medical conditions not currently in the Rating Schedule; (3) refine evaluation criteria based on medical advances that have occurred since the last revision; and (4) incorporate current understanding of functional changes associated with, or resulting from, cardiovascular disease or injury (pathophysiology). I. § 4.100 Application of the Evaluation Criteria for Diagnostic Codes 7000–7007, 7011, and 7015–7020 In almost all cases, the current § 4.100 specifically requires testing for metabolic equivalent of tasks when evaluating heart diseases. Medical literature more commonly refers to metabolic equivalent of tasks as simply metabolic equivalents, or METs. Exceptions to METs testing for rating purposes occur when medically contraindicated, when the left ejection fraction is 50 percent or less, with chronic congestive heart failure, when more than one episode of heart failure occurred in the past year, or when VA may assign a 100 percent evaluation on another basis. 38 CFR 4.100(b). As explained below, this proposed rule will eliminate considering ejection fractions or congestive heart failure when evaluating cardiovascular disability. Therefore, for clarity and simplicity, VA proposes to delete paragraphs (b)(2), PO 00000 Frm 00001 Fmt 4702 Sfmt 4702 (b)(3), and (c), and redesignate paragraphs (b)(4) as (b)(2) of this section. II. General Rating Formula for Diseases of the Heart VA proposes to revise § 4.104 to include a new General Rating Formula for Diseases of the Heart (General Formula). VA will use this new General Formula to clarify and standardize the evaluation of many cardiovascular diseases. As discussed below, it will provide a more timely, efficient, and accurate method of evaluating these diseases. The proposed General Formula reflects current concepts in cardiovascular disability. The Institute of Medicine (now called the National Academy of Medicine) stated, ‘‘It is important for the Rating Schedule to be as up-to-date as possible in current medical approaches and terminology to serve veterans with disabilities most effectively. This ensures that the criteria in the Rating Schedule are based on concepts and terms used by medical personnel who provide medical evidence, and that evolving understanding of, or recognition of, new disabling conditions are reflected.’’ Institute of Medicine, Committee on Medical Evaluation of Veterans for Disability Compensation, ‘‘A 21st Century System for Evaluating Veterans for Disability Benefits,’’ 5 (Michael McGeary et al. eds. 2007). As in the current Rating Schedule, the proposed General Formula is based primarily on Metabolic equivalents (METs), which objectively and accurately measure the cardiac work capacity and which clinicians routinely obtain for all patients with heart disease. The examiner eliminates spurious results by considering various parameters, such as age and expected maximal heart rate achieved when factors other than heart disease are present. In situations where a person is unable to walk, or walk well, the patient may test on a bicycle or with the use of certain medications. VA notes that a number of diagnostic codes (DCs) within current § 4.104, including DCs 7000–7007, 7011, 7015– 7017, and 7019–7020, already utilize METs in evaluating their respective cardiovascular conditions. Specifically, each level of evaluation (10, 30, 60, and 100 percent) outlines a range of METs, as well as a list of associated symptoms, E:\FR\FM\01AUP1.SGM 01AUP1 jspears on DSK3GMQ082PROD with PROPOSALS Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules within which an individual must fall to warrant that particular evaluation. Additionally, VA may assign higher ratings (e.g., 60 and 100 percent) for congestive heart failure or left ventricular dysfunction as demonstrated by ejection fraction. Finally, VA may also assign a 30 percent evaluation with evidence on electrocardiogram, echocardiogram, or X-ray of cardiac hypertrophy or dilatation. Lastly, VA may assign a 10 percent evaluation if the condition requires continuous medication. VA proposes to rely on METs as the primary indicator of cardiac ability and eliminate other indicators currently found in the VASRD, such as ejection fractions or the number of any episodes of acute congestive heart failure in the past year. These latter indicators are less reliable in assessing cardiac function. Congestive heart failure may be due to poor conditioning, salt consumption, poor medication compliance, body weight, additional disease burden, or a variety of other factors not associated with the underlying cardiovascular disease itself. See Joshi, Mohanan et al., ‘‘Factors precipitating Congestive Heart Failure—role of patient noncompliance,’’ 47 J. Assoc. Physicians India 294–95 (Mar. 1999) (emphasizing ‘‘the importance of patient noncompliance with prescribed therapy as a leading precipitating factor for congestive heart failure . . . which can be prevented by appropriate cost saving strategies aimed to improve patient compliance.’’) Similarly, ejection fractions are unreliable because factors unrelated to cardiovascular disability, such as fluid intake, salt ingestion, and exercise, may influence them. See Ramachandran S. Vasan, MD, et al., ‘‘Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction,’’ 33(7) 1948–55 (1999). Conversely, METs form the most reliable basis of cardiac capability, even after heart disease weakens the ability of the heart to function at full capacity. See Charles K. Morris, MD, et al., ‘‘Nomogram based on metabolic equivalents and age for assessing aerobic exercise capacity in men,’’ 22(1) J. Am. College of Cardiology, 175–82 (1993). The heart is often described as the pump of the human body, and, as such, requires power to function. Power is the rate that energy is consumed to work. Various types of energy employ different measures of rate (power), such as kW (kilowatts) for electrical energy; Btu/hr (British Thermal Units per hour) for heat energy; hp (horsepower) for mechanical energy; and, for our VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 purposes, METs (metabolic equivalent of tasks) for cardiac energy. In evaluating cardiovascular disabilities, METs refer to the intensity of activities. For example, an activity with a MET of 2, such as walking at a slow pace (e.g., 2 mph), would require twice the energy that an average person consumes at rest (e.g., sitting quietly), which requires 1 MET. See ‘‘The Compendium of Physical Activities,’’ Arnold School of Public HealthPrevention Research Center, available at http://prevention.sph.sc.edu/tools/ compendium.htm. VA does not propose any alteration to the ranges of METs provided in the current VASRD, nor will it eliminate the references to dyspnea, fatigue, angina, dizziness, or syncope. Instead, VA proposes to state that these symptoms may represent heart failure. VA also proposes to use the more common term ‘‘breathlessness’’ for the more obscure term ‘‘dyspnea,’’ and to expand the list of common findings associated with congestive heart failure to include arrhythmia and palpitations. See ‘‘Congestive Heart Failure,’’ Johns Hopkins Medicine, available at http:// www.hopkinsmedicine.org/heart_ vascular_institute/conditions_ treatments/conditions/congestive_ heart_failure.html (last visited Apr. 30, 2014). Although VA proposes to eliminate the use of congestive heart failure and ejection fraction as indicators for evaluation, it will retain the non-MET criteria provided in the current 10 and 30 percent evaluations because these criteria remain valid. Id. VA proposes to apply the General Formula to those DCs within § 4.104 that instruct rating personnel to consider METs (among other indicators). The DCs using METS as the primary rating criteria include 7003, 7004, 7005, 7007, 7015, and 7020. On the other hand, DCs 7000, 7001, 7002, 7006, 7011, 7016, 7017, and 7019 have 100 percent evaluation criteria unique to each particular DC. VA does not intend to disturb the 100 percent evaluations currently prescribed in these DCs; rather, it proposes to apply the General Formula following the total evaluations. To ensure clarity and consistency in applying the General Formula, VA intends to instruct personnel to rate disabilities under § 4.104 using the General Formula unless otherwise directed. With respect to DCs 7010, 7011, 7015, and newly proposed DC 7009, regardless of the DC, the resulting impairment and disability are essentially indistinguishable. To offer more than one evaluation under those circumstances would be contrary to PO 00000 Frm 00002 Fmt 4702 Sfmt 4702 37595 § 4.14 (pyramiding). VA will provide an instruction immediately before DC 7009 which states ‘‘For DCs 7009, 7010, 7011, and 7015, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture.’’ The discussion that follows explains the changes to each DC affected by the General Formula, and explains additional changes to these DCs (e.g., title changes, note changes, etc.). A. Diagnostic Code 7000 DC 7000 currently provides a 100 percent evaluation during active infection with valvular heart damage and for three months following the cessation of treatment for the active infection. VA proposes no change to this provision. Following the three months, VA will evaluate residual cardiac disability using the General Rating Formula for Diseases of the Heart. B. Diagnostic Codes 7001 and 7002 The current DCs 7001 and 7002 (endocarditis and pericarditis, respectively) provide a 100 percent evaluation during active infection with cardiac involvement, and for three months following the cessation of treatment for the active infection. VA proposes no change to these provisions. Following the three months, VA will evaluate any residual cardiac disability using the General Rating Formula for Diseases of the Heart. C. Diagnostic Codes 7003, 7004, 7005, 7007, and 7020 VA proposes to evaluate disability due to these conditions (pericardial adhesions, syphilitic heart disease, arteriosclerotic heart disease, hypertensive heart disease, and cardiomyopathy, respectively) using the General Rating Formula. D. Diagnostic Code 7006 The current DC 7006 provides a 100 percent evaluation during, and for three months following, a documented myocardial infarction. VA proposes no change to this provision. Following the three months, VA proposes to evaluate residual disability under the General Rating Formula. E. Diagnostic Code 7011 VA does not propose any change to the current DC 7011 provisions establishing a 100 percent evaluation for sustained ventricular arrhythmia or ventricular aneurysmectomy from the date of hospital admission. However, VA proposes to apply the General Rating Formula following the mandatory examination provided six E:\FR\FM\01AUP1.SGM 01AUP1 37596 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules jspears on DSK3GMQ082PROD with PROPOSALS months after discharge to determine residual disability rating. Additionally, DC 7011 currently includes a note indicating VA will conduct a mandatory examination six months following discharge and therapy for a sustained arrhythmia or ventricular aneurysmectomy. The intent is to monitor the extent of disability following inpatient hospitalization for surgical intervention and therapy. VA proposes to add the phrase ‘‘discharge from inpatient hospitalization’’ to the note to clarify that the timing for mandatory re-examination is based upon discharge from inpatient hospitalization, rather than discharge from an outpatient treatment program. This proposed clarification does not represent a change in VA policy. F. Diagnostic Code 7015 VA proposes to update this DC to reflect modern treatment and to more accurately evaluate impairment by separating the various forms of atrioventricular block into two specific categories: benign and non-benign i.e., the latter requiring immediate treatment. ‘‘Types of Heart Block,’’ National Heart, Lung, and Blood Institute (July 9, 2012), http:// www.nhlbi.nih.gov/health/healthtopics/topics/hb/types.html (last visited April 22, 2014). The benign, or less severe, category of atrioventricular block includes firstdegree heart block (first-degree) and second-degree heart block, type I (second-degree type I). First-degree (seen as a delayed or prolonged P–R interval on electrocardiogram), involves the slowing of the heart’s electrical signals, often without any symptoms and, therefore, without requiring any treatment. Id. In second-degree type I, the electrical signals are slowed more and more with each heartbeat until the heart eventually skips a beat. An occasional, transitory, and mild symptom may be associated with second-degree type I heart block. Id. No specific therapy is required for seconddegree type I heart block. Ali A. Sovari, ‘‘Second-Degree Atrioventricular Block Treatment & Management,’’ Medscape— Reference (May 9, 2013) http:// emedicine.medscape.com/article/ 161919-treatment (last visited April 22, 2014). VA proposes to evaluate the benign form of atrioventricular block under the General Rating Formula. The non-benign, or more severe, category of atrioventricular block include second-degree heart block, type II (second-degree type II) and thirddegree heart block (third-degree). In second-degree type II, some of the heart’s electrical signals do not reach VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 the ventricles, which may result in symptoms of dizziness, lightheadedness, or syncope. In addition, individuals with second degree may experience chest pain, hypoperfusion, and hypotension. Ali A. Sovari, ‘‘Second-Degree Atrioventricular Block Clinical Presentation,’’ Medscape— Reference (May 9, 2013), http:// emedicine.medscape.com/article/ 161919-clinical (last visited April 22, 2014). Second-degree type II presents a much more immediate medical risk as it may progress rapidly to complete heart block. As a result, affected individuals may receive permanent pacemakers. Third-degree heart block occurs when none of the heart’s electrical signals reach the ventricles, which often requires emergency treatment because it can result in cardiac arrest or death. Like second-degree type II, this severe type of atrioventricular block requires pacemaker implantation. Based on this treatment, VA proposes to evaluate the non-benign categories of atrioventricular block (second-degree, type II and thirddegree) under DC 7018, implantable cardiac pacemakers. Given the proposed amendments to DC 7015, the note that currently follows is no longer relevant. The VA proposes to remove the note following DC 7015. G. Diagnostic Code 7016 VA does not propose any change to the current DC 7016 provisions establishing a 100 percent evaluation for heart valve replacement (prosthesis). However, VA proposes to apply the General Rating Formula following the mandatory examination provided six months after discharge to determine residual disability rating. Additionally, DC 7016 currently includes a note indicating VA will examine this disability six months following discharge. The intent is to monitor the extent of the disability following hospitalization for surgery. Similar to DC 7011, VA proposes to link the evaluation with discharge from inpatient hospitalization for this particular dysrhythmia. This clarification does not represent a change in VA policy. H. Diagnostic Code 7017 DC 7017 currently provides a 100 percent evaluation for three months following hospital admission for coronary bypass surgery. VA proposes no change to this provision. Following the three months, VA proposes to evaluate any residual cardiac disability under the General Rating Formula. PO 00000 Frm 00003 Fmt 4702 Sfmt 4702 I. Diagnostic Code 7019 Currently, DC 7019 provides a 100 percent evaluation from the date of hospital admission for cardiac transplantation, continuing for ‘‘an indefinite period.’’ The current note also states, however, that one year following discharge, VA should examine the individual to determine the appropriate disability rating, assigning a minimum evaluation of 30 percent. VA applies 38 CFR 3.105(e) to any change in evaluation. VA proposes no changes to this process or the minimum evaluation of 30 percent. However, VA proposes to eliminate the phrase ‘‘for an indefinite period’’ and replace it with ‘‘for a minimum of one year.’’ This will eliminate any confusion as to whether the Veteran’s 100 percent evaluation may be subject to reduction during the year following transplantation. Practically, a Veteran will receive a 100 percent evaluation for at least one year plus hospitalization time as VA will not re-evaluate the Veteran until one year following hospital discharge. In addition to this change, VA proposes to evaluate residual cardiac disability under the General Rating Formula. Additionally, DC 7019 currently includes a note indicating VA will examine this disability one year following discharge. The note’s intent is to assess the extent of residual cardiac disability following hospitalization for surgery. VA proposes to add the phrase ‘‘discharge from inpatient hospitalization’’ to clarify when the point at which the timing for mandatory examination begins. Discharge from an outpatient treatment program does not activate this provision. This clarification does not represent a change in VA policy. III. Proposed Changes to Diagnostic Codes Not Rated Under the General Formula A. Diagnostic Code 7008 The DC 7008 addresses hyperthyroid heart disease. This DC was amended with the final publication of 82 FR 50804, Schedule for Rating Disabilities; The Endocrine System, effective December 10, 2017. VA’s update of the endocrine system (38 CFR 4.117) revised the evaluation criteria for hyperthyroidism under DC 7900. See RIN 2900–AO44. Specifically, VA eliminated any current rating criteria in DC 7900 that referred to cardiovascular findings. Instead, VA evaluates any hyperthyroid heart disease under DC 7008, which directs rating personnel to evaluate any cardiovascular findings according to the appropriate DC. The E:\FR\FM\01AUP1.SGM 01AUP1 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules jspears on DSK3GMQ082PROD with PROPOSALS VA does not propose any additional changes for DC 7008 at this time. B. Diagnostic Code 7010 VA proposes to change the name of the current DC 7010 from supraventricular arrhythmias to the more modern and accurate supraventricular tachycardia. Arrhythmia generally refers to an irregular heartbeat and includes a heartbeat that is too fast, too slow, or irregular. ‘‘What Is an Arrhythmia?’’ National Heart, Lung, and Blood Institute (July 1, 2011), http:// www.nhlbi.nih.gov/health/healthtopics/topics/arr/ (last visited April 22, 2014). Supraventricular tachycardia is an irregularly fast heartbeat that originates above or within the atrioventricular node18 or in the upper part of the heart. Id. The various forms of supraventricular tachycardia include, but are not limited to, atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Id. VA proposes to add an explanatory Note 1 to provide a non-exhaustive list of examples of supraventricular tachycardia. VA proposes to use tachycardia, rather than arrhythmia, in the title to clarify that rating personnel should use this DC to evaluate individuals with abnormally fast heartbeats. VA also proposes to update the evaluation criteria for supraventricular tachycardia, utilizing hospitalization as a more accurate measure of disability. The current criteria in DC 7010 assign evaluations based on the number of episodes of supraventricular arrhythmias documented by electrocardiogram (ECG or EKG) or Holter monitor, without considering the need for hospital treatment. Supraventricular tachycardia is usually non-lethal and does not result in disabling symptoms in otherwise healthy individuals. See ‘‘Paroxysmal supraventricular tachycardia’’ in ‘‘A.D.A.M. Medical Encyclopedia,’’ PubMed Health, U.S. National Library of Medicine (June 18, 2012), http:// www.nlm.nih.gov/medlineplus/ency/ article/000183.htm (last visited Apr. 30, 2014). For example, some patients with supraventricular tachycardias have many short episodes throughout the day and remain asymptomatic. Id. Others may have atrial fibrillation on a permanent basis, also without symptoms. These non-disabling episodes do not require hospitalization or treatment, but may be recorded VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 incidentally by an ECG or Holter monitor without any other findings. Id. Therefore, the mere presence of episodes of supraventricular tachycardia, as well as their number, is unrelated to symptomatology or disability. However, some episodes of supraventricular tachycardia result in hypotension, shortness of breath, dizziness, or chest pain in patients who are older or have underlying cardiac disorders. Id. These symptomatic episodes typically require a controlled medical setting to monitor and treat heart rate control, anticoagulation, cardioversion, electrophysiological studies, or catheter-based arrhythmia ablation. Id. Medical intervention for supraventricular tachycardia more accurately indicates impairment, as the purpose of treatment is to eliminate or reduce any disabling symptoms. As mentioned previously, the mere documentation of supraventricular tachycardia on an ECG or Holter monitor does not confirm the existence of symptoms or impairment. As such, VA proposes to replace the current reference to episodes documented by ECG or Holter monitor in DC 7010 with treatment interventions. For the purposes of this DC, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. For clarity, VA proposes to add Note 2 to identify when a treatment occurs. VA will assign a 10 percent evaluation for supraventricular tachycardia, documented by ECG, with one to four treatment interventions per year; VA will assign a 30 percent evaluation with five or more treatment interventions per year. VA proposes the number of interventions annually because benign, non-disabling episodes may occur throughout the year. However, only episodes that require treatment interventions are most likely disabling, because they require treatment within a controlled medical setting and typically prevent an individual from working. C. Diagnostic Code 7018 DC 7018 currently provides a 100 percent evaluation for two months following hospital admission for implantation or reimplantation of a cardiac pacemaker. Following these two months, VA evaluates the disability under DC 7010, 7011, or 7015, with a minimum evaluation of 10 percent. Advances in surgical methods and medical technology have drastically reduced the recovery time following implantation of a cardiac pacemaker. PO 00000 Frm 00004 Fmt 4702 Sfmt 4702 37597 Surgical techniques for cardiac pacemakers have changed and improved drastically over the past several years and recovery currently requires less than 30 days. According to the National Institutes of Health (NIH), hospitalization following surgical implantation of a pacemaker usually lasts one to two days. ‘‘What to Expect After Pacemaker Surgery,’’ NIH— National Heart, Lung, and Blood Institute (February 28, 2012), http:// www.nhlbi.nih.gov/health/healthtopics/topics/pace/after.html (last visited April 14, 2014). NIH also indicates that mild pain, swelling, and tenderness at the site of pacemaker implantation may continue from a few days to a few weeks. Id. While healthcare providers may instruct patients to avoid vigorous activity, including heavy lifting, for up to one month following surgery, most patients may return to their normal activity level within a few days. Id. VA proposes to reduce the period of 100 percent evaluation from two months to one month. Additionally, VA proposes to add a second note to this DC, crossreferencing DC 7009, which will be addressed in greater detail below. VA proposes no other changes to this DC. D. Diagnostic Code 7110 The current DC 7110 addresses impairment due to aortic aneurysm. VA proposes to change the name of the code to ‘‘Aortic aneurysm: ascending, thoracic, or abdominal’’ to clarify the location of aortic aneurysm that this DC will evaluate. VA proposes to eliminate the 60 percent evaluation for an aortic aneurysm that precludes exertion while expanding the criteria for a 100 percent evaluation to include symptomatic aneurysm (e.g., precludes exertion). VA proposes to omit the 60 percent category as it is does not provide an adequate evaluation for a symptomatic aneurysm in which exertion may hasten rupture. See Emile R. Mohler III, MD, ‘‘Patient information: Abdominal aortic aneurysm (Beyond the Basics),’’ Up-todate (Aug. 21, 2013), http:// www.uptodate.com/contents/ abdominal-aortic-aneurysm-beyond-thebasics#H4 (last visited May 2, 2014). A symptomatic aneurysm presents a medical emergency and requires surgical treatment to prevent the aneurysm from rupturing. Id. Under the proposed criteria, VA will grant a total evaluation when a patient becomes a surgical candidate and is unable to exert him/herself. Additionally, if a person cannot exert him/herself due to aortic aneurysm but is unable to undergo surgery due to a co- E:\FR\FM\01AUP1.SGM 01AUP1 jspears on DSK3GMQ082PROD with PROPOSALS 37598 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules morbid medical condition (e.g., kidney dysfunction requiring dialysis), VA will grant a total evaluation. Jeffrey Jim, MD and Robert W. Thompson, MD, ‘‘Management of symptomatic (nonruptured) and ruptured abdominal aortic aneurysm,’’ UpToDate (Feb. 12, 2013), http://www.uptodate.com/ contents/management-of-symptomaticnon-ruptured-and-ruptured-abdominalaortic-aneurysm?source=see_ link&anchor=H53322839#H53322839 (last visited May 5, 2014). ‘‘Although there are rare reports of patient survival following ruptured abdominal aortic aneurysm (AAA) without repair, in general, expectant management of ruptured AAA is nearly uniformly fatal. Thus, when ruptured AAA is identified, repair should be undertaken emergently to give the patient the best chance for survival.’’ Id. As such, expanding the 100 percent evaluation to the date a physician recommended surgical correction will include Veterans who have severely disabling aneurysms but, due to co-morbid medical conditions or other reasons, cannot undergo surgical intervention. This 100 percent evaluation will continue for six months following hospital discharge. In addition, VA proposes to add a 0 percent rating if an aneurysm is present but does not meet the requirements for surgical correction. Asymptomatic aneurysms may expand rapidly until they require surgical correction, so they need close medical follow-up. This provision allowing service connection for aneurysms not requiring surgery eliminates barriers to frequent medical check-ups by VA to monitor the progress of those aneurysms. VA will also add a directive for raters to evaluate non-cardiovascular residuals according to the body systems affected. This is done to take into acount any disabling residuals related to surgical correction (e.g., infection, bowel adhesions, kidney failure, and so forth). The current DC 7110 also includes a note indicating that VA will assign the 100 percent rating as of the date of admission for surgical correction. VA will re-evaluate the condition after a mandatory examination six months following discharge. VA proposes to add the phrase ‘‘discharge from inpatient hospitalization’’ to clarify that the starting point to calculate the mandatory re-examination begins with discharge from inpatient hospitalization. VA also proposes to clarify in the rating criteria for a 100 percent evaluation that it shall assign the 100 percent evaluation as of the date a physician recommends surgical correction. This practice will allow VA to assign 100 percent evaluations to individuals who require VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 surgical correction but, due to comorbid medical conditions or other reasons, cannot undergo surgical procedures. E. Diagnostic Code 7111 The current DC 7111 provides 100 percent evaluations for aneurysms of large arteries which are symptomatic. It also provides 100 percent evaluations for indefinite periods of time from the date of hospital admission for surgical corrections. VA proposes to amend the latter criteria to provide a 100 percent evaluation from the date a physician recommends surgical correction, rather than the date of hospital admission. Aneurysms of any large artery are known to spontaneously rupture, which, depending on its location, can lead to death if not immediately addressed by surgery. This expansion to the 100 percent evaluation criteria requires that VA amend the note in DC 7111. Currently, VA assigns the 100 percent rating as of the date of admission for surgical correction, and VA assesses any residual disability by a mandatory examination six months following discharge. VA proposes to add the phrase ‘‘discharge from inpatient hospitalization’’ in the criteria note to clarify that the timing for the mandatory re-examination is based upon discharge from inpatient hospitalization. Additionally, VA proposes to clarify that it shall assign the 100 percent evaluation beginning from the date a physician recommends surgical correction, in the event individuals who require surgical correction cannot undergo it due to comorbid medical conditions or other reasons. The 100 percent evaluation shall continue for six months following hospital discharge for surgical correction. The current DC 7111 provides rating criteria following surgical intervention that is based on the ankle-brachial index, claudication on walking certain distances, and other symptoms related to poor blood flow to the extremities. These criteria provide for evaluations ranging from 20 to 100 percent; notes (1) and (2) provide additional information when evaluating post-surgical large artery aneurysms. The residual disabilities after post-surgical repair of large artery aneurysms are similar to those under DC 7114. For greater ease of use and simplicity, VA therefore proposes to remove these criteria and notes and replace them with instructions to evaluate post-surgical residuals under DC 7114. The section of the preamble below specifically addressing DC 7114 discusses any PO 00000 Frm 00005 Fmt 4702 Sfmt 4702 changes related to these criteria and notes. F. Diagnostic Code 7113 DC 7113, arteriovenous (AV) fistula, traumatic, currently includes the phrase ‘‘with edema’’ as one of the disabling symptoms present at the 50, 40, 30, and 20 percent levels. However, such wording does not distinguish between chronic and transitory edema, resulting in evaluations that may be based on symptoms that are unrelated to arteriovenous fistula or do not adequately represent its chronic residual disability. Transitory edema may occur following prolonged standing, prolonged sitting during travel, the wearing of tight hosiery, taking certain medications, consuming excessive salt, or being pregnant. Transitory edema due to these causes is non-disabling and typically resolves without complication. However, edema due to an AV fistula requires medical treatment and may impair function. Therefore, VA proposes to clarify that evaluations at the 50, 40, 30, and 20 percent levels under DC 7113 must involve ‘‘chronic edema’’ to better comply with 38 CFR 4.1, which states the accurate application of the VASRD requires an emphasis upon ‘‘the limitation of activity imposed by the disabling condition.’’ G. Diagnostic Code 7114 The current DC 7114, titled ‘‘Arteriosclerosis obliterans,’’ addresses impairment of the lower extremities due to narrowing and hardening of the arteries. The term ‘‘arteriosclerosis’’ is also used in current note (2). VA proposes to replace the term ‘‘arteriosclerosis obliterans’’ with ‘‘peripheral arterial disease’’ to conform to current medical terminology. Peter Libby et al., ‘‘Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine,’’ 1491–1515 (8th ed. 2007). The evaluation criteria of the current DC 7114 include the ankle/brachial index (ABI), associated examination findings and symptoms, or claudication (pain in the extremities) upon walking certain distances. The current criteria, however, have two major shortcomings: (1) They do not account for veterans with non-compressible arteries (these veterans have either a normal or elevated ABI, which would be noncompensable); and (2) they rely in large part on claudication, which is an inconsistent measure of disability. To that end, VA will employ a more objective approach as outlined below. VA will create evaluation criteria based on a modified version of the ischemia scoring table found in J. Mills, E:\FR\FM\01AUP1.SGM 01AUP1 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules jspears on DSK3GMQ082PROD with PROPOSALS ‘‘The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI)’’ J Vasc Surg; vol 59, pg 226. 2014. This table uses the ABI, as well as ankle pressure (AP), toe pressure (TP) and transcutaneous oximetry (TcPO2) to describe four different levels of impairment. The ABI is the ratio of the systolic blood pressure measured at the ankle to that measured at the antecubital fossa. For VA disability compensation purposes, normal is greater than or equal to 0.80. The reason this normal value is used, rather than normal values cited in the 2016 ACC/ AHA Guidelines is that an ABI between 0.90 and 0.81 is not consistently associated with objective signs of disability beyond symptomatic complaints (e.g., wounds or infections). The AP is the systolic blood pressure measured at the ankle. Normal is greater than or equal to 100 mm Hg. The TP is the systolic blood pressure measured at the great toe. Normal is greater than or equal to 60 mm Hg. TcPO2 is measured at the first intercostal space on the foot. Normal is greater than or equal to 60 mm Hg. See also M. Kalani ‘‘Transcutaneous Oxygen Tension and Toe Blood Pressure as Predictors for Outcome of Diabetic Foot Ulcers,’’ Diabetes Care, vol. 22, Pgs 147–52. 1999. The levels of impairment as described in the previously referenced ischemia scoring table directly correlate to levels of disability (i.e., evaluation levels). VA will slightly modify this table to describe four levels of disability (and thus, evaluation levels) consistent with these criteria, while preserving the 20, 40, 60, and 100 percent evaluation levels. Turning to the three notes associated with DC 7114, VA will make two significant revisions. First, VA will revise Note (1) to add definitions and normal values for ABI, AP, TP, and TcPO2. Next, VA will redesignate current Note (2) as Note (3), and current Note (3) as Note (4). Finally, VA will then add a new Note (2), which directs the rater to select the value (ABI, AP, TP, or TcPO2) which yields the highest level of impairment for evaluation. H. Diagnostic Code 7115 DC 7115 currently uses lower extremity findings to evaluate thromboangiitis obliterans (Buerger’s Disease). VA proposes new criteria for the evaluation of upper extremity disease because Buerger’s Disease can affect either upper or lower extremities. Buerger’s disease is a nonatherosclerotic segmental inflammatory disease that affects the small and medium-sized VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 arteries, veins, and nerves of the arms, legs, and rarely elsewhere. See Topol, E.J., Textbook of Cardiovascular Medicine Chap. 108, Pg 1535. (2007). DC 7115 currently evaluates impairment of the lower extremity using the ankle/ brachial index (ABI) or associated signs and symptoms upon examination (as found in current DC 7114). For the reasons discussed above in DC 7114, VA proposes to clarify the evaluation criteria by using objective signs, with the ABI as the primary criteria for the lower extremities. VA proposes to delete claudication on walking from all evaluation criteria as it inaccurately measures the extent of this disability. VA also proposes to remove current Note (1), as DC 7115 will now direct rating personnel to evaluate lower extremities under DC 7114 and the information regarding the ABI is contained in that diagnostic code. With elimination of current Note (1), VA proposes to rename existing Note (2) as Note (1) with clarification similar to that proposed in Note (3) DC 7114 (as explained above). Additionally, a new Note (2) is proposed to give raters examples of trophic changes so it will be easier to recognize when encountered in clinical documentation. I. Diagnostic Code 7117 Currently, DC 7117 addresses impairment due to Raynaud’s syndrome, in which cold or stress abnormally reduces blood flow in the extremities. Raynaud’s syndrome (also called secondary Raynaud’s phenomenon) is often confused with Raynaud’s disease (also called primary Raynaud’s phenomenon or primary Raynaud’s), which is different in terms of etiology and severity. While both conditions present with vasospasm, Raynaud’s disease (primary Raynaud’s phenomenon) has few, if any, long term residuals. In contrast, Raynaud’s syndrome (secondary Raynaud’s phenomenon) is associated with another illness, most commonly an autoimmune disease. The residuals tend to be permanent, more extensive, and more disabling. To improve clarity, ensure more accurate evaluations, and promote consistency and usability of the VASRD, VA proposes to focus DC 7117 on Raynaud’s syndrome (secondary Raynaud’s phenomenon) only, while creating a new DC 7124 for Raynaud’s disease (primary Raynaud’s phenomenon or primary Raynaud’s). In addition, VA proposes to use the existing note to emphasize that DC 7117 is only for evaluating Raynaud’s syndrome (secondary Raynaud’s phenomenon), and add a note emphasizing that Raynaud’s disease PO 00000 Frm 00006 Fmt 4702 Sfmt 4702 37599 (primary Raynaud’s phenomenon) should be rated under DC 7124. As stated, Raynaud’s syndrome (secondary Raynaud’s phenomenon) and Raynaud’s disease (primary Raynaud’s phenomenon) are unrelated in both etiology and severity. According to the NIH’s National Heart, Lung, and Blood Institute, Raynaud’s syndrome (secondary Raynaud’s phenomenon) is typically caused by autoimmune diseases such as scleroderma, lupus, rheumatoid arthritis, atherosclerosis, or polycythemia. ‘‘Raynaud Phenomenon.’’ Medscape (September 6, 2017), http:// emedicine.medscape.com/article/ 331197-overview (last visited September 12, 2017). On the other hand. the cause of Raynaud’s disease (primary Raynaud’s phenomenon) is not known. Id. Raynaud’s disease (primary Raynaud’s phenomenon) is more common and tends to be less severe than Raynaud’s syndrome (secondary Raynaud’s phenomenon). Ray W. Gifford, Jr. & Edgar A. Hines, Jr., ‘‘Raynaud’s Disease Among Women and Girls,’’ 16 Circulation 1012, 1019 (1957). VA discusses how to properly evaluate Raynaud’s disease (primary Raynaud’s phenomenon) below in the section proposing the new DC 7124. No other changes are proposed to DC 7117. J. Diagnostic Code 7120 DC 7121 currently evaluates postphlebitic syndrome of any etiology, with its rating criteria identical to that used in DC 7120, Varicose veins. VA currently maintains separate DCs for these disabilities to monitor in the Veteran population the incidence and outcome of claims for these specific and separate diagnoses. However, for clarity, consistency, and improved ease of use, VA proposes to delete the duplicative rating criteria and instruct rating personnel to evaluate DC 7120, Varicose veins, under DC 7121, Post-phlebitic syndrome. VA does not propose any changes to the content of DC 7121 itself. K. Diagnostic Code 7122 VA last amended the rating criteria for DC 7122, Cold injury residuals, in 1998. 63 FR 37778. In the time since, medicine has documented new chronic residuals of cold injury. Therefore, VA proposes to update the criteria to include the findings specifically noted by the Veterans Health Initiative, Department of Veterans Affairs, ‘‘Cold Injury: Diagnosis and Management of Long-Term Sequelae,’’ revised in March 2002. https://www.publichealth.va.gov/ docs/vhi/coldinjury.pdf This study collected medical and anecdotal information on cold injury E:\FR\FM\01AUP1.SGM 01AUP1 37600 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules residuals from veterans. The study indicated that the effects of cold weather injuries may be irreversible and worsen with age. Id. at 15. The residuals of cold injuries include residual pain, numbness, cold sensitivity, tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, x-ray abnormalities, anhydrosis, muscle atrophy, muscle fibrosis, deformity in flexion and/or extension of certain joints, loss of fat pads in the fingers and toes, bone death, skin ulcers, and carpal or tarsal tunnel syndrome. Id. at 24–25. VA proposes to include these updated residuals of cold injuries within this DC, which assigns evaluations based on the number of cold injury residuals present. jspears on DSK3GMQ082PROD with PROPOSALS IV. Proposed New Diagnostic Codes A. New Diagnostic Code 7009 VA proposes to add a new DC 7009, titled ‘‘Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation,’’ to account for impairment in the Veteran population due to this condition. Individuals generally have a normal resting heart rate ranging from 60 to 100 beats per minute. Individuals with bradycardia, however, have a resting heart rate of less than 60 beats per minute. ‘‘Bradycardia,’’ Harvard Health Topic at Drugs.com, http://www.drugs.com/ health-guide/bradycardia.html (last visited May 5, 2014). Notably, asymptomatic bradycardia occurs normally in individuals when sleeping and in many healthy, athletic adults. Id. See also ‘‘Bradycardia (Slow Heart Rate)—Topic Overview,’’ WebMD (Nov. 21, 2011), http://www.webmd.com/ heart-disease/tc/bradycardia-slowheart-rate-overview (last visited May 5, 2014). It should be noted that asymptomatic bradycardia is a medical finding, does not require medical intervention, and is not subject to service-connected compensation. Symptomatic bradycardia can be caused by changes due to aging, certain medications, diseases, and infections, all of which can damage the heart and slow its electrical impulses. See Amy Scholten, MPH, ‘‘Bradycardia (Bradyarrhythmia),’’ NYU Langone Cardiac and Vascular Institute, 2–3 (Feb. 2008). When medical management for symptomatic bradycardia is not effective, a pacemaker implant is the treatment of choice. Id. at 3. Implantation of a pacemaker aids in normalizing the heart rate and returning the individual to baseline cardiac function. VA proposes to evaluate this condition at 100 percent for one month following hospitalization for VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 implantation or re-implantation. Following the initial month, the disability will be evaluated using the General Rating Formula. To assist rating personnel in understanding and evaluating bradycardia, VA also proposes to include a note under DC 7009 which defines bradycardia and describes the five general classes of bradyarrhythmias. B. New Diagnostic Code 7124 VA proposes to add a new DC 7124, titled ‘‘Raynaud’s disease (also known as primary Raynaud’s phenomenon or primary Raynaud’s):.’’ The VASRD currently evaluates Raynaud’s disease using the criteria under DC 7117, which is for ‘‘Raynaud’s syndrome,’’ a different and more severe disability. Therefore, VA proposes a new DC to specifically evaluate Raynaud’s disease. This DC will also include notes to define characteristic attacks as well as to emphasize rating Raynaud’s syndrome (Raynaud’s phenomenon, Secondary Raynaud’s) under DC 7117. As stated previously, Raynaud’s disease is more common and tends to be less severe than Raynaud’s syndrome. The Mayo Clinic performed a study involving 474 women and girls with Raynaud’s disease. Follow-up information obtained from 307 of those who received conservative treatment confirmed the benign nature of the disease, with no deaths attributed to it and extremely little disability. The study found that uncomplicated Raynaud’s disease may be inconvenient because of the need to protect the extremities from cold and trauma, but it is not disabling. Raynaud’s disease, the less severe form of Raynaud’s, rarely involves trophic changes because it involves brief spasms of the arteries rather than occlusion of the peripheral arteries. See ‘‘What is Raynaud’s?’’ National Heart, Lung, and Blood Institute (Mar. 21, 2014), https://www.nhlbi.nih.gov/ health/health-topics/topics/raynaud/ (last visited May 5, 2014). Furthermore, when trophic changes are present, they are limited to the distal skin of the digits. ‘‘Raynaud’s disease,’’ Mayo Clinic (Oct. 20, 2011), http:// www.mayoclinic.org/diseasesconditions/raynauds-disease/basics/ complications/con-20022916 (last visited May 5, 2014). Therefore, VA proposes a non-compensable evaluation when Raynaud’s disease manifests without lasting impairment in the form of trophic changes. VA proposes a 10 percent evaluation with residual trophic changes (e.g., skin changes such as thinning, atrophy fissuring, ulceration, scarring, absence of hair; nail changes PO 00000 Frm 00007 Fmt 4702 Sfmt 4702 (clubbing, deformities).) VA proposes the addition of a note to provide examples of trophic changes for clarification purposes, consistent with other proposed changes. VA also proposes to include a note to clarify and assist assigning evaluations under this DC by defining a characteristic attack of Raynaud’s disease. As with DC 7117, this note will also indicate that evaluations under this code are for the disease as a whole. To further promote clarity and consistency, another proposed note would emphasize that the purpose of DC 7124 is to evaluate only Raynaud’s disease, as opposed to Raynaud’s syndrome. A veteran cannot receive simultaneous ratings under both DC 7117 and DC 7124, because Raynaud’s disease and Raynaud’s syndrome cannot be comorbid conditions. Effect of Rulemaking Title 38 of the Code of Federal Regulations, as revised by this proposed rulemaking, would represent VA’s implementation of its legal authority on this subject. Other than future amendments to these regulations or governing statutes, no contrary guidance or procedures are authorized. All existing or subsequent VA guidance must be read to conform with this proposed rulemaking if possible or, if not possible, such guidance is superseded by this rulemaking. Executive Orders 12866 and 13563 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a ‘‘significant regulatory action,’’ which requires review by the Office of Management and Budget (OMB), 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 E:\FR\FM\01AUP1.SGM 01AUP1 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules 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 to be a significant regulatory action under Executive Order 12866, because it raises novel legal or policy issues arising out of legal mandates, the President’s priorities, or the principles set forth in this Executive Order. VA’s impact analysis can be found as a supporting document at http:// www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA’s website at http:// www.va.gov/orpm by following the link for VA Regulations Published from FY 2004 through Fiscal Year to Date. This proposed rule is not expected to be subject to the requirements of EO13771 because this proposed rule is expected to result in no more than de minimis costs. jspears on DSK3GMQ082PROD with PROPOSALS Paperwork Reduction Act This regulatory action contains provisions constituting a collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. 3501 et seq.). The information collection requirements for 38 CFR 3.151 are associated with this rule, but do not constitute a new or revised collection of information; OMB has already approved these requirements under control number 2900–0747. Regulatory Flexibility Act The Secretary hereby certifies that the adoption of this rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601–612. This rule would not directly affect any small entities; only individuals could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this rule is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604. VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 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 1 year. This rule will have no such effect on State, local, and tribal governments, or on the private sector. 37601 § 4.100 Application of the evaluation criteria for diagnostic codes 7000–7007, 7011, and 7015–7020. * * * * * (b) Even if the requirement for a 10% (based on the need for continuous medication) or 30% (based on the presence of cardiac hypertrophy or dilatation) evaluation is met, METs testing is required in all cases except: (1) When there is a medical contraindication. (2) When a 100% evaluation can be assigned on another basis. Catalog of Federal Domestic Assistance (Authority: 38 U.S.C. 1155) The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.104, Pension for Non-Service-Connected Disability for Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death. ■ ■ Authority: 38 U.S.C. 1155, unless otherwise noted. 3. Amend § 4.104 by: a. Adding the General Rating Formula for Diseases of the Heart ■ b. Adding the instruction to DCs 7000, 7001, 7002, 7006, 7017 to evaluate disability using the General Rating Formula to evaluate residual disability after three months ■ c. Adding the instruction to DCs 7003, 7004, 7005, 7007, and 7020 to evaluate disability using the General Rating Formula ■ d. Adding the instruction to DCs 7011, 7016 to evaluate disability using the General Rating Formula by mandatory examination six months after discharge ■ e. Revising the evaluation criteria for DC 7015 ■ f. Revising the evaluation criteria for DC 7019 ■ g. Retitling and revise the evaluation criteria for DC 7010 ■ h. Revising the evaluation criteria for DC 7018 ■ i. Retitling and revise the evaluation criteria for DC 7110 ■ j. Revising the evaluation criteria for DC 7111 ■ k. Revising DC 7113 to add explanatory information ■ l. Revising the evaluation criteria for DC 7114 ■ m. Revising the evaluation criteria for DC 7115 ■ n. Revising the evaluation criteria for DC 7117 ■ o. Revising the evaluation criteria for DC 7120 ■ p. Revising the evaluation criteria for DC 7122 ■ q. Adding new DC 7009 ■ r. Adding new DC 7124. The revisions and additions read as follows: 2. Revise § 4.100 paragraph (b) to read as follows: § 4.104 Schedule of ratings— cardiovascular system. 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 submit it to the Office of the Federal Register for electronic publication as an official document of the Department of Veterans Affairs. Robert L. Wilkie, Secretary, Department of Veterans Affairs, approved this document on April 10, 2019, for publication. Dated: July 23, 2019. Jeffrey M. Martin, Assistant Director, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs. For the reasons set out in the preamble, VA proposes to amend 38 CFR part 4 as set forth below: PART 4—SCHEDULE FOR RATING DISABILITIES Subpart B—Disability Ratings 1. The authority citation for part 4 continues to read as follows: ■ ■ PO 00000 Frm 00008 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 37602 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules Rating jspears on DSK3GMQ082PROD with PROPOSALS Diseases of the Heart Unless otherwise directed, use this general rating formula to evaluate diseases of the heart. Note (1): Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it. Note (2): One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner may estimate the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms. Note (3): For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. General Rating Formula for Diseases of the Heart: Workload of 3.0 METs or less results in heart failure symptoms ................................................................................................ Workload of 3.1–5.0 METs results in heart failure symptoms ..................................................................................................... Workload of 5.1–7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging) ....................................... Workload of 7.1–10.0 METs results in heart failure symptoms; or continuous medication required for control ......................... 7000 Valvular heart disease (including rheumatic heart disease), 7001 Endocarditis, or 7002 Pericarditis: During active infection with cardiac involvement and for three months following cessation of therapy for the active infection Thereafter, with diagnosis confirmed by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization, use the General Rating Formula. 7003 Pericardial adhesions. 7004 Syphilitic heart disease: Note: Evaluate syphilitic aortic aneurysms under DC 7110 (Aortic aneurysm: Ascending, thoracic, abdominal). 7005 Arteriosclerotic heart disease (coronary artery disease). Note: If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other nonarteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms. 7006 Myocardial infarction: During and for three months following myocardial infarction, confirmed by laboratory tests ...................................................... Thereafter, use the General Rating Formula. 7007 Hypertensive heart disease. 7008 Hyperthyroid heart disease: Rate under the appropriate cardiovascular diagnostic code, depending on particular findings. For DCs 7009, 7010, 7011, and 7015, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture. 7009 Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation: For one month following hospital discharge for implantation or re-implantation ......................................................................... Thereafter, use the General Rating Formula. Note (1): Bradycardia (bradyarrhythmia) refers to conduction abnormalities that produce a heart rate less than 60 beats/ min. There are five general classes of bradyarrhythmias: —Sinus bradycardia, including sinoatrial block; —Atrioventricular (AV) junctional (nodal) escape rhythm; —AV heart block (second or third degree) or AV dissociation; —Atrial fibrillation or flutter with a slow ventricular response; and —Idioventricular escape rhythm. Note (2): Asymptomatic bradycardia (bradyarrhythmia) is a medical finding which does not require medical intervention, thus, it is not entitled to service connection. 7010 Supraventricular tachycardia: Confirmed by ECG, with five or more treatment interventions per year ...................................................................................... Confirmed by ECG, with one to four treatment interventions per year ....................................................................................... Note (1): Examples of supraventricular tachycardia include, but are not limited to, atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Note (2): For the purposes of this diagnostic code, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. 