Schedule for Rating Disabilities: Neurological Conditions and Convulsive Disorders, 88917-88940 [2024-25665]

Download as PDF Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules DEPARTMENT OF VETERANS AFFAIRS 38 CFR Parts 3 and 4 RIN 2900–AQ73 Schedule for Rating Disabilities: Neurological Conditions and Convulsive Disorders Department of Veterans Affairs. Proposed rule. AGENCY: ACTION: The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or Rating Schedule) that addresses neurological conditions and convulsive disorders. The purpose of these changes is to incorporate medical advancements that have occurred since the last revision, update current medical terminology, and provide clear evaluation criteria. The proposed rule reflects advances in medical knowledge and recommendations contained in the report from the Institute of Medicine, part of the National Academy of Sciences, titled ‘‘A 21st Century System for Evaluating Veterans for Disability Benefits,’’ National Academies Press, 2007. SUMMARY: Comments must be received on or before January 13, 2025. ADDRESSES: Comments must be submitted through www.regulations.gov. Except as provided below, comments received before the close of the comment period will be available at www.regulations.gov for public viewing, inspection, or copying, including any personally identifiable or confidential business information that is included in a comment. We post the comments received before the close of the comment period on www.regulations.gov as soon as possible after they have been received. VA will not post on Regulations.gov public comments that make threats to individuals or institutions or suggest that the commenter will take actions to harm an individual. VA encourages individuals not to submit duplicative comments; however, we will post comments from multiple unique commenters even if the content is identical or nearly identical to other comments. Any public comment received after the comment period’s closing date is considered late and will not be considered in the final rulemaking. In accordance with the Providing Accountability Through Transparency Act of 2023, a plain language summary (not more than 100 words in length) of this proposed rule khammond on DSKJM1Z7X2PROD with PROPOSALS DATES: VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 is available at www.regulations.gov, under RIN 2900–AQ73. FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Medical Officer, Part 4 VASRD Staff (218), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, 218VASRDPMO.VBACO@va.gov, (202) 461–9700. (This is not a toll-free telephone number.) SUPPLEMENTARY INFORMATION: VA has periodically revised portions of the Schedule for Rating Disabilities, to include the Neurological Conditions and Convulsive Disorders (herein referred to as the Neurological body system), since it was created in 1919. Important advances in the neurological sciences—particularly in the areas related to biochemistry, genetics, physiopathology, as well as electrodiagnosis and imaging of the nervous system—have produced drastic changes in the understanding of neurological diseases since the second half of the 20th century. The extent and repercussion of these advances triggered profound changes in approaches to diagnosis, classification of disease, and care of patients with neurological illnesses. 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 (38 CFR) §§ 4.120 and 4.123–4.124a, which pertain to the neurological conditions and convulsive disorders. The proposed changes will: (1) update the medical terminology of certain neurological conditions and convulsive disorders; (2) add medical conditions frequently encountered but not currently found in the rating schedule; (3) refine evaluation criteria based on medical advances that have occurred since the last revision and current understanding of functional changes associated with or resulting from disease or injury (pathophysiology), and; (4) remove or modify certain diagnostic codes (DC) that are outdated or obsolete. I. Retitle and Revise §§ 4.120 Evaluations by Comparison, 4.123 Neuritis, Cranial or Peripheral, and 4.124 Neuralgia, Cranial or Peripheral VA proposes to retitle and revise § 4.120, Evaluations by comparison, because the approach to evaluating neurologic conditions has evolved over the time since this section was included in the 1945 rating schedule. See 29 FR 6718, 6749–6750 (May 22, 1964). As medical understanding has increased, the additional knowledge permits VA to PO 00000 Frm 00012 Fmt 4702 Sfmt 4702 88917 develop evaluation criteria within the individual diagnostic codes that more accurately consider motor, sensory, and mental impairment. The instructions contained in the last sentence of § 4.120, which apply to peripheral nerves, will be updated to better align with modern medical knowledge and relocated to the revised § 4.123, titled ‘‘Cranial and peripheral nerve impairment,’’ paragraph (a)(1). VA proposes to relocate instructions relating to organic