7011 Ventricular arrhythmias (sustained): For an indefinite period from the date of hospital admission for initial medical therapy for a sustained ventricular arrhythmia; or for an indefinite period from the date of hospital admission for ventricular aneurysmectomy; or with an automatic implantable cardioverter-defibrillator (AICD) in place ............................................................................................................... Thereafter, use the General Rating Formula. Note: Six months following discharge from inpatient hospitalization for sustained ventricular arrhythmia or for ventricular aneurysmectomy, disability evaluation shall be conducted by mandatory VA examination using the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7015 Atrioventricular block: Benign (First-Degree and Second-Degree, Type I): Evaluate under the General Rating Formula. Non-Benign (Second-Degree, Type II and Third-Degree): Evaluate under DC 7018 (implantable cardiac pacemakers). 7016 Heart valve replacement (prosthesis): For an indefinite period following date of hospital admission for valve replacement .................................................................. Thereafter, use the General Rating Formula. VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 PO 00000 Frm 00009 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 100 60 30 10 100 100 100 30 10 100 100 37603 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules Rating Note: Six months following discharge from inpatient hospitalization, disability evaluation shall be conducted by mandatory VA examination using the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7017 Coronary bypass surgery:. For three months following hospital admission for surgery ......................................................................................................... Thereafter, use the General Rating Formula. 7018 Implantable cardiac pacemakers: For one month following hospital discharge for implantation or re-implantation ......................................................................... Thereafter: Evaluate as supraventricular tachycardia (DC 7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC 7015). Minimum ................................................................................................................................................................................ Note (1): Evaluate automatic implantable cardioverter-defibrillators (AICDs) under DC 7011. 7019 Cardiac transplantation: For a minimum of one year from the date of hospital admission for cardiac transplantation ..................................................... Thereafter: Evaluate under the General Rating Formula. Minimum ................................................................................................................................................................................ Note: One year following discharge from inpatient hospitalization, determine the appropriate disability rating by mandatory VA examination. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination. 7020 Cardiomyopathy. 100 100 10 100 30 jspears on DSK3GMQ082PROD with PROPOSALS Diseases of the Arteries and Veins 7110 Aortic aneurysm: Ascending, thoracic, or abdominal: If 5 centimeters (cm) or larger in diameter; or, if symptomatic (e.g., precludes exertion) and a physician recommends surgical correction, for the period beginning on the date a physician recommends surgical correction and continuing for six months following hospital discharge for surgical correction (including any type of graft insertion) ......................................... If less than 5 cm in diameter; or, surgical correction not recommended .................................................................................... Evaluate non-cardiovascular residuals of surgical correction according to organ systems affected. Note: Six months following discharge from inpatient hospitalization for surgery, disability evaluation shall be determined by mandatory VA examination of cardiovascular residuals using the General Rating Formula for Diseases of the Heart. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. 7111 Aneurysm, any large artery: If symptomatic; or, for the period beginning on the date a physician recommends surgical correction and continuing for six months following discharge from inpatient hospital admission for surgical correction ............................................................ Following surgery: Evaluate under DC 7114 (peripheral arterial disease). Note: Six months following discharge from inpatient hospitalization for surgery, determine the appropriate disability rating 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. . * * * * * * 7113 Arteriovenous fistula, traumatic: With high-output heart failure ....................................................................................................................................................... Without heart failure but with enlarged heart, wide pulse pressure, and tachycardia ................................................................. Without cardiac involvement but with chronic edema, stasis dermatitis, and either ulceration or cellulitis: Lower extremity ..................................................................................................................................................................... Upper extremity ..................................................................................................................................................................... Without cardiac involvement but with chronic edema or stasis dermatitis: Lower extremity ..................................................................................................................................................................... Upper extremity ..................................................................................................................................................................... 7114 Peripheral arterial disease: At least one of the following: Ankle/brachial index less than or equal to 0.39; ankle pressure less than 50 mm Hg; toe pressure less than 30 mm Hg; or transcutaneous oxygen tension less than 30 mm Hg ............................................................... At least one of the following: Ankle/brachial index of 0.40–0.53; ankle pressure of 50–65 mm Hg; toe pressure of 30–39 mm Hg; or transcutaneous oxygen tension of 30–39 mm Hg ................................................................................................. At least one of the following: Ankle/brachial index of 0.54–0.66; ankle pressure of 66–83 mm Hg; toe pressure of 40–49 mm Hg; or transcutaneous oxygen tension of 40–49 mm Hg ................................................................................................. At least one of the following: Ankle/brachial index of 0.67–0.79; ankle pressure of 84–99 mm Hg; toe pressure of 50–59 mm Hg; or transcutaneous oxygen tension of 50–59 mm Hg ................................................................................................. Note (1): The ankle/brachial index (ABI) is the ratio of the systolic blood pressure at the ankle divided by the simultaneous brachial artery systolic blood pressure. For the purposes of this diagnostic code, normal ABI will be greater than or equal to 0.80. The ankle pressure (AP) is the systolic blood pressure measured at the ankle. Normal AP is greater than or equal to 100 mm Hg. The toe pressure (TP) is the systolic blood pressure measured at the great toe. Normal TP is greater than or equal to 60 mm Hg. Transcutaneous oxygen tension (TcPO2) is measured at the first intercostal space on the foot. Normal TcPO2 is greater than or equal to 60 mm Hg. All measurements must be determined by objective testing. Note (2): Select the highest impairment value of ABI, AP, TP, or TcPO2 for evaluation. Note (3): Evaluate residuals of aortic and large arterial bypass surgery or arterial graft as peripheral arterial disease. Note (4): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. 7115 Thrombo-angiitis obliterans (Buerger’s Disease): VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 PO 00000 Frm 00010 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 100 0 100 * 100 60 50 40 30 20 100 60 40 20 37604 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules Rating jspears on DSK3GMQ082PROD with PROPOSALS Lower extremity: Rate under DC 7114. Upper extremity: Deep ischemic ulcers and necrosis of the fingers with persistent coldness of the extremity, trophic changes with pains in the hand during physical activity, and diminished upper extremity pulses ................................................................... Persistent coldness of the extremity, trophic changes with pains in the hands during physical activity, and diminished upper extremity pulses ...................................................................................................................................................... Trophic changes with numbness and paresthesia at the tips of the fingers, and diminished upper extremity pulses ........ Diminished upper extremity pulses ....................................................................................................................................... Note (1): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable. Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities). 7117 Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon or secondary Raynaud’s). With two or more digital ulcers plus auto-amputation of one or more digits and history of characteristic attacks ..................... With two or more digital ulcers and history of characteristic attacks ........................................................................................... Characteristic attacks occurring at least daily .............................................................................................................................. Characteristic attacks occurring four to six times a week ............................................................................................................ Characteristic attacks occurring one to three times a week ........................................................................................................ Note (1): For purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for Raynaud’s syndrome as a whole, regardless of the number of extremities involved or whether the nose and ears are involved. Note (2): This section is for evaluating Raynaud’s syndrome (secondary Raynaud’s phenomenon or secondary Raynaud’s). For evaluation of Raynaud’s disease (primary Raynaud’s phenomenon, or primary Raynaud’s), see DC 7124. . * * * * * * 7120 Varicose veins: Evaluate under diagnostic code 7121. . * * * * * * 7122 Cold injury residuals: With the following in affected parts: Arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome ................................................................................................................................................................ Arthralgia or other pain, numbness, or cold sensitivity plus one of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome ................................................................................................................................................................ Arthralgia or other pain, numbness, or cold sensitivity ......................................................................................................... Note (1): Separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, under other diagnostic codes. Separately evaluate other disabilities diagnosed as the residual effects of cold injury, such as Raynaud’s syndrome (which is otherwise known as secondary Raynaud’s phenomenon), muscle atrophy, etc., unless they are used to support an evaluation under diagnostic code 7122. Note (2): Evaluate each affected part (e.g., hand, foot, ear, nose) separately and combine the ratings in accordance with §§ 4.25 and 4.26. . * * * * * * 7124 Raynaud’s disease (also known as primary Raynaud’s phenomenon or primary Raynaud’s):. Characteristic attacks associated with trophic change(s), such as tight, shiny skin ................................................................... Characteristic attacks without trophic change(s) .......................................................................................................................... Note (1): For purposes of this section, characteristic attacks consist of intermittent and episodic color changes of the digits of one or more extremities, lasting minutes or longer, with occasional pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved. Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities). Note (3): This section is for evaluating Raynaud’s disease (primary Raynaud’s phenomenon or primary Raynaud’s). For evaluation of Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon, or secondary Raynaud’s), see DC 7117. (Authority: 38 U.S.C. 1155) 4. Amend Appendix A to Part 4 by: a. Adding an entry for the General Rating Formula for Diseases of the Heart to 4.104; ■ ■ VerDate Sep<11>2014 17:45 Jul 31, 2019 b. Revising the entries for diagnostic codes 7000 through 7008; ■ c. Adding, in numerical order, an entry for diagnostic code 7009; ■ d. Revising the entries for diagnostic codes 7010, 7011, 7015 through 7020, ■ Jkt 247001 PO 00000 Frm 00011 Fmt 4702 Sfmt 4702 100 60 40 20 100 60 40 20 10 * * 30 20 10 * 10 0 7110 through 7111, 7113 through 7115, 7117, and 7121 through 7122; and ■ e. Adding, in numerical order, an entry for diagnostic code 7124. The revisions and additions read as follows: E:\FR\FM\01AUP1.SGM 01AUP1 37605 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946 Sec. Diagnostic code No. * 4.104 .............. * ........................ 7000 7006 7007 7008 7009 7010 7011 * * * * * General Rating Formula for Diseases of the Heart [Effective date of final rule]. Evaluation July 6, 1950; evaluation September 22, 1928, evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation January 12, 1998; criterion [Effective date of final rule]. Criterion September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation September 9, 1975; evaluation September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation January 12, 1998; criterion [Effective date of final rule] Evaluation September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. Evaluation January 12, 1998; evaluation [Effective date of final rule]. Added [Effective date of final rule]. Evaluation January 12, 1998; title, criterion [Effective date of final rule]. Evaluation January 12, 1998; note, criterion [Effective date of final rule]. * * 7015 7016 7017 7018 7019 7020 * * * * Evaluation September 9, 1975; criterion January 12, 1998; criterion [Effective date of final rule]. Added September 9, 1975; criterion January 12, 1998; note, criterion [Effective date of final rule]. Added September 22, 1978; evaluation January 12, 1998; criterion [Effective date of final rule]. Added January 12, 1998; criterion [Effective date of final rule]. Added January 12, 1998; note, criterion [Effective date of final rule]. Added January 12, 1998; criterion [Effective date of final rule]. * * 7110 7111 * * * * * Evaluation September 9, 1975; evaluation January 12, 1998; title, criterion, note [Effective date of final rule]. Criterion September 9, 1975; evaluation January 12, 1998; note, criterion [Effective date of final rule]. * * 7113 7114 7115 * * * * * Evaluation January 12, 1998; criterion [Effective date of final rule]. Added June 9, 1952; evaluation January 12, 1998; title, criterion, note [Effective date of final rule]. Added June 9, 1952; evaluation January 12, 1998; note, criterion, evaluation [Effective date of final rule]. * * 7117 * * * * Added June 9, 1952; evaluation January 12, 1998; title, note [Effective date of final rule]. * * 7121 * * * * * Criterion July 6, 1950; evaluation March 10, 1976; evaluation January 12, 1998; criterion [Effective date of final rule]. Last sentence of Note following July 6, 1950; evaluation January 12, 1998; criterion August 13, 1998; criterion [Effective date of final rule]. 7001 7002 7003 7004 7005 7122 * * * * 7124 * Added [Effective date of final rule]. * * * * * * * * * * * 5. Amend Appendix B to Part 4, § 4.104 by: ■ a. Adding, in numerical order, an entry for diagnostic code 7009; ■ b. Revising diagnostic codes 7010, 7110, 7114, and 7117; and ■ c. Adding, in numerical order, an entry for diagnostic code 7124. The revisions and additions read as follows: ■ APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES jspears on DSK3GMQ082PROD with PROPOSALS Diagnostic code No. * * * * * * * * * The Cardiovascular System—Diseases of the Heart * 7009 ................ VerDate Sep<11>2014 * * * * Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation. 17:45 Jul 31, 2019 Jkt 247001 PO 00000 Frm 00012 Fmt 4702 Sfmt 4702 E:\FR\FM\01AUP1.SGM 01AUP1 37606 Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES—Continued Diagnostic code No. * 7010 ................ * Supraventricular tachycardia. * 7110 ................ * * * * * * Aortic aneurysm: ascending, thoracic, abdominal. * * * * * 7114 ................ * Peripheral arterial disease. * * * * * 7117 ................ * * * Raynaud’s syndrome (secondary Raynaud’s phenomenon). * * * * 7124 ................ * * * * Raynaud’s disease (primary Raynaud’s phenomenon, primary Raynaud’s). * * * * * * * * * 6. Revise Appendix C to Part 4, § 4.104 by: ■ a. Revising the entry for Aneurysm: Aortic: ascending, thoracic, abdominal; ■ b. Adding, in alphabetical order, under the entry for Bones an entry for Bradycardia (Bradyarrhthmia), symptomatic, requiring permanent pacemaker implantation; ■ * * c. Revising the entries for Hypertension (isolated systolic, diastolic, or combined systolic and diastolic hypertension) and Peripheral arterial disease; ■ d. Adding, in alphabetical order, under the entry for Pyelonephritis, chronic, an entry for Raynaud’s disease ■ (primary Raynaud’s phenomenon, primary Raynaud’s); and e. Revising the entries for Raynaud’s syndrome (Raynaud’s phenomenon, secondary Raynaud’s) and Supraventricular tachycardia. ■ The revisions and additions read as follows: APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES jspears on DSK3GMQ082PROD with PROPOSALS Diagnostic code No. * * * * * * Aneurysm: Aortic: ascending, thoracic, abdominal ........................................................................................................................................ Large artery .................................................................................................................................................................................. Small artery .................................................................................................................................................................................. * * * * * * * Arrhythmia: Ventricular ..................................................................................................................................................................................... * * * * * * * Bones: Bradycardia ................................................................................................................................................................................... (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation. * * * * * * * Peripheral arterial disease ................................................................................................................................................................... * * * * * * * Raynaud’s disease (primary Raynaud’s) ............................................................................................................................................. Raynaud’s syndrome (Raynaud’s phenomenon, secondary Raynaud’s) ........................................................................................... * * * * * * * Supraventricular tachycardia ............................................................................................................................................................... * * VerDate Sep<11>2014 * 18:24 Jul 31, 2019 * Jkt 247001 PO 00000 * Frm 00013 Fmt 4702 * Sfmt 4702 E:\FR\FM\01AUP1.SGM * 01AUP1 7110 7111 7118 7011 7009 7114 7124 7117 7010 * Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / Proposed Rules [FR Doc. 2019–15904 Filed 7–31–19; 8:45 am] BILLING CODE 8320–01–P ENVIRONMENTAL PROTECTION AGENCY 40 CFR Part 52 [EPA–R03–OAR–2019–0277; FRL–9997–70– Region 3 ] Approval and Promulgation of Air Quality Implementation Plans; Virginia; Source-Specific Reasonably Available Control Technology Determinations for 2008 Ozone National Ambient Air Quality Standard Environmental Protection Agency (EPA). ACTION: Proposed rule. AGENCY: The Environmental Protection Agency (EPA) is proposing to approve three state implementation plan (SIP) revisions submitted by the Commonwealth of Virginia. These revisions address reasonably available control technology (RACT) requirements under the 2008 ozone national ambient air quality standard (NAAQS) for three facilities in Northern Virginia through source-specific determinations. This action is being taken under the Clean Air Act (CAA). DATES: Written comments must be received on or before September 3, 2019. SUMMARY: Submit your comments, identified by Docket ID No. EPA–R03– OAR–2019–0277 at https:// www.regulations.gov, or via email to spielberger.susan@epa.gov. For comments submitted at Regulations.gov, follow the online instructions for submitting comments. Once submitted, comments cannot be edited or removed from Regulations.gov. For either manner of submission, EPA may publish any comment received to its public docket. Do not submit electronically any information you consider to be confidential business information (CBI) or other information whose disclosure is restricted by statute. Multimedia submissions (audio, video, etc.) must be accompanied by a written comment. The written comment is considered the official comment and should include discussion of all points you wish to make. EPA will generally not consider comments or comment contents located outside of the primary submission (i.e. on the web, cloud, or other file sharing system). For additional submission methods, please contact the person identified in the FOR FURTHER INFORMATION CONTACT section. For the jspears on DSK3GMQ082PROD with PROPOSALS ADDRESSES: VerDate Sep<11>2014 17:45 Jul 31, 2019 Jkt 247001 full EPA public comment policy, information about CBI or multimedia submissions, and general guidance on making effective comments, please visit http://www2.epa.gov/dockets/ commenting-epa-dockets. FOR FURTHER INFORMATION CONTACT: Emlyn Ve´lez-Rosa, Planning & Implementation Branch (3AD30), Air & Radiation Division, U.S. Environmental Protection Agency, Region III, 1650 Arch Street, Philadelphia, Pennsylvania 19103. The telephone number is (215) 814–2038. Ms. Ve´lez-Rosa can also be reached via electronic mail at velezrosa.emlyn@epa.gov. SUPPLEMENTARY INFORMATION: On February 1, 14, and 15, 2019, the Virginia Department of Environmental Quality (VADEQ) submitted three separate revisions to its SIP addressing RACT under the 2008 ozone NAAQS for three facilities in Northern Virginia. The SIP revisions consist of source-specific RACT determinations for each facility. I. Background RACT is an important strategy for reducing oxides of nitrogen (NOX) and volatile organic compounds (VOC) emissions from major stationary sources within areas not meeting the ozone NAAQS. Since the 1970’s, EPA has consistently defined ‘‘RACT’’ as the lowest emission limit that a particular source is capable of meeting by the application of the control technology that is reasonably available considering technological and economic feasibility.1 Section 172(c)(1) of the CAA provides that SIPs for nonattainment areas must include reasonably available control measures (RACM) for demonstrating attainment of all NAAQS, including emissions reductions from existing sources through adoption of RACT. In addition, Section 182 of the CAA sets forth additional RACT requirements for the ozone NAAQS for moderate, serious or severe nonattainment areas. Section 182 requires states to implement RACT for VOC sources in the area covered by a control technique guideline (CTG) document issued by EPA, all other major stationary sources of VOCs that are located in the area, and major stationary sources of NOX. The section 182 RACT requirements are usually referred to as CTG RACT, major nonCTG VOC RACT, and major NOX RACT. Further, section 184(b)(1)(B) of the CAA requires states to implement RACT 1 See December 9, 1976 memorandum from Roger Strelow, Assistant Administrator for Air and Waste Management, to Regional Administrators, ‘‘Guidance for Determining Acceptability of SIP Regulations in Non-Attainment Areas,’’ and also 44 FR 53762; September 17, 1979. PO 00000 Frm 00014 Fmt 4702 Sfmt 4702 37607 in any areas located within ozone transport regions established pursuant to section 184. This requirement is referred to as OTR RACT. A single ozone transport region (the OTR) has been established under section 184(a), which comprises of 12 States, including the District of Columbia, the Northern portion of Virginia, and portions of Maryland as part of the Consolidated Metropolitan Statistical Area (CMSA). The Northern portion of Virginia (hereafter Northern Virginia) consists of the Arlington County, Fairfax County, Loudoun County, Prince William County, Alexandria City, Fairfax City, Falls Church City, Manassas City, Manassas Park City, and Strafford County. The three facilities which are the subject of this Notice of Proposed Rulemaking are located in Northern Virginia, and thus subject to OTR RACT. On March 12, 2008, EPA revised the 8-hour ozone standards, by lowering the standard to 0.075 parts per million (ppm) averaged over an 8-hour period (2008 ozone NAAQS). See 73 FR 16436. On May 21, 2012, EPA designated the Washington, DC-MD-VA area as a marginal ozone nonattainment area for the 2008 ozone NAAQS. The Washington, DC-MD-VA marginal ozone nonattainment area includes all cities and counties in the Northern portion of Virginia that are part of the OTR, with exception of the Strafford County. See 77 FR 30088 and 40 CFR 81.347. On March 6, 2015, EPA issued its final rule for implementing the 2008 ozone NAAQS (‘‘the 2008 Ozone SIP Requirements Rule’’).2 In addressing RACT requirements, the 2008 Ozone SIP Requirements Rule is consistent with existing policy and EPA’s previous ozone implementation rule. For 2008 ozone NAAQS, only Northern Virginia is subject to RACT due to its location in the OTR, as no moderate nonattainment areas were designated by EPA under the standard. II. Summary of SIP Revision and EPA Analysis Virginia’s February 1, 14, and 15, 2019 SIP revisions address NOX and/or VOC RACT for the following facilities: Virginia Electric and Power Company— Possum Point Power Station, Covanta Alexandria/Arlington, Inc., and Covanta Fairfax, Inc. VADEQ is adopting as part of these SIP revisions additional NOX control requirements for these three facilities to meet RACT under the 2008 ozone NAAQS, all of which are implemented via Federally enforceable permits issued by VADEQ. These RACT permits, as listed on Table 1, have been 2 80 E:\FR\FM\01AUP1.SGM FR 12264 (March 6, 2015). 01AUP1

Agencies

[Federal Register Volume 84, Number 148 (Thursday, August 1, 2019)]
[Proposed Rules]
[Pages 37594-37607]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-15904]


========================================================================
Proposed Rules
                                                Federal Register
________________________________________________________________________

This section of the FEDERAL REGISTER contains notices to the public of 
the proposed issuance of rules and regulations. The purpose of these 
notices is to give interested persons an opportunity to participate in 
the rule making prior to the adoption of the final rules.

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Federal Register / Vol. 84, No. 148 / Thursday, August 1, 2019 / 
Proposed Rules

[[Page 37594]]



DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AQ67


Schedule for Rating Disabilities: The Cardiovascular System

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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

SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
section of the VA Schedule for Rating Disabilities (VASRD or Rating 
Schedule) that addresses the cardiovascular system. The proposed 
changes incorporate medical advances that have occurred since the last 
review, update medical terminology, and clarify evaluation criteria 
where necessary.
    Where changes to the scientific and/or medical nature of a given 
condition have been proposed, VA has cited the published, publicly-
available sources for these changes. The proposed changes are not a 
reflection of any particular expert's comments or recommendations, but 
were based on published, peer-reviewed materials. Materials from the 
public forum, held in 2011, are available for public inspection at the 
Office of Regulation Policy and Management (see the ADDRESSES section 
of this rulemaking), and other deliberative materials are cited herein.

DATES: VA must receive comments on or before September 30, 2019.