diseases of the central nervous system to § 4.120. See section II B. Orgranic diseases of the central nervous system below for additional detail. VA also proposes to retitle and revise §§ 4.123 Neuritis, cranial or peripheral and 4.124 Neuralgia, cranial or peripheral. These sections provide information regarding symptoms and evaluations associated with neuritis and neuralgia. Neuritis and neuralgia are used to describe symptoms associated with motor and sensory neuropathy involving cranial and peripheral nerves. However, VA proposes their removal in favor of more objective criteria to assess disability in the cranial and peripheral nerves. In the 1940s, the term neuritis was advanced by Dr. S.A. Kinnier Wilson as an all-encompassing term for most peripheral nerve conditions. Dr. S.A. Kinnier Wilson, ‘‘Neurology,’’ 279 (Ninian Bruce ed., 1970). As the field of peripheral neuropathology evolved, it became apparent that use of the term neuritis was obsolete and should be replaced by neuropathy, the preferred term for peripheral nerve diseases. While neuritis is sometimes used as a synonym for neuropathy, this use is erroneous and should only be used for certain specified inflammatory diseases. Drs. A.K. Asbury & Peter Johnson, ‘‘Neurology,’’ 258 (James Bennington ed., 1978). While the term neuragia is still used today, for compensation purposes, VA evaluates nerves affected by neuralgia by the sensory impairment caused by neuralgia, not the diagnosis itself. To that end, and as discussed in more detail below, VA proposes to remove neuritis as a separate ratable condition for both cranial nerves (DC series 8300) and peripheral nerves (DC series 8600) and neuralgia as a separate ratable condition for both cranial nerves (DC series 8400) and peripheral nerves (DC series 8700). VA will address evaluations for motor neuropathy and sensory neuropathy in revised § 4.123, as discussed below. The underlying purpose behind the § 4.123 revision is to provide a central location for instructions specific to cranial and peripheral nerve conditions. This revision will promote rating E:\FR\FM\12NOP1.SGM 12NOP1 khammond on DSKJM1Z7X2PROD with PROPOSALS 88918 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules quality and consistency. First, VA proposes to retitle the section as ‘‘Cranial and peripheral nerve impairment.’’ Next, VA proposes informational language explaining, generally, how disabilities from cranial and peripheral nerve impairment are evaluated. After that, VA proposes to describe how disability from motor neuropathy (complete and incomplete paralysis) will be evaluated. Finally, VA proposes to describe how disability from sensory neuropathy will be evaluated. Concerning the general instructions described in the revised § 4.123, VA proposes to relocate to this section several instructions that are currently located in multiple areas. The current VASRD contains an instruction directly above diagnostic code 8205; this instruction explains that disability from lesions of peripheral portions of first, second, third, fourth, sixth, and eighth nerves are rated under the Organs of Special Sense. Additionally, it explains that the ratings for the cranial nerves are for unilateral involvement; when bilateral, combine but without the bilateral factor. VA proposes to revise these two sentences, add an additional sentence, and include them in § 4.123. Specifically, proposed § 4.123(a)(3) explains that a cranial nerve will be evaluated strictly as a cranial nerve, regardless of any portions which lie outside the cranium (skull). This is consistent with current medical practice which considers cranial nerves outside of the cranium as separate and distinct from other peripheral nerves. Proposed § 4.123(a)(3) further explains that the evaluations in the rating schedule for the cranial nerves are for unilateral involvement; when bilateral involvement occurs, evaluate separately, then combine under § 4.25 without using the bilateral factor. While all cranial nerves begin inside the cranium, most exit the cranium to insert at various destinations, where they function in a manner similar to peripheral nerves. Nevertheless, VA proposes to evaluate the entire nerve, uniformly, as a cranial nerve. Proposed § 4.123(a)(2) explains that disability from impairments of the first, second, third, fourth, sixth, and eighth cranial nerves will be rated under the Organs of Special Sense. Additionally, the current VASRD contains an instruction directly above diagnostic code 8510; this instruction states, in part, that ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. VA will add a reference to evaluate bilateral disabilities VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 separately, then combine using § 4.25 whenever bilateral involvement occurs; this will specify, as opposed to merely imply, how bilateral disabilities are to be evaluated. Additionally, VA will move the instruction to § 4.123(a)(4) because it is a general instruction since it applies to both