ADDRESSES: Submit written comments through www.Regulations.gov; by mail 
or hand-delivery to the Director, Office of Regulations Policy and 
Management (00REG), Department of Veterans Affairs, 810 Vermont Ave. 
NW, Room 1064, Washington, DC 20420; or by fax to (202) 273-9026. 
Comments should indicate that they are submitted in response to RIN 
2900-AQ67--Schedule for Rating Disabilities: The Cardiovascular System. 
Copies of comments received will be available for public inspection in 
the Office of Regulation Policy and Management, Room 1068, between the 
hours of 8:00 a.m. and 4:30 p.m. Monday through Friday (except 
holidays). Please call (202) 461-4902 for an appointment. (This is not 
a toll-free number.) In addition, during the comment period, please 
view comments online through the Federal Docket Management System 
(FDMS) at www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, MD, Medical Officer, 
Regulations Staff (211D), 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: As part of VA's ongoing revision of the VA 
Schedule for Rating Disabilities (VASRD or Rating Schedule), VA 
proposes changes to 38 Code of Federal Regulations (CFR) Sec. Sec.  
4.100 and 4.104, which pertain to the cardiovascular system. The 
proposed changes will: (1) Update the medical terminology of certain 
conditions; (2) add medical conditions not currently in the Rating 
Schedule; (3) refine evaluation criteria based on medical advances that 
have occurred since the last revision; and (4) incorporate current 
understanding of functional changes associated with, or resulting from, 
cardiovascular disease or injury (pathophysiology).

I. Sec.  4.100 Application of the Evaluation Criteria for Diagnostic 
Codes 7000-7007, 7011, and 7015-7020

    In almost all cases, the current Sec.  4.100 specifically requires 
testing for metabolic equivalent of tasks when evaluating heart 
diseases. Medical literature more commonly refers to metabolic 
equivalent of tasks as simply metabolic equivalents, or METs. 
Exceptions to METs testing for rating purposes occur when medically 
contraindicated, when the left ejection fraction is 50 percent or less, 
with chronic congestive heart failure, when more than one episode of 
heart failure occurred in the past year, or when VA may assign a 100 
percent evaluation on another basis. 38 CFR 4.100(b). As explained 
below, this proposed rule will eliminate considering ejection fractions 
or congestive heart failure when evaluating cardiovascular disability. 
Therefore, for clarity and simplicity, VA proposes to delete paragraphs 
(b)(2), (b)(3), and (c), and redesignate paragraphs (b)(4) as (b)(2) of 
this section.

II. General Rating Formula for Diseases of the Heart

    VA proposes to revise Sec.  4.104 to include a new General Rating 
Formula for Diseases of the Heart (General Formula). VA will use this 
new General Formula to clarify and standardize the evaluation of many 
cardiovascular diseases. As discussed below, it will provide a more 
timely, efficient, and accurate method of evaluating these diseases.
    The proposed General Formula reflects current concepts in 
cardiovascular disability. The Institute of Medicine (now called the 
National Academy of Medicine) stated, ``It is important for the Rating 
Schedule to be as up-to-date as possible in current medical approaches 
and terminology to serve veterans with disabilities most effectively. 
This ensures that the criteria in the Rating Schedule are based on 
concepts and terms used by medical personnel who provide medical 
evidence, and that evolving understanding of, or recognition of, new 
disabling conditions are reflected.'' Institute of Medicine, Committee 
on Medical Evaluation of Veterans for Disability Compensation, ``A 21st 
Century System for Evaluating Veterans for Disability Benefits,'' 5 
(Michael McGeary et al. eds. 2007).
    As in the current Rating Schedule, the proposed General Formula is 
based primarily on Metabolic equivalents (METs), which objectively and 
accurately measure the cardiac work capacity and which clinicians 
routinely obtain for all patients with heart disease. The examiner 
eliminates spurious results by considering various parameters, such as 
age and expected maximal heart rate achieved when factors other than 
heart disease are present. In situations where a person is unable to 
walk, or walk well, the patient may test on a bicycle or with the use 
of certain medications.
    VA notes that a number of diagnostic codes (DCs) within current 
Sec.  4.104, including DCs 7000-7007, 7011, 7015-7017, and 7019-7020, 
already utilize METs in evaluating their respective cardiovascular 
conditions. Specifically, each level of evaluation (10, 30, 60, and 100 
percent) outlines a range of METs, as well as a list of associated 
symptoms,

[[Page 37595]]

within which an individual must fall to warrant that particular 
evaluation. Additionally, VA may assign higher ratings (e.g., 60 and 
100 percent) for congestive heart failure or left ventricular 
dysfunction as demonstrated by ejection fraction. Finally, VA may also 
assign a 30 percent evaluation with evidence on electrocardiogram, 
echocardiogram, or X-ray of cardiac hypertrophy or dilatation. Lastly, 
VA may assign a 10 percent evaluation if the condition requires 
continuous medication.
    VA proposes to rely on METs as the primary indicator of cardiac 
ability and eliminate other indicators currently found in the VASRD, 
such as ejection fractions or the number of any episodes of acute 
congestive heart failure in the past year. These latter indicators are 
less reliable in assessing cardiac function. Congestive heart failure 
may be due to poor conditioning, salt consumption, poor medication 
compliance, body weight, additional disease burden, or a variety of 
other factors not associated with the underlying cardiovascular disease 
itself. See Joshi, Mohanan et al., ``Factors precipitating Congestive 
Heart Failure--role of patient non-compliance,'' 47 J. Assoc. 
Physicians India 294-95 (Mar. 1999) (emphasizing ``the importance of 
patient non-compliance with prescribed therapy as a leading 
precipitating factor for congestive heart failure . . . which can be 
prevented by appropriate cost saving strategies aimed to improve 
patient compliance.'') Similarly, ejection fractions are unreliable 
because factors unrelated to cardiovascular disability, such as fluid 
intake, salt ingestion, and exercise, may influence them. See 
Ramachandran S. Vasan, MD, et al., ``Congestive heart failure in 
subjects with normal versus reduced left ventricular ejection 
fraction,'' 33(7) 1948-55 (1999). Conversely, METs form the most 
reliable basis of cardiac capability, even after heart disease weakens 
the ability of the heart to function at full capacity. See Charles K. 
Morris, MD, et al., ``Nomogram based on metabolic equivalents and age 
for assessing aerobic exercise capacity in men,'' 22(1) J. Am. College 
of Cardiology, 175-82 (1993).
    The heart is often described as the pump of the human body, and, as 
such, requires power to function. Power is the rate that energy is 
consumed to work. Various types of energy employ different measures of 
rate (power), such as kW (kilowatts) for electrical energy; Btu/hr 
(British Thermal Units per hour) for heat energy; hp (horsepower) for 
mechanical energy; and, for our purposes, METs (metabolic equivalent of 
tasks) for cardiac energy.
    In evaluating cardiovascular disabilities, METs refer to the 
intensity of activities. For example, an activity with a MET of 2, such 
as walking at a slow pace (e.g., 2 mph), would require twice the energy 
that an average person consumes at rest (e.g., sitting quietly), which 
requires 1 MET. See ``The Compendium of Physical Activities,'' Arnold 
School of Public Health- Prevention Research Center, available at 
http://prevention.sph.sc.edu/tools/compendium.htm. VA does not propose 
any alteration to the ranges of METs provided in the current VASRD, nor 
will it eliminate the references to dyspnea, fatigue, angina, 
dizziness, or syncope. Instead, VA proposes to state that these 
symptoms may represent heart failure. VA also proposes to use the more 
common term ``breathlessness'' for the more obscure term ``dyspnea,'' 
and to expand the list of common findings associated with congestive 
heart failure to include arrhythmia and palpitations. See ``Congestive 
Heart Failure,'' Johns Hopkins Medicine, available at http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/congestive_heart_failure.html (last visited Apr. 30, 2014). 
Although VA proposes to eliminate the use of congestive heart failure 
and ejection fraction as indicators for evaluation, it will retain the 
non-MET criteria provided in the current 10 and 30 percent evaluations 
because these criteria remain valid. Id.
    VA proposes to apply the General Formula to those DCs within Sec.  
4.104 that instruct rating personnel to consider METs (among other 
indicators). The DCs using METS as the primary rating criteria include 
7003, 7004, 7005, 7007, 7015, and 7020. On the other hand, DCs 7000, 
7001, 7002, 7006, 7011, 7016, 7017, and 7019 have 100 percent 
evaluation criteria unique to each particular DC. VA does not intend to 
disturb the 100 percent evaluations currently prescribed in these DCs; 
rather, it proposes to apply the General Formula following the total 
evaluations. To ensure clarity and consistency in applying the General 
Formula, VA intends to instruct personnel to rate disabilities under 
Sec.  4.104 using the General Formula unless otherwise directed.
    With respect to DCs 7010, 7011, 7015, and newly proposed DC 7009, 
regardless of the DC, the resulting impairment and disability are 
essentially indistinguishable. To offer more than one evaluation under 
those circumstances would be contrary to Sec.  4.14 (pyramiding). VA 
will provide an instruction immediately before DC 7009 which states 
``For DCs 7009, 7010, 7011, and 7015, a single evaluation will be 
assigned under the diagnostic code which reflects the predominant 
disability picture.''
    The discussion that follows explains the changes to each DC 
affected by the General Formula, and explains additional changes to 
these DCs (e.g., title changes, note changes, etc.).

A. Diagnostic Code 7000

    DC 7000 currently provides a 100 percent evaluation during active 
infection with valvular heart damage and for three months following the 
cessation of treatment for the active infection. VA proposes no change 
to this provision. Following the three months, VA will evaluate 
residual cardiac disability using the General Rating Formula for 
Diseases of the Heart.

B. Diagnostic Codes 7001 and 7002

    The current DCs 7001 and 7002 (endocarditis and pericarditis, 
respectively) provide a 100 percent evaluation during active infection 
with cardiac involvement, and for three months following the cessation 
of treatment for the active infection. VA proposes no change to these 
provisions. Following the three months, VA will evaluate any residual 
cardiac disability using the General Rating Formula for Diseases of the 
Heart.

C. Diagnostic Codes 7003, 7004, 7005, 7007, and 7020

    VA proposes to evaluate disability due to these conditions 
(pericardial adhesions, syphilitic heart disease, arteriosclerotic 
heart disease, hypertensive heart disease, and cardiomyopathy, 
respectively) using the General Rating Formula.

D. Diagnostic Code 7006

    The current DC 7006 provides a 100 percent evaluation during, and 
for three months following, a documented myocardial infarction. VA 
proposes no change to this provision. Following the three months, VA 
proposes to evaluate residual disability under the General Rating 
Formula.

E. Diagnostic Code 7011

    VA does not propose any change to the current DC 7011 provisions 
establishing a 100 percent evaluation for sustained ventricular 
arrhythmia or ventricular aneurysmectomy from the date of hospital 
admission. However, VA proposes to apply the General Rating Formula 
following the mandatory examination provided six

[[Page 37596]]

months after discharge to determine residual disability rating.
    Additionally, DC 7011 currently includes a note indicating VA will 
conduct a mandatory examination six months following discharge and 
therapy for a sustained arrhythmia or ventricular aneurysmectomy. The 
intent is to monitor the extent of disability following inpatient 
hospitalization for surgical intervention and therapy. VA proposes to 
add the phrase ``discharge from inpatient hospitalization'' to the note 
to clarify that the timing for mandatory re-examination is based upon 
discharge from inpatient hospitalization, rather than discharge from an 
outpatient treatment program. This proposed clarification does not 
represent a change in VA policy.

F. Diagnostic Code 7015

    VA proposes to update this DC to reflect modern treatment and to 
more accurately evaluate impairment by separating the various forms of 
atrioventricular block into two specific categories: benign and non-
benign i.e., the latter requiring immediate treatment. ``Types of Heart 
Block,'' National Heart, Lung, and Blood Institute (July 9, 2012), 
http://www.nhlbi.nih.gov/health/health-topics/topics/hb/types.html 
(last visited April 22, 2014).
    The benign, or less severe, category of atrioventricular block 
includes first-degree heart block (first-degree) and second-degree 
heart block, type I (second-degree type I). First-degree (seen as a 
delayed or prolonged P-R interval on electrocardiogram), involves the 
slowing of the heart's electrical signals, often without any symptoms 
and, therefore, without requiring any treatment. Id. In second-degree 
type I, the electrical signals are slowed more and more with each 
heartbeat until the heart eventually skips a beat. An occasional, 
transitory, and mild symptom may be associated with second-degree type 
I heart block. Id. No specific therapy is required for second-degree 
type I heart block. Ali A. Sovari, ``Second-Degree Atrioventricular 
Block Treatment & Management,'' Medscape--Reference (May 9, 2013) 
http://emedicine.medscape.com/article/161919-treatment (last visited 
April 22, 2014). VA proposes to evaluate the benign form of 
atrioventricular block under the General Rating Formula.
    The non-benign, or more severe, category of atrioventricular block 
include second-degree heart block, type II (second-degree type II) and 
third-degree heart block (third-degree). In second-degree type II, some 
of the heart's electrical signals do not reach the ventricles, which 
may result in symptoms of dizziness, light-headedness, or syncope. In 
addition, individuals with second degree may experience chest pain, 
hypoperfusion, and hypotension. Ali A. Sovari, ``Second-Degree 
Atrioventricular Block Clinical Presentation,'' Medscape--Reference 
(May 9, 2013), http://emedicine.medscape.com/article/161919-clinical 
(last visited April 22, 2014). Second-degree type II presents a much 
more immediate medical risk as it may progress rapidly to complete 
heart block. As a result, affected individuals may receive permanent 
pacemakers. Third-degree heart block occurs when none of the heart's 
electrical signals reach the ventricles, which often requires emergency 
treatment because it can result in cardiac arrest or death. Like 
second-degree type II, this severe type of atrioventricular block 
requires pacemaker implantation. Based on this treatment, VA proposes 
to evaluate the non-benign categories of atrioventricular block 
(second-degree, type II and third-degree) under DC 7018, implantable 
cardiac pacemakers. Given the proposed amendments to DC 7015, the note 
that currently follows is no longer relevant. The VA proposes to remove 
the note following DC 7015.

G. Diagnostic Code 7016

    VA does not propose any change to the current DC 7016 provisions 
establishing a 100 percent evaluation for heart valve replacement 
(prosthesis). However, VA proposes to apply the General Rating Formula 
following the mandatory examination provided six months after discharge 
to determine residual disability rating.
    Additionally, DC 7016 currently includes a note indicating VA will 
examine this disability six months following discharge. The intent is 
to monitor the extent of the disability following hospitalization for 
surgery. Similar to DC 7011, VA proposes to link the evaluation with 
discharge from inpatient hospitalization for this particular 
dysrhythmia. This clarification does not represent a change in VA 
policy.

H. Diagnostic Code 7017

    DC 7017 currently provides a 100 percent evaluation for three 
months following hospital admission for coronary bypass surgery. VA 
proposes no change to this provision. Following the three months, VA 
proposes to evaluate any residual cardiac disability under the General 
Rating Formula.

I. Diagnostic Code 7019

    Currently, DC 7019 provides a 100 percent evaluation from the date 
of hospital admission for cardiac transplantation, continuing for ``an 
indefinite period.'' The current note also states, however, that one 
year following discharge, VA should examine the individual to determine 
the appropriate disability rating, assigning a minimum evaluation of 30 
percent. VA applies 38 CFR 3.105(e) to any change in evaluation. VA 
proposes no changes to this process or the minimum evaluation of 30 
percent. However, VA proposes to eliminate the phrase ``for an 
indefinite period'' and replace it with ``for a minimum of one year.'' 
This will eliminate any confusion as to whether the Veteran's 100 
percent evaluation may be subject to reduction during the year 
following transplantation. Practically, a Veteran will receive a 100 
percent evaluation for at least one year plus hospitalization time as 
VA will not re-evaluate the Veteran until one year following hospital 
discharge. In addition to this change, VA proposes to evaluate residual 
cardiac disability under the General Rating Formula.
    Additionally, DC 7019 currently includes a note indicating VA will 
examine this disability one year following discharge. The note's intent 
is to assess the extent of residual cardiac disability following 
hospitalization for surgery. VA proposes to add the phrase ``discharge 
from inpatient hospitalization'' to clarify when the point at which the 
timing for mandatory examination begins. Discharge from an outpatient 
treatment program does not activate this provision. This clarification 
does not represent a change in VA policy.

III. Proposed Changes to Diagnostic Codes Not Rated Under the General 
Formula

A. Diagnostic Code 7008

    The DC 7008 addresses hyperthyroid heart disease. This DC was 
amended with the final publication of 82 FR 50804, Schedule for Rating 
Disabilities; The Endocrine System, effective December 10, 2017. VA's 
update of the endocrine system (38 CFR 4.117) revised the evaluation 
criteria for hyperthyroidism under DC 7900. See RIN 2900-AO44. 
Specifically, VA eliminated any current rating criteria in DC 7900 that 
referred to cardiovascular findings. Instead, VA evaluates any 
hyperthyroid heart disease under DC 7008, which directs rating 
personnel to evaluate any cardiovascular findings according to the 
appropriate DC. The

[[Page 37597]]

VA does not propose any additional changes for DC 7008 at this time.

B. Diagnostic Code 7010

    VA proposes to change the name of the current DC 7010 from 
supraventricular arrhythmias to the more modern and accurate 
supraventricular tachycardia. Arrhythmia generally refers to an 
irregular heartbeat and includes a heartbeat that is too fast, too 
slow, or irregular. ``What Is an Arrhythmia?'' National Heart, Lung, 
and Blood Institute (July 1, 2011), http://www.nhlbi.nih.gov/health/health-topics/topics/arr/ (last visited April 22, 2014). 
Supraventricular tachycardia is an irregularly fast heartbeat that 
originates above or within the atrioventricular node18 or in the upper 
part of the heart. Id. The various forms of supraventricular 
tachycardia include, but are not limited to, atrial fibrillation, 
atrial flutter, sinus tachycardia, sinoatrial nodal reentrant 
tachycardia, atrioventricular nodal reentrant tachycardia, 
atrioventricular reentrant tachycardia, atrial tachycardia, junctional 
tachycardia, and multifocal atrial tachycardia. Id. VA proposes to add 
an explanatory Note 1 to provide a non-exhaustive list of examples of 
supraventricular tachycardia. VA proposes to use tachycardia, rather 
than arrhythmia, in the title to clarify that rating personnel should 
use this DC to evaluate individuals with abnormally fast heartbeats.
    VA also proposes to update the evaluation criteria for 
supraventricular tachycardia, utilizing hospitalization as a more 
accurate measure of disability. The current criteria in DC 7010 assign 
evaluations based on the number of episodes of supraventricular 
arrhythmias documented by electrocardiogram (ECG or EKG) or Holter 
monitor, without considering the need for hospital treatment. 
Supraventricular tachycardia is usually non-lethal and does not result 
in disabling symptoms in otherwise healthy individuals. See 
``Paroxysmal supraventricular tachycardia'' in ``A.D.A.M. Medical 
Encyclopedia,'' PubMed Health, U.S. National Library of Medicine (June 
18, 2012), http://www.nlm.nih.gov/medlineplus/ency/article/000183.htm 
(last visited Apr. 30, 2014). For example, some patients with 
supraventricular tachycardias have many short episodes throughout the 
day and remain asymptomatic. Id. Others may have atrial fibrillation on 
a permanent basis, also without symptoms. These non-disabling episodes 
do not require hospitalization or treatment, but may be recorded 
incidentally by an ECG or Holter monitor without any other findings. 
Id. Therefore, the mere presence of episodes of supraventricular 
tachycardia, as well as their number, is unrelated to symptomatology or 
disability.
    However, some episodes of supraventricular tachycardia result in 
hypotension, shortness of breath, dizziness, or chest pain in patients 
who are older or have underlying cardiac disorders. Id. These 
symptomatic episodes typically require a controlled medical setting to 
monitor and treat heart rate control, anticoagulation, cardioversion, 
electrophysiological studies, or catheter-based arrhythmia ablation. 
Id. Medical intervention for supraventricular tachycardia more 
accurately indicates impairment, as the purpose of treatment is to 
eliminate or reduce any disabling symptoms. As mentioned previously, 
the mere documentation of supraventricular tachycardia on an ECG or 
Holter monitor does not confirm the existence of symptoms or 
impairment.
    As such, VA proposes to replace the current reference to episodes 
documented by ECG or Holter monitor in DC 7010 with treatment 
interventions. For the purposes of this DC, a treatment intervention 
occurs whenever a symptomatic patient requires intravenous 
pharmacologic adjustment, cardioversion, and/or ablation for symptom 
relief. For clarity, VA proposes to add Note 2 to identify when a 
treatment occurs. VA will assign a 10 percent evaluation for 
supraventricular tachycardia, documented by ECG, with one to four 
treatment interventions per year; VA will assign a 30 percent 
evaluation with five or more treatment interventions per year. VA 
proposes the number of interventions annually because benign, non-
disabling episodes may occur throughout the year. However, only 
episodes that require treatment interventions are most likely 
disabling, because they require treatment within a controlled medical 
setting and typically prevent an individual from working.

C. Diagnostic Code 7018

    DC 7018 currently provides a 100 percent evaluation for two months 
following hospital admission for implantation or reimplantation of a 
cardiac pacemaker. Following these two months, VA evaluates the 
disability under DC 7010, 7011, or 7015, with a minimum evaluation of 
10 percent. Advances in surgical methods and medical technology have 
drastically reduced the recovery time following implantation of a 
cardiac pacemaker.
    Surgical techniques for cardiac pacemakers have changed and 
improved drastically over the past several years and recovery currently 
requires less than 30 days. According to the National Institutes of 
Health (NIH), hospitalization following surgical implantation of a 
pacemaker usually lasts one to two days. ``What to Expect After 
Pacemaker Surgery,'' NIH--National Heart, Lung, and Blood Institute 
(February 28, 2012), http://www.nhlbi.nih.gov/health/health-topics/topics/pace/after.html (last visited April 14, 2014). NIH also 
indicates that mild pain, swelling, and tenderness at the site of 
pacemaker implantation may continue from a few days to a few weeks. Id. 
While healthcare providers may instruct patients to avoid vigorous 
activity, including heavy lifting, for up to one month following 
surgery, most patients may return to their normal activity level within 
a few days. Id. VA proposes to reduce the period of 100 percent 
evaluation from two months to one month. Additionally, VA proposes to 
add a second note to this DC, cross-referencing DC 7009, which will be 
addressed in greater detail below. VA proposes no other changes to this 
DC.

D. Diagnostic Code 7110

    The current DC 7110 addresses impairment due to aortic aneurysm. VA 
proposes to change the name of the code to ``Aortic aneurysm: 
ascending, thoracic, or abdominal'' to clarify the location of aortic 
aneurysm that this DC will evaluate.
    VA proposes to eliminate the 60 percent evaluation for an aortic 
aneurysm that precludes exertion while expanding the criteria for a 100 
percent evaluation to include symptomatic aneurysm (e.g., precludes 
exertion). VA proposes to omit the 60 percent category as it is does 
not provide an adequate evaluation for a symptomatic aneurysm in which 
exertion may hasten rupture. See Emile R. Mohler III, MD, ``Patient 
information: Abdominal aortic aneurysm (Beyond the Basics),'' Up-to-
date (Aug. 21, 2013), http://www.uptodate.com/contents/abdominal-aortic-aneurysm-beyond-the-basics#H4 (last visited May 2, 2014). A 
symptomatic aneurysm presents a medical emergency and requires surgical 
treatment to prevent the aneurysm from rupturing. Id. Under the 
proposed criteria, VA will grant a total evaluation when a patient 
becomes a surgical candidate and is unable to exert him/herself.
    Additionally, if a person cannot exert him/herself due to aortic 
aneurysm but is unable to undergo surgery due to a co-

[[Page 37598]]

morbid medical condition (e.g., kidney dysfunction requiring dialysis), 
VA will grant a total evaluation. Jeffrey Jim, MD and Robert W. 
Thompson, MD, ``Management of symptomatic (non-ruptured) and ruptured 
abdominal aortic aneurysm,'' UpToDate (Feb. 12, 2013), http://www.uptodate.com/contents/management-of-symptomatic-non-ruptured-and-ruptured-abdominal-aortic-aneurysm?source=see_link&anchor=H53322839#H53322839 (last visited May 
5, 2014). ``Although there are rare reports of patient survival 
following ruptured abdominal aortic aneurysm (AAA) without repair, in 
general, expectant management of ruptured AAA is nearly uniformly 
fatal. Thus, when ruptured AAA is identified, repair should be 
undertaken emergently to give the patient the best chance for 
survival.'' Id. As such, expanding the 100 percent evaluation to the 
date a physician recommended surgical correction will include Veterans 
who have severely disabling aneurysms but, due to co-morbid medical 
conditions or other reasons, cannot undergo surgical intervention. This 
100 percent evaluation will continue for six months following hospital 
discharge.
    In addition, VA proposes to add a 0 percent rating if an aneurysm 
is present but does not meet the requirements for surgical correction. 
Asymptomatic aneurysms may expand rapidly until they require surgical 
correction, so they need close medical follow-up. This provision 
allowing service connection for aneurysms not requiring surgery 
eliminates barriers to frequent medical check-ups by VA to monitor the 
progress of those aneurysms.
    VA will also add a directive for raters to evaluate non-
cardiovascular residuals according to the body systems affected. This 
is done to take into acount any disabling residuals related to surgical 
correction (e.g., infection, bowel adhesions, kidney failure, and so 
forth).
    The current DC 7110 also includes a note indicating that VA will 
assign the 100 percent rating as of the date of admission for surgical 
correction. VA will re-evaluate the condition after a mandatory 
examination six months following discharge. VA proposes to add the 
phrase ``discharge from inpatient hospitalization'' to clarify that the 
starting point to calculate the mandatory re-examination begins with 
discharge from inpatient hospitalization. VA also proposes to clarify 
in the rating criteria for a 100 percent evaluation that it shall 
assign the 100 percent evaluation as of the date a physician recommends 
surgical correction. This practice will allow VA to assign 100 percent 
evaluations to individuals who require surgical correction but, due to 
co-morbid medical conditions or other reasons, cannot undergo surgical 
procedures.

E. Diagnostic Code 7111

    The current DC 7111 provides 100 percent evaluations for aneurysms 
of large arteries which are symptomatic. It also provides 100 percent 
evaluations for indefinite periods of time from the date of hospital 
admission for surgical corrections. VA proposes to amend the latter 
criteria to provide a 100 percent evaluation from the date a physician 
recommends surgical correction, rather than the date of hospital 
admission. Aneurysms of any large artery are known to spontaneously 
rupture, which, depending on its location, can lead to death if not 
immediately addressed by surgery.
    This expansion to the 100 percent evaluation criteria requires that 
VA amend the note in DC 7111. Currently, VA assigns the 100 percent 
rating as of the date of admission for surgical correction, and VA 
assesses any residual disability by a mandatory examination six months 
following discharge. VA proposes to add the phrase ``discharge from 
inpatient hospitalization'' in the criteria note to clarify that the 
timing for the mandatory re-examination is based upon discharge from 
inpatient hospitalization. Additionally, VA proposes to clarify that it 
shall assign the 100 percent evaluation beginning from the date a 
physician recommends surgical correction, in the event individuals who 
require surgical correction cannot undergo it due to co-morbid medical 
conditions or other reasons. The 100 percent evaluation shall continue 
for six months following hospital discharge for surgical correction.
    The current DC 7111 provides rating criteria following surgical 
intervention that is based on the ankle-brachial index, claudication on 
walking certain distances, and other symptoms related to poor blood 
flow to the extremities. These criteria provide for evaluations ranging 
from 20 to 100 percent; notes (1) and (2) provide additional 
information when evaluating post-surgical large artery aneurysms. The 
residual disabilities after post-surgical repair of large artery 
aneurysms are similar to those under DC 7114. For greater ease of use 
and simplicity, VA therefore proposes to remove these criteria and 
notes and replace them with instructions to evaluate post-surgical 
residuals under DC 7114. The section of the preamble below specifically 
addressing DC 7114 discusses any changes related to these criteria and 
notes.

F. Diagnostic Code 7113

    DC 7113, arteriovenous (AV) fistula, traumatic, currently includes 
the phrase ``with edema'' as one of the disabling symptoms present at 
the 50, 40, 30, and 20 percent levels. However, such wording does not 
distinguish between chronic and transitory edema, resulting in 
evaluations that may be based on symptoms that are unrelated to 
arteriovenous fistula or do not adequately represent its chronic 
residual disability. Transitory edema may occur following prolonged 
standing, prolonged sitting during travel, the wearing of tight 
hosiery, taking certain medications, consuming excessive salt, or being 
pregnant. Transitory edema due to these causes is non-disabling and 
typically resolves without complication.
    However, edema due to an AV fistula requires medical treatment and 
may impair function. Therefore, VA proposes to clarify that evaluations 
at the 50, 40, 30, and 20 percent levels under DC 7113 must involve 
``chronic edema'' to better comply with 38 CFR 4.1, which states the 
accurate application of the VASRD requires an emphasis upon ``the 
limitation of activity imposed by the disabling condition.''

G. Diagnostic Code 7114

    The current DC 7114, titled ``Arteriosclerosis obliterans,'' 
addresses impairment of the lower extremities due to narrowing and 
hardening of the arteries. The term ``arteriosclerosis'' is also used 
in current note (2). VA proposes to replace the term ``arteriosclerosis 
obliterans'' with ``peripheral arterial disease'' to conform to current 
medical terminology. Peter Libby et al., ``Braunwald's Heart Disease: A 
Textbook of Cardiovascular Medicine,'' 1491-1515 (8th ed. 2007).
    The evaluation criteria of the current DC 7114 include the ankle/
brachial index (ABI), associated examination findings and symptoms, or 
claudication (pain in the extremities) upon walking certain distances. 
The current criteria, however, have two major shortcomings: (1) They do 
not account for veterans with non-compressible arteries (these veterans 
have either a normal or elevated ABI, which would be non-compensable); 
and (2) they rely in large part on claudication, which is an 
inconsistent measure of disability. To that end, VA will employ a more 
objective approach as outlined below.
    VA will create evaluation criteria based on a modified version of 
the ischemia scoring table found in J. Mills,

[[Page 37599]]

``The Society for Vascular Surgery Lower Extremity Threatened Limb 
Classification System: Risk stratification based on Wound, Ischemia, 
and foot Infection (WIfI)'' J Vasc Surg; vol 59, pg 226. 2014. This 
table uses the ABI, as well as ankle pressure (AP), toe pressure (TP) 
and transcutaneous oximetry (TcPO2) to describe 
four different levels of impairment. The ABI is the ratio of the 
systolic blood pressure measured at the ankle to that measured at the 
antecubital fossa. For VA disability compensation purposes, normal is 
greater than or equal to 0.80. The reason this normal value is used, 
rather than normal values cited in the 2016 ACC/AHA Guidelines is that 
an ABI between 0.90 and 0.81 is not consistently associated with 
objective signs of disability beyond symptomatic complaints (e.g., 
wounds or infections). The AP is the systolic blood pressure measured 
at the ankle. Normal is greater than or equal to 100 mm Hg. The TP is 
the systolic blood pressure measured at the great toe. Normal is 
greater than or equal to 60 mm Hg. TcPO2 is 
measured at the first intercostal space on the foot. Normal is greater 
than or equal to 60 mm Hg. See also M. Kalani ``Transcutaneous Oxygen 
Tension and Toe Blood Pressure as Predictors for Outcome of Diabetic 
Foot Ulcers,'' Diabetes Care, vol. 22, Pgs 147-52. 1999. The levels of 
impairment as described in the previously referenced ischemia scoring 
table directly correlate to levels of disability (i.e., evaluation 
levels). VA will slightly modify this table to describe four levels of 
disability (and thus, evaluation levels) consistent with these 
criteria, while preserving the 20, 40, 60, and 100 percent evaluation 
levels.
    Turning to the three notes associated with DC 7114, VA will make 
two significant revisions. First, VA will revise Note (1) to add 
definitions and normal values for ABI, AP, TP, and 
TcPO2. Next, VA will redesignate current Note (2) 
as Note (3), and current Note (3) as Note (4). Finally, VA will then 
add a new Note (2), which directs the rater to select the value (ABI, 
AP, TP, or TcPO2) which yields the highest level 
of impairment for evaluation.

H. Diagnostic Code 7115

    DC 7115 currently uses lower extremity findings to evaluate 
thrombo-angiitis obliterans (Buerger's Disease). VA proposes new 
criteria for the evaluation of upper extremity disease because 
Buerger's Disease can affect either upper or lower extremities. 
Buerger's disease is a nonatherosclerotic segmental inflammatory 
disease that affects the small and medium-sized arteries, veins, and 
nerves of the arms, legs, and rarely elsewhere. See Topol, E.J., 
Textbook of Cardiovascular Medicine Chap. 108, Pg 1535. (2007). DC 7115 
currently evaluates impairment of the lower extremity using the ankle/
brachial index (ABI) or associated signs and symptoms upon examination 
(as found in current DC 7114). For the reasons discussed above in DC 
7114, VA proposes to clarify the evaluation criteria by using objective 
signs, with the ABI as the primary criteria for the lower extremities. 
VA proposes to delete claudication on walking from all evaluation 
criteria as it inaccurately measures the extent of this disability. VA 
also proposes to remove current Note (1), as DC 7115 will now direct 
rating personnel to evaluate lower extremities under DC 7114 and the 
information regarding the ABI is contained in that diagnostic code. 
With elimination of current Note (1), VA proposes to rename existing 
Note (2) as Note (1) with clarification similar to that proposed in 
Note (3) DC 7114 (as explained above). Additionally, a new Note (2) is 
proposed to give raters examples of trophic changes so it will be 
easier to recognize when encountered in clinical documentation.