motor and sensory impairment. Section 4.120 currently includes a sentence explaining that when rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. VA proposes the following changes to this sentence: clarify that the sentence applies to cranial and peripheral nerves; remove the reference to trophic changes, which do not consistently correlate to disability; replace the reference to motor function with a reference to movement or muscle strength, corresponding with the proposed evaluation criteria for cranial and peripheral motor nerve function, respectively; and relocate the sentence to § 4.123(a)(1). The purpose of these changes is to remedy confusion and inconsistent application of the instructions caused by the current placement of instructions in multiple locations. Therefore, VA proposes to combine them into a centralized location. Motor nerve impairment affects muscle function (typically by decreased muscle strength), which can have a significant impact on movement activities, including, but not limited to, walking and grasping. Therefore, VA proposes to focus the complete and incomplete paralysis sections of each cranial and peripheral nerve on motor nerve impairment. Concerning incomplete paralysis of cranial motor nerves, VA proposes to evaluate disability by replacing the current ‘‘severe’’ with ‘‘[a]ttempted movement with inability to complete such movement (muscle twitching present).’’ Additionally, VA proposes to revise the cranial evaluation criteria for ‘‘moderate’’ incomplete paralysis with ‘‘[m]uscle movement intact, but task performed with difficulty.’’ The proposed revisions replace subjective criteria with objective and measurable criteria, which will promote rating consistency and accuracy. Regarding cranial nerve notes, in the current VASRD, each cranial nerve criteria set contains a note describing functions of that particular nerve. These notes are currently placed after the ‘‘paralysis, incomplete’’ diagnostic code section of the individual nerve. VA proposes to update the notes to provide more detailed examples of affected PO 00000 Frm 00013 Fmt 4702 Sfmt 4702 nerve functions and move them, placing them below the evaluation criteria of each individual cranial nerve. VA proposes this change because each note applies to both sensory and motor impairment of the particular cranial nerve. Concerning peripheral motor nerves, VA proposes to evaluate disability by replacing the current rating criteria, which refer to complete and incomplete paralysis at the severe, moderate, and mild incomplete paralysis level, with criteria that align with the Medical Research Council (MRC) Scale for Muscle Strength (this is also commonly referred to as manual muscle testing). This scale is universally known and used throughout the medical community to evaluate peripheral nerves. ‘‘How to Assess Muscle Strength,’’ Merck Manual, https:// www.merckmanuals.com/professional/ neurologic-disorders/neurologicexamination/how-to-assess-musclestrength?query=Medical, (last reviewed February 2018). The MRC grades muscle strength on a range from ‘‘0’’ (completely paralyzed) to ‘‘5’’ (normal muscle function). ‘‘To distinguish among the various degrees of muscle strength within a given level, this scale has been modified with the addition of intermediate levels (e.g., 4+ and 4¥).’’ Frontera, W.R. ‘‘Delisa’s Physical Medicine & Rehabilitation: Principles and Practice,’’ 5th Edition, p 74 (2010). Instead of ‘‘mild,’’ VA will use Grade 4 muscle strength. This represents measurable muscle weakness. Instead of ‘‘moderate,’’ VA will use Grade 3 muscle strength. This represents muscle strength that can oppose gravity, but cannot oppose resistance greater than gravity. Instead of ‘‘moderately severe,’’ VA will use Grade 2+ muscle strength. This represents muscle strength that is unable to oppose gravity completely, though muscle strength with gravity eliminated is present. That is, muscle strength that is greater than Grade 2, but less than Grade 3. Only the sciatic nerve has a ‘‘moderately severe’’ category. Instead of ‘‘severe,’’ VA will use Grade 2 muscle strength. This represents muscle strength that, though present, cannot oppose gravity at all. Complete paralysis will be identified as Grade 0 muscle strength (no muscle contraction or complete paralysis) or Grade 1 muscle strength (meaning a flicker or trace of contraction). Id. The proposed revisions replace subjective criteria with objective and measurable criteria, which will promote rating consistency and accuracy. Regarding peripheral nerve instructions, in the current VASRD, there is a three-sentence instruction E:\FR\FM\12NOP1.SGM 12NOP1 khammond on DSKJM1Z7X2PROD with PROPOSALS Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules directly above DC 8510; this instruction explains, in part, that incomplete paralysis with peripheral nerve injuries indicates a degree of impaired function substantially less than the type picture for complete paralysis, whether due to varied level of the nerve lesion or to partial regeneration. VA proposes to leave this sentence intact with two aesthetic revisions. These revisions involve changing ‘‘picture’’ to ‘‘pictured’’ and ‘‘level’’ to ‘‘levels.’’ VA believes these revisions will enable the verbiage to flow more smoothly without changing the meaning. The third sentence will remain intact, with the addition of a reference to § 4.25 in the third sentence, as discussed above. Both sentences will be moved to this instructional section. The remaining sentence will be removed, as it refers to sensory nerve evaluation criteria that VA is proposing to revise. The purpose of these changes is to remedy confusion and inconsistent application of the instructions caused by the current placement of instructions in multiple locations. Therefore, VA proposes to combine them into the most appropriate location. Currently, each peripheral nerve includes a description in the entry for complete paralysis. For example, the entry for complete paralysis for DC 8510 for the upper radicular group (fifth and sixth cervicals) contains a description of all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected. VA proposes to remove all peripheral nerve descriptions. Since VA is changing the subjective criteria to objective criteria and examiners are aware of the muscles affected by each nerve, VA believes the descriptions are no longer needed. Concerning sensory neuropathy, sensory nerve impairment affects the ability to notice sensations, to include but not limited to, sharpness, heat, or coldness, and it can also produce abnormal spontaneous sensations, to include but not limited to, burning, tingling, and pain (pins and needles). Therefore, VA proposes to focus the sensory neuropathy sections of each nerve on sensory nerve impairment and remove neuritis and neuralgia as separate ratable conditions. Having separate diagnostic codes for neuritis and neuralgia requires VA to change the diagnostic code a veteran is rated under when the impairment associated with the condition changes, which creates additional work and complexity with no benefit to the veteran or VA. VA proposes to remove the diagnostic codes for neuritis and neuralgia, retitle the diagnostic codes addressing paralysis, and address motor and sensory VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 impairment as criteria under the retitled diagnostic codes. Additionally, in light of the removal of DCs 8619 and 8719, VA proposes to number the notes that will appear under DC 8519. In the current VASRD, the instructions under § 4.124, Neuralgia, cranial or peripheral, consist of three sentences. The first two sentences provide information regarding symptoms associated with neuralgia and instructions regarding the maximum evaluations for neuralgia. The last sentence provides rating instructions for tic douloureux. VA proposes to address sensory impairments in a new section, § 4.123(c). Instead of defining neuralgia, § 4.123(c)(1) will address altered sensation, with or without pain, on the basis of incomplete or complete sensory neuropathy. VA proposes to delete the last sentence of § 4.124, which addresses tic douloureux, because it is redundant. A note under the entry for the fifth (trigeminal) cranial nerve provides instructions on how to evaluate tic douloureux. The current evaluation criteria focus on neuritis, neuralgia, and degrees of paralysis, with a maximum rating for neuritis equal to severe, incomplete, paralysis of the nerve involved, and a maximum rating for neuralgia equal to moderate incomplete paralysis. There is also an instruction at the beginning of the schedule of ratings for diseases of the peripheral nerves indicating that the rating should be for the mild, or at most, the moderate degree when the involvement is wholly sensory. Certain cranial and all peripheral nerves are evaluated using neuritis, neuralgia, and degrees of paralysis, regardless if the nerve has only sensory function, only muscle function, or both sensory function and muscle function (found in mixed nerves). There are several problems with the current approach. While both neuritis and neuralgia involve distorted sensation, the disability associated with these distorted sensations cannot be quantified by objective diagnostic testing and is unpredictable. Furthermore, the evaluation criteria for pure sensory nerves are the same as for pure motor nerves and mixed nerves, which is incorrect from a medical science perspective. For example, the external cutaneous nerve of the thigh and the obturator nerve have the same evaluation criteria (varying degrees of paralysis, which currently form the basis for rating neuritis and neuralgia), even though it is scientifically incorrect to evaluate a pure sensory nerve, such as the external cutaneous nerve of the thigh, for paralysis. It is this difficulty with measurement, unpredictability, PO 00000 Frm 00014 Fmt 4702 Sfmt 4702 88919 and inappropriate application of certain evaluation criteria that VA seeks to remedy with the