I. Diagnostic Code 7117

    Currently, DC 7117 addresses impairment due to Raynaud's syndrome, 
in which cold or stress abnormally reduces blood flow in the 
extremities. Raynaud's syndrome (also called secondary Raynaud's 
phenomenon) is often confused with Raynaud's disease (also called 
primary Raynaud's phenomenon or primary Raynaud's), which is different 
in terms of etiology and severity. While both conditions present with 
vasospasm, Raynaud's disease (primary Raynaud's phenomenon) has few, if 
any, long term residuals. In contrast, Raynaud's syndrome (secondary 
Raynaud's phenomenon) is associated with another illness, most commonly 
an autoimmune disease. The residuals tend to be permanent, more 
extensive, and more disabling. To improve clarity, ensure more accurate 
evaluations, and promote consistency and usability of the VASRD, VA 
proposes to focus DC 7117 on Raynaud's syndrome (secondary Raynaud's 
phenomenon) only, while creating a new DC 7124 for Raynaud's disease 
(primary Raynaud's phenomenon or primary Raynaud's). In addition, VA 
proposes to use the existing note to emphasize that DC 7117 is only for 
evaluating Raynaud's syndrome (secondary Raynaud's phenomenon), and add 
a note emphasizing that Raynaud's disease (primary Raynaud's 
phenomenon) should be rated under DC 7124.
    As stated, Raynaud's syndrome (secondary Raynaud's phenomenon) and 
Raynaud's disease (primary Raynaud's phenomenon) are unrelated in both 
etiology and severity. According to the NIH's National Heart, Lung, and 
Blood Institute, Raynaud's syndrome (secondary Raynaud's phenomenon) is 
typically caused by autoimmune diseases such as scleroderma, lupus, 
rheumatoid arthritis, atherosclerosis, or polycythemia. ``Raynaud 
Phenomenon.'' Medscape (September 6, 2017), http://emedicine.medscape.com/article/331197-overview (last visited September 
12, 2017).
    On the other hand. the cause of Raynaud's disease (primary 
Raynaud's phenomenon) is not known. Id. Raynaud's disease (primary 
Raynaud's phenomenon) is more common and tends to be less severe than 
Raynaud's syndrome (secondary Raynaud's phenomenon). Ray W. Gifford, 
Jr. & Edgar A. Hines, Jr., ``Raynaud's Disease Among Women and Girls,'' 
16 Circulation 1012, 1019 (1957). VA discusses how to properly evaluate 
Raynaud's disease (primary Raynaud's phenomenon) below in the section 
proposing the new DC 7124. No other changes are proposed to DC 7117.

J. Diagnostic Code 7120

    DC 7121 currently evaluates post-phlebitic syndrome of any 
etiology, with its rating criteria identical to that used in DC 7120, 
Varicose veins. VA currently maintains separate DCs for these 
disabilities to monitor in the Veteran population the incidence and 
outcome of claims for these specific and separate diagnoses. However, 
for clarity, consistency, and improved ease of use, VA proposes to 
delete the duplicative rating criteria and instruct rating personnel to 
evaluate DC 7120, Varicose veins, under DC 7121, Post-phlebitic 
syndrome. VA does not propose any changes to the content of DC 7121 
itself.

K. Diagnostic Code 7122

    VA last amended the rating criteria for DC 7122, Cold injury 
residuals, in 1998. 63 FR 37778. In the time since, medicine has 
documented new chronic residuals of cold injury. Therefore, VA proposes 
to update the criteria to include the findings specifically noted by 
the Veterans Health Initiative, Department of Veterans Affairs, ``Cold 
Injury: Diagnosis and Management of Long-Term Sequelae,'' revised in 
March 2002. https://www.publichealth.va.gov/docs/vhi/coldinjury.pdf
    This study collected medical and anecdotal information on cold 
injury

[[Page 37600]]

residuals from veterans. The study indicated that the effects of cold 
weather injuries may be irreversible and worsen with age. Id. at 15. 
The residuals of cold injuries include residual pain, numbness, cold 
sensitivity, tissue loss, nail abnormalities, color changes, locally 
impaired sensation, hyperhidrosis, x-ray abnormalities, anhydrosis, 
muscle atrophy, muscle fibrosis, deformity in flexion and/or extension 
of certain joints, loss of fat pads in the fingers and toes, bone 
death, skin ulcers, and carpal or tarsal tunnel syndrome. Id. at 24-25. 
VA proposes to include these updated residuals of cold injuries within 
this DC, which assigns evaluations based on the number of cold injury 
residuals present.

IV. Proposed New Diagnostic Codes

A. New Diagnostic Code 7009

    VA proposes to add a new DC 7009, titled ``Bradycardia 
(Bradyarrhythmia), symptomatic, requiring permanent pacemaker 
implantation,'' to account for impairment in the Veteran population due 
to this condition. Individuals generally have a normal resting heart 
rate ranging from 60 to 100 beats per minute. Individuals with 
bradycardia, however, have a resting heart rate of less than 60 beats 
per minute. ``Bradycardia,'' Harvard Health Topic at Drugs.com, http://www.drugs.com/health-guide/bradycardia.html (last visited May 5, 2014). 
Notably, asymptomatic bradycardia occurs normally in individuals when 
sleeping and in many healthy, athletic adults. Id. See also 
``Bradycardia (Slow Heart Rate)--Topic Overview,'' WebMD (Nov. 21, 
2011), http://www.webmd.com/heart-disease/tc/bradycardia-slow-heart-rate-overview (last visited May 5, 2014). It should be noted that 
asymptomatic bradycardia is a medical finding, does not require medical 
intervention, and is not subject to service-connected compensation.
    Symptomatic bradycardia can be caused by changes due to aging, 
certain medications, diseases, and infections, all of which can damage 
the heart and slow its electrical impulses. See Amy Scholten, MPH, 
``Bradycardia (Bradyarrhythmia),'' NYU Langone Cardiac and Vascular 
Institute, 2-3 (Feb. 2008). When medical management for symptomatic 
bradycardia is not effective, a pacemaker implant is the treatment of 
choice. Id. at 3. Implantation of a pacemaker aids in normalizing the 
heart rate and returning the individual to baseline cardiac function. 
VA proposes to evaluate this condition at 100 percent for one month 
following hospitalization for implantation or re-implantation. 
Following the initial month, the disability will be evaluated using the 
General Rating Formula. To assist rating personnel in understanding and 
evaluating bradycardia, VA also proposes to include a note under DC 
7009 which defines bradycardia and describes the five general classes 
of bradyarrhythmias.

B. New Diagnostic Code 7124

    VA proposes to add a new DC 7124, titled ``Raynaud's disease (also 
known as primary Raynaud's phenomenon or primary Raynaud's):.'' The 
VASRD currently evaluates Raynaud's disease using the criteria under DC 
7117, which is for ``Raynaud's syndrome,'' a different and more severe 
disability. Therefore, VA proposes a new DC to specifically evaluate 
Raynaud's disease. This DC will also include notes to define 
characteristic attacks as well as to emphasize rating Raynaud's 
syndrome (Raynaud's phenomenon, Secondary Raynaud's) under DC 7117.
    As stated previously, Raynaud's disease is more common and tends to 
be less severe than Raynaud's syndrome. The Mayo Clinic performed a 
study involving 474 women and girls with Raynaud's disease. Follow-up 
information obtained from 307 of those who received conservative 
treatment confirmed the benign nature of the disease, with no deaths 
attributed to it and extremely little disability. The study found that 
uncomplicated Raynaud's disease may be inconvenient because of the need 
to protect the extremities from cold and trauma, but it is not 
disabling.
    Raynaud's disease, the less severe form of Raynaud's, rarely 
involves trophic changes because it involves brief spasms of the 
arteries rather than occlusion of the peripheral arteries. See ``What 
is Raynaud's?'' National Heart, Lung, and Blood Institute (Mar. 21, 
2014), https://www.nhlbi.nih.gov/health/health-topics/topics/raynaud/ 
(last visited May 5, 2014). Furthermore, when trophic changes are 
present, they are limited to the distal skin of the digits. ``Raynaud's 
disease,'' Mayo Clinic (Oct. 20, 2011), http://www.mayoclinic.org/diseases-conditions/raynauds-disease/basics/complications/con-20022916 
(last visited May 5, 2014). Therefore, VA proposes a non-compensable 
evaluation when Raynaud's disease manifests without lasting impairment 
in the form of trophic changes. VA proposes a 10 percent evaluation 
with residual trophic changes (e.g., skin changes such as thinning, 
atrophy fissuring, ulceration, scarring, absence of hair; nail changes 
(clubbing, deformities).) VA proposes the addition of a note to provide 
examples of trophic changes for clarification purposes, consistent with 
other proposed changes.
    VA also proposes to include a note to clarify and assist assigning 
evaluations under this DC by defining a characteristic attack of 
Raynaud's disease. As with DC 7117, this note will also indicate that 
evaluations under this code are for the disease as a whole. To further 
promote clarity and consistency, another proposed note would emphasize 
that the purpose of DC 7124 is to evaluate only Raynaud's disease, as 
opposed to Raynaud's syndrome. A veteran cannot receive simultaneous 
ratings under both DC 7117 and DC 7124, because Raynaud's disease and 
Raynaud's syndrome cannot be comorbid conditions.

Effect of Rulemaking

    Title 38 of the Code of Federal Regulations, as revised by this 
proposed rulemaking, would represent VA's implementation of its legal 
authority on this subject. Other than future amendments to these 
regulations or governing statutes, no contrary guidance or procedures 
are authorized. All existing or subsequent VA guidance must be read to 
conform with this proposed rulemaking if possible or, if not possible, 
such guidance is superseded by this rulemaking.

Executive Orders 12866 and 13563

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

[[Page 37601]]

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 to be a significant regulatory action under Executive 
Order 12866, because it raises novel legal or policy issues arising out 
of legal mandates, the President's priorities, or the principles set 
forth in this Executive Order. VA's impact analysis can be found as a 
supporting document at http://www.regulations.gov, usually within 48 
hours after the rulemaking document is published. Additionally, a copy 
of the rulemaking and its impact analysis are available on VA's website 
at http://www.va.gov/orpm by following the link for VA Regulations 
Published from FY 2004 through Fiscal Year to Date. This proposed rule 
is not expected to be subject to the requirements of EO13771 because 
this proposed rule is expected to result in no more than de minimis 
costs.

Paperwork Reduction Act

    This regulatory action contains provisions constituting a 
collection of information under the provisions of the Paperwork 
Reduction Act (44 U.S.C. 3501 et seq.).
    The information collection requirements for 38 CFR 3.151 are 
associated with this rule, but do not constitute a new or revised 
collection of information; OMB has already approved these requirements 
under control number 2900-0747.

Regulatory Flexibility Act

    The Secretary hereby certifies that the adoption of this rule would 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This rule would not directly affect any small entities; 
only individuals could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this rule 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 1 year. This rule will have no such effect on State, 
local, and tribal governments, or on the private sector.

Catalog of Federal Domestic Assistance

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

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 submit it to the Office of 
the Federal Register for electronic publication as an official document 
of the Department of Veterans Affairs. Robert L. Wilkie, Secretary, 
Department of Veterans Affairs, approved this document on April 10, 
2019, for publication.

    Dated: July 23, 2019.
Jeffrey M. Martin,
Assistant Director, Office of Regulation Policy & Management, Office of 
the Secretary, Department of Veterans Affairs.

    For the reasons set out in the preamble, VA proposes to amend 38 
CFR part 4 as set forth below:

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. Revise Sec.  4.100 paragraph (b) to read as follows:


Sec.  4.100  Application of the evaluation criteria for diagnostic 
codes 7000-7007, 7011, and 7015-7020.

* * * * *
    (b) Even if the requirement for a 10% (based on the need for 
continuous medication) or 30% (based on the presence of cardiac 
hypertrophy or dilatation) evaluation is met, METs testing is required 
in all cases except:
    (1) When there is a medical contraindication.
    (2) When a 100% evaluation can be assigned on another basis.

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


0
3. Amend Sec.  4.104 by:
0
a. Adding the General Rating Formula for Diseases of the Heart
0
b. Adding the instruction to DCs 7000, 7001, 7002, 7006, 7017 to 
evaluate disability using the General Rating Formula to evaluate 
residual disability after three months
0
c. Adding the instruction to DCs 7003, 7004, 7005, 7007, and 7020 to 
evaluate disability using the General Rating Formula
0
d. Adding the instruction to DCs 7011, 7016 to evaluate disability 
using the General Rating Formula by mandatory examination six months 
after discharge
0
e. Revising the evaluation criteria for DC 7015
0
f. Revising the evaluation criteria for DC 7019
0
g. Retitling and revise the evaluation criteria for DC 7010
0
h. Revising the evaluation criteria for DC 7018
0
i. Retitling and revise the evaluation criteria for DC 7110
0
j. Revising the evaluation criteria for DC 7111
0
k. Revising DC 7113 to add explanatory information
0
l. Revising the evaluation criteria for DC 7114
0
m. Revising the evaluation criteria for DC 7115
0
n. Revising the evaluation criteria for DC 7117
0
o. Revising the evaluation criteria for DC 7120
0
p. Revising the evaluation criteria for DC 7122
0
q. Adding new DC 7009
0
r. Adding new DC 7124.
    The revisions and additions read as follows:


Sec.  4.104   Schedule of ratings--cardiovascular system.

[[Page 37602]]



------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
                          Diseases of the Heart
------------------------------------------------------------------------
Unless otherwise directed, use this general rating
 formula to evaluate diseases of the heart.
Note (1): Evaluate cor pulmonale, which is a form of
 secondary heart disease, as part of the pulmonary
 condition that causes it.
Note (2): One MET (metabolic equivalent) is the energy
 cost of standing quietly at rest and represents an
 oxygen uptake of 3.5 milliliters per kilogram of body
 weight per minute. When the level of METs at which
 breathlessness, fatigue, angina, dizziness, or syncope
 develops is required for evaluation, and a laboratory
 determination of METs by exercise testing cannot be
 done for medical reasons, a medical examiner may
 estimate the level of activity (expressed in METs and
 supported by specific examples, such as slow stair
 climbing or shoveling snow) that results in those
 symptoms.
Note (3): For this general formula, heart failure
 symptoms include, but are not limited to,
 breathlessness, fatigue, angina, dizziness, arrhythmia,
 palpitations, or syncope.
General Rating Formula for Diseases of the Heart:
    Workload of 3.0 METs or less results in heart                    100
     failure symptoms...................................
    Workload of 3.1-5.0 METs results in heart failure                 60
     symptoms...........................................
    Workload of 5.1-7.0 METs results in heart failure                 30
     symptoms; or evidence of cardiac hypertrophy or
     dilatation confirmed by echocardiogram or
     equivalent (e.g., multigated acquisition scan or
     magnetic resonance imaging)........................
    Workload of 7.1-10.0 METs results in heart failure                10
     symptoms; or continuous medication required for
     control............................................
7000 Valvular heart disease (including rheumatic heart
 disease), 7001 Endocarditis, or 7002 Pericarditis:
    During active infection with cardiac involvement and             100
     for three months following cessation of therapy for
     the active infection...............................
    Thereafter, with diagnosis confirmed by findings on
     physical examination and either echocardiogram,
     Doppler echocardiogram, or cardiac catheterization,
     use the General Rating Formula.
7003 Pericardial adhesions.
7004 Syphilitic heart disease:
    Note: Evaluate syphilitic aortic aneurysms under DC
     7110 (Aortic aneurysm: Ascending, thoracic,
     abdominal).
7005 Arteriosclerotic heart disease (coronary artery
 disease).
    Note: If non-service-connected arteriosclerotic
     heart disease is superimposed on service-connected
     valvular or other non-arteriosclerotic heart
     disease, request a medical opinion as to which
     condition is causing the current signs and
     symptoms.
7006 Myocardial infarction:
    During and for three months following myocardial                 100
     infarction, confirmed by laboratory tests..........
    Thereafter, use the General Rating Formula.
7007 Hypertensive heart disease.
7008 Hyperthyroid heart disease:
    Rate under the appropriate cardiovascular diagnostic
     code, depending on particular findings.
For DCs 7009, 7010, 7011, and 7015, a single evaluation
 will be assigned under the diagnostic code which
 reflects the predominant disability picture.
7009 Bradycardia (Bradyarrhythmia), symptomatic,
 requiring permanent pacemaker implantation:
    For one month following hospital discharge for                   100
     implantation or re-implantation....................
Thereafter, use the General Rating Formula.
    Note (1): Bradycardia (bradyarrhythmia) refers to
     conduction abnormalities that produce a heart rate
     less than 60 beats/min. There are five general
     classes of bradyarrhythmias:
        --Sinus bradycardia, including sinoatrial block;
        --Atrioventricular (AV) junctional (nodal)
         escape rhythm;
        --AV heart block (second or third degree) or AV
         dissociation;
        --Atrial fibrillation or flutter with a slow
         ventricular response; and
        --Idioventricular escape rhythm.
    Note (2): Asymptomatic bradycardia (bradyarrhythmia)
     is a medical finding which does not require medical
     intervention, thus, it is not entitled to service
     connection.
7010 Supraventricular tachycardia:
    Confirmed by ECG, with five or more treatment                     30
     interventions per year.............................
    Confirmed by ECG, with one to four treatment                      10
     interventions per year.............................
    Note (1): Examples of supraventricular tachycardia
     include, but are not limited to, atrial
     fibrillation, atrial flutter, sinus tachycardia,
     sinoatrial nodal reentrant tachycardia,
     atrioventricular nodal reentrant tachycardia,
     atrioventricular reentrant tachycardia, atrial
     tachycardia, junctional tachycardia, and multifocal
     atrial tachycardia.
    Note (2): For the purposes of this diagnostic code,
     a treatment intervention occurs whenever a
     symptomatic patient requires intravenous
     pharmacologic adjustment, cardioversion, and/or
     ablation for symptom relief.
7011 Ventricular arrhythmias (sustained):
    For an indefinite period from the date of hospital               100
     admission for initial medical therapy for a
     sustained ventricular arrhythmia; or for an
     indefinite period from the date of hospital
     admission for ventricular aneurysmectomy; or with
     an automatic implantable cardioverter-defibrillator
     (AICD) in place....................................
    Thereafter, use the General Rating Formula.
    Note: Six months following discharge from inpatient
     hospitalization for sustained ventricular
     arrhythmia or for ventricular aneurysmectomy,
     disability evaluation shall be conducted by
     mandatory VA examination using the General Rating
     Formula. Apply the provisions of Sec.   3.105(e) of
     this chapter to any change in evaluation based upon
     that or any subsequent examination.
7015 Atrioventricular block:
    Benign (First-Degree and Second-Degree, Type I):
        Evaluate under the General Rating Formula.
    Non-Benign (Second-Degree, Type II and Third-
     Degree):
        Evaluate under DC 7018 (implantable cardiac
         pacemakers).
7016 Heart valve replacement (prosthesis):
    For an indefinite period following date of hospital              100
     admission for valve replacement....................
    Thereafter, use the General Rating Formula.

[[Page 37603]]

 
    Note: Six months following discharge from inpatient
     hospitalization, disability evaluation shall be
     conducted by mandatory VA examination using the
     General Rating Formula. Apply the provisions of
     Sec.   3.105(e) of this chapter to any change in
     evaluation based upon that or any subsequent
     examination.
7017 Coronary bypass surgery:...........................
    For three months following hospital admission for                100
     surgery............................................
    Thereafter, use the General Rating Formula.
7018 Implantable cardiac pacemakers:
    For one month following hospital discharge for                   100
     implantation or re-implantation....................
    Thereafter:
        Evaluate as supraventricular tachycardia (DC
         7010), ventricular arrhythmias (DC 7011), or
         atrioventricular block (DC 7015).
        Minimum.........................................              10
    Note (1): Evaluate automatic implantable
     cardioverter-defibrillators (AICDs) under DC 7011.
7019 Cardiac transplantation:
    For a minimum of one year from the date of hospital              100
     admission for cardiac transplantation..............
    Thereafter:
        Evaluate under the General Rating Formula.
        Minimum.........................................              30
    Note: One year following discharge from inpatient
     hospitalization, determine the appropriate
     disability rating by mandatory VA examination.
     Apply the provisions of Sec.   3.105(e) of this
     chapter to any change in evaluation based upon that
     or any subsequent examination.
7020 Cardiomyopathy.
------------------------------------------------------------------------
                   Diseases of the Arteries and Veins
------------------------------------------------------------------------
7110 Aortic aneurysm: Ascending, thoracic, or abdominal:
    If 5 centimeters (cm) or larger in diameter; or, if              100
     symptomatic (e.g., precludes exertion) and a
     physician recommends surgical correction, for the
     period beginning on the date a physician recommends
     surgical correction and continuing for six months
     following hospital discharge for surgical
     correction (including any type of graft insertion).
    If less than 5 cm in diameter; or, surgical                        0
     correction not recommended.........................
    Evaluate non-cardiovascular residuals of surgical
     correction according to organ systems affected.
    Note: Six months following discharge from inpatient
     hospitalization for surgery, disability evaluation
     shall be determined by mandatory VA examination of
     cardiovascular residuals using the General Rating
     Formula for Diseases of the Heart. 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.
7111 Aneurysm, any large artery:
    If symptomatic; or, for the period beginning on the              100
     date a physician recommends surgical correction and
     continuing for six months following discharge from
     inpatient hospital admission for surgical
     correction.........................................
    Following surgery: Evaluate under DC 7114
     (peripheral arterial disease).
    Note: Six months following discharge from inpatient
     hospitalization for surgery, determine the
     appropriate disability rating 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.
 
                              * * * * * * *
7113 Arteriovenous fistula, traumatic:
    With high-output heart failure......................             100
    Without heart failure but with enlarged heart, wide               60
     pulse pressure, and tachycardia....................
    Without cardiac involvement but with chronic edema,
     stasis dermatitis, and either ulceration or
     cellulitis:
        Lower extremity.................................              50
        Upper extremity.................................              40
    Without cardiac involvement but with chronic edema
     or stasis dermatitis:
        Lower extremity.................................              30
        Upper extremity.................................              20
7114 Peripheral arterial disease:
    At least one of the following: Ankle/brachial index              100
     less than or equal to 0.39; ankle pressure less
     than 50 mm Hg; toe pressure less than 30 mm Hg; or
     transcutaneous oxygen tension less than 30 mm Hg...
    At least one of the following: Ankle/brachial index               60
     of 0.40-0.53; ankle pressure of 50-65 mm Hg; toe
     pressure of 30-39 mm Hg; or transcutaneous oxygen
     tension of 30-39 mm Hg.............................
    At least one of the following: Ankle/brachial index               40
     of 0.54-0.66; ankle pressure of 66-83 mm Hg; toe
     pressure of 40-49 mm Hg; or transcutaneous oxygen
     tension of 40-49 mm Hg.............................
    At least one of the following: Ankle/brachial index               20
     of 0.67-0.79; ankle pressure of 84-99 mm Hg; toe
     pressure of 50-59 mm Hg; or transcutaneous oxygen
     tension of 50-59 mm Hg.............................
    Note (1): The ankle/brachial index (ABI) is the
     ratio of the systolic blood pressure at the ankle
     divided by the simultaneous brachial artery
     systolic blood pressure. For the purposes of this
     diagnostic code, normal ABI will be greater than or
     equal to 0.80. The ankle pressure (AP) is the
     systolic blood pressure measured at the ankle.
     Normal AP is greater than or equal to 100 mm Hg.
     The toe pressure (TP) is the systolic blood
     pressure measured at the great toe. Normal TP is
     greater than or equal to 60 mm Hg. Transcutaneous
     oxygen tension (TcPO2) is measured at the first
     intercostal space on the foot. Normal TcPO2 is
     greater than or equal to 60 mm Hg. All measurements
     must be determined by objective testing.
    Note (2): Select the highest impairment value of
     ABI, AP, TP, or TcPO2 for evaluation.
    Note (3): Evaluate residuals of aortic and large
     arterial bypass surgery or arterial graft as
     peripheral arterial disease.
    Note (4): These evaluations involve a single
     extremity. If more than one extremity is affected,
     evaluate each extremity separately and combine
     (under Sec.   4.25), using the bilateral factor
     (Sec.   4.26), if applicable.
7115 Thrombo-angiitis obliterans (Buerger's Disease):

[[Page 37604]]

 
    Lower extremity: Rate under DC 7114.
    Upper extremity:
        Deep ischemic ulcers and necrosis of the fingers             100
         with persistent coldness of the extremity,
         trophic changes with pains in the hand during
         physical activity, and diminished upper
         extremity pulses...............................
        Persistent coldness of the extremity, trophic                 60
         changes with pains in the hands during physical
         activity, and diminished upper extremity pulses
        Trophic changes with numbness and paresthesia at              40
         the tips of the fingers, and diminished upper
         extremity pulses...............................
        Diminished upper extremity pulses...............              20
    Note (1): These evaluations involve a single
     extremity. If more than one extremity is affected,
     evaluate each extremity separately and combine
     (under Sec.   4.25), using the bilateral factor
     (Sec.   4.26), if applicable.
    Note (2): Trophic changes include, but are not
     limited to, skin changes (thinning, atrophy,
     fissuring, ulceration, scarring, absence of hair)
     as well as nail changes (clubbing, deformities).
7117 Raynaud's syndrome (also known as secondary
 Raynaud's phenomenon or secondary Raynaud's)...........
    With two or more digital ulcers plus auto-amputation             100
     of one or more digits and history of characteristic
     attacks............................................
    With two or more digital ulcers and history of                    60
     characteristic attacks.............................
    Characteristic attacks occurring at least daily.....              40
    Characteristic attacks occurring four to six times a              20
     week...............................................
    Characteristic attacks occurring one to three times               10
     a week.............................................
    Note (1): For purposes of this section,
     characteristic attacks consist of sequential color
     changes of the digits of one or more extremities
     lasting minutes to hours, sometimes with pain and
     paresthesias, and precipitated by exposure to cold
     or by emotional upsets. These evaluations are for
     Raynaud's syndrome as a whole, regardless of the
     number of extremities involved or whether the nose
     and ears are involved.
    Note (2): This section is for evaluating Raynaud's
     syndrome (secondary Raynaud's phenomenon or
     secondary Raynaud's). For evaluation of Raynaud's
     disease (primary Raynaud's phenomenon, or primary
     Raynaud's), see DC 7124.
 
                              * * * * * * *
7120 Varicose veins:
    Evaluate under diagnostic code 7121.
 
                              * * * * * * *
7122 Cold injury residuals:
    With the following in affected parts:
        Arthralgia or other pain, numbness, or cold                   30
         sensitivity plus two or more of the following:
         Tissue loss, nail abnormalities, color changes,
         locally impaired sensation, hyperhidrosis,
         anhydrosis, X-ray abnormalities (osteoporosis,
         subarticular punched-out lesions, or
         osteoarthritis), atrophy or fibrosis of the
         affected musculature, flexion or extension
         deformity of distal joints, volar fat pad loss
         in fingers or toes, avascular necrosis of bone,
         chronic ulceration, carpal or tarsal tunnel
         syndrome.......................................
        Arthralgia or other pain, numbness, or cold                   20
         sensitivity plus one of the following: Tissue
         loss, nail abnormalities, color changes,
         locally impaired sensation, hyperhidrosis,
         anhydrosis, X-ray abnormalities (osteoporosis,
         subarticular punched-out lesions, or
         osteoarthritis), atrophy or fibrosis of the
         affected musculature, flexion or extension
         deformity of distal joints, volar fat pad loss
         in fingers or toes, avascular necrosis of bone,
         chronic ulceration, carpal or tarsal tunnel
         syndrome.......................................
        Arthralgia or other pain, numbness, or cold                   10
         sensitivity....................................
    Note (1): Separately evaluate amputations of fingers
     or toes, and complications such as squamous cell
     carcinoma at the site of a cold injury scar or
     peripheral neuropathy, under other diagnostic
     codes. Separately evaluate other disabilities
     diagnosed as the residual effects of cold injury,
     such as Raynaud's syndrome (which is otherwise
     known as secondary Raynaud's phenomenon), muscle
     atrophy, etc., unless they are used to support an
     evaluation under diagnostic code 7122.
    Note (2): Evaluate each affected part (e.g., hand,
     foot, ear, nose) separately and combine the ratings
     in accordance with Sec.  Sec.   4.25 and 4.26.
 
                              * * * * * * *
7124 Raynaud's disease (also known as primary Raynaud's
 phenomenon or primary Raynaud's):......................
    Characteristic attacks associated with trophic                    10
     change(s), such as tight, shiny skin...............
    Characteristic attacks without trophic change(s)....               0
    Note (1): For purposes of this section,
     characteristic attacks consist of intermittent and
     episodic color changes of the digits of one or more
     extremities, lasting minutes or longer, with
     occasional pain and paresthesias, and precipitated
     by exposure to cold or by emotional upsets. These
     evaluations are for the disease as a whole,
     regardless of the number of extremities involved or
     whether the nose and ears are involved.
    Note (2): Trophic changes include, but are not
     limited to, skin changes (thinning, atrophy,
     fissuring, ulceration, scarring, absence of hair)
     as well as nail changes (clubbing, deformities).
    Note (3): This section is for evaluating Raynaud's
     disease (primary Raynaud's phenomenon or primary
     Raynaud's). For evaluation of Raynaud's syndrome
     (also known as secondary Raynaud's phenomenon, or
     secondary Raynaud's), see DC 7117.
------------------------------------------------------------------------


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


0
4. Amend Appendix A to Part 4 by:
0
a. Adding an entry for the General Rating Formula for Diseases of the 
Heart to 4.104;
0
 b. Revising the entries for diagnostic codes 7000 through 7008;
0
c. Adding, in numerical order, an entry for diagnostic code 7009;
0
d. Revising the entries for diagnostic codes 7010, 7011, 7015 through 
7020, 7110 through 7111, 7113 through 7115, 7117, and 7121 through 
7122; and
0
e. Adding, in numerical order, an entry for diagnostic code 7124.
    The revisions and additions read as follows:

[[Page 37605]]



Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
------------------------------------------------------------------------
                              Diagnostic
           Sec.                code No.
------------------------------------------------------------------------
 
                              * * * * * * *
4.104.....................  ..............  General Rating Formula for
                                             Diseases of the Heart
                                             [Effective date of final
                                             rule].
                                      7000  Evaluation July 6, 1950;
                                             evaluation September 22,
                                             1928, evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7001  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7002  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7003  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7004  Criterion September 22,
                                             1978; evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7005  Evaluation September 9,
                                             1975; evaluation September
                                             22, 1978; evaluation
                                             January 12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7006  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule]
                                      7007  Evaluation September 22,
                                             1978; evaluation January
                                             12, 1998; criterion
                                             [Effective date of final
                                             rule].
                                      7008  Evaluation January 12, 1998;
                                             evaluation [Effective date
                                             of final rule].
                                      7009  Added [Effective date of
                                             final rule].
                                      7010  Evaluation January 12, 1998;
                                             title, criterion [Effective
                                             date of final rule].
                                      7011  Evaluation January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
 
                              * * * * * * *
                                      7015  Evaluation September 9,
                                             1975; criterion January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7016  Added September 9, 1975;
                                             criterion January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
                                      7017  Added September 22, 1978;
                                             evaluation January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7018  Added January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7019  Added January 12, 1998;
                                             note, criterion [Effective
                                             date of final rule].
                                      7020  Added January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
 
                              * * * * * * *
                                      7110  Evaluation September 9,
                                             1975; evaluation January
                                             12, 1998; title, criterion,
                                             note [Effective date of
                                             final rule].
                                      7111  Criterion September 9, 1975;
                                             evaluation January 12,
                                             1998; note, criterion
                                             [Effective date of final
                                             rule].
 
                              * * * * * * *
                                      7113  Evaluation January 12, 1998;
                                             criterion [Effective date
                                             of final rule].
                                      7114  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; title, criterion,
                                             note [Effective date of
                                             final rule].
                                      7115  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; note, criterion,
                                             evaluation [Effective date
                                             of final rule].
 
                              * * * * * * *
                                      7117  Added June 9, 1952;
                                             evaluation January 12,
                                             1998; title, note
                                             [Effective date of final
                                             rule].
 
                              * * * * * * *
                                      7121  Criterion July 6, 1950;
                                             evaluation March 10, 1976;
                                             evaluation January 12,
                                             1998; criterion [Effective
                                             date of final rule].
                                      7122  Last sentence of Note
                                             following July 6, 1950;
                                             evaluation January 12,
                                             1998; criterion August 13,
                                             1998; criterion [Effective
                                             date of final rule].
 
                              * * * * * * *
                                      7124  Added [Effective date of
                                             final rule].
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Amend Appendix B to Part 4, Sec.  4.104 by:
0
 a. Adding, in numerical order, an entry for diagnostic code 7009;
0
b. Revising diagnostic codes 7010, 7110, 7114, and 7117; and
0
c. Adding, in numerical order, an entry for diagnostic code 7124.
    The revisions and additions read as follows:

          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
   Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
            The Cardiovascular System--Diseases of the Heart
------------------------------------------------------------------------
 
                              * * * * * * *
7009....................  Bradycardia (Bradyarrhythmia), symptomatic,
                           requiring permanent pacemaker implantation.
 

[[Page 37606]]

 
                              * * * * * * *
7010....................  Supraventricular tachycardia.
 
                              * * * * * * *
7110....................  Aortic aneurysm: ascending, thoracic,
                           abdominal.
 
                              * * * * * * *
7114....................  Peripheral arterial disease.
 
                              * * * * * * *
7117....................  Raynaud's syndrome (secondary Raynaud's
                           phenomenon).
 
                              * * * * * * *
7124....................  Raynaud's disease (primary Raynaud's
                           phenomenon, primary Raynaud's).
 
                              * * * * * * *
------------------------------------------------------------------------

0
6. Revise Appendix C to Part 4, Sec.  4.104 by:
0
a. Revising the entry for Aneurysm: Aortic: ascending, thoracic, 
abdominal;
0
b. Adding, in alphabetical order, under the entry for Bones an entry 
for Bradycardia (Bradyarrhthmia), symptomatic, requiring permanent 
pacemaker implantation;
0
c. Revising the entries for Hypertension (isolated systolic, diastolic, 
or combined systolic and diastolic hypertension) and Peripheral 
arterial disease;
0
d. Adding, in alphabetical order, under the entry for Pyelonephritis, 
chronic, an entry for Raynaud's disease (primary Raynaud's phenomenon, 
primary Raynaud's); and
0
e. Revising the entries for Raynaud's syndrome (Raynaud's phenomenon, 
secondary Raynaud's) and Supraventricular tachycardia.
    The revisions and additions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                            Diagnostic
                                                             code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Aneurysm:
    Aortic: ascending, thoracic, abdominal..............            7110
    Large artery........................................            7111
    Small artery........................................            7118
 
                              * * * * * * *
Arrhythmia:
    Ventricular.........................................            7011
 
                              * * * * * * *
Bones:
    Bradycardia.........................................            7009
    (Bradyarrhythmia), symptomatic, requiring permanent
     pacemaker implantation.............................
 
                              * * * * * * *
Peripheral arterial disease.............................            7114
 
                              * * * * * * *
Raynaud's disease (primary Raynaud's)...................            7124
Raynaud's syndrome (Raynaud's phenomenon, secondary                 7117
 Raynaud's).............................................
 
                              * * * * * * *
Supraventricular tachycardia............................            7010
 
                              * * * * * * *
------------------------------------------------------------------------


[[Page 37607]]

[FR Doc. 2019-15904 Filed 7-31-19; 8:45 am]
 BILLING CODE 8320-01-P