following proposed changes. VA proposes to change the sensory evaluation criteria to a more easily measured sensory deprivation standard. Impairment of sensory function will be quantified as either incomplete or complete sensory deprivation. This simplifies the evaluation criteria and is much more easily measured during physical examination. These criteria will be applied to certain cranial nerves as well as all peripheral nerves. Muscle function in certain cranial nerves and all peripheral nerves will be evaluated in isolation using the previously discussed methods. Using the incomplete/complete characterization of sensory deprivation described above, VA proposes to use a more straightforward description for disability when sensory neuropathy is involved. VA will consider sensory neuropathy as incomplete when sensation is impaired, although not absent, or when unpleasant sensations are experienced by the nerve such as dysesthesia, numbness, or paresthesia. Dysesthesia refers to any unpleasant sensation produced by a stimulus that is normally painless. Numbness refers to a sense of heaviness, weakness, or deadness in part of the body. Paresthesia refers to abnormal spontaneous sensations such as burning, tingling, pins and needles, etc. Clinical Neurology, 11th Edition, 2021, Chapter 10: Sensory Disorders. editors Greenberg, D.A., Aminoff, M.J., and Simon, R.P. VA will consider sensory neuropathy complete when sensation is absent. In cranial nerves, which have compensable evaluations at the moderate evaluation level, VA will assign an evaluation at the moderate evaluation level if there is incomplete or complete sensory neuropathy. However, this will not be applied to the eleventh cranial nerve, also known as the spinal accessory nerve, because it only has a muscle function. For peripheral nerves, which mostly have compensable evaluations at the mild evaluation level, VA will assign an evaluation similar to the mild evaluation if there is incomplete sensory neuropathy. VA will assign an evaluation similar to the moderate evaluation if there is complete sensory neuropathy. Where the evaluation of a peripheral nerve remains the same whether it is at the mild or moderate evaluation level (DCs 8525, 8527, 8528, 8529, and 8530), VA will assign an evaluation at the moderate evaluation if there is incomplete or complete sensory neuropathy. E:\FR\FM\12NOP1.SGM 12NOP1 88920 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules II. Schedule of Ratings—Neurological Conditions and Convulsive Disorders khammond on DSKJM1Z7X2PROD with PROPOSALS A. Location of Section Currently, the schedule of ratings for the Neurological body system is located in 38 CFR 4.124a. When the 1945 VA Schedule for Rating Disabilities was originally published in title 38 of the Code of Federal Regulations in 1964, VA organized it such that specific body systems started at specific locations. The Musculoskeletal body system, for example, began in § 4.40 even though the preceding section was § 4.31, leaving sections §§ 4.32 through 4.39 without content. See 29 FR 6718, 6722 (May 22, 1964). VA also designed the Rating Schedule so that the Mental Disorders body system started with § 4.125; however, due to the number of sections necessary to establish the Neurological body system, which precedes the Mental Disorders body system, the schedule of ratings for neurological conditions and convulsive disorders was placed in § 4.124a. See 29 FR 6718, 6749–53 (May 22, 1964). As proposed above, disability previously addressed in § 4.124 will now be addressed in the revision of § 4.123, which makes § 4.124 available. Therefore, VA also proposes to relocate the Schedule of Ratings from § 4.124a to § 4.124 and remove § 4.124a. VA proposes corresponding revisions to the references to § 4.124a in 38 CFR 3.809(d) and 38 CFR 4.71a, DC 5244. B. Organic Diseases of the Central Nervous System Currently, the introductory instruction under § 4.124a provides guidance concerning how to evaluate residuals of organic diseases of the central nervous system. There is a note currently located under DC 8025, Myasthenia gravis, which also provides guidance concerning how to evaluate residuals of organic diseases of the central nervous system. VA proposes to consolidate both notes, revising them and relocating them to § 4.120. VA further proposes to specify the diagnostic codes to which the instructions apply in order to promote consistent application of the VASRD. First, VA proposes to clarify when ascertainable residuals are required. For diagnostic codes 8000–8036, there are 2 categories of diagnostic codes that consider minimum evaluations: unconditional and conditional minimums. Unconditional minimum diagnostic codes are 8002, 8004, 8007, 8010, 8018, 8021, 8023, 8024, and 8025. The aforementioned diagnostic codes do not require ascertainable residuals for a minimum evaluation, and will not VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 require ascertainable residuals in this proposed regulation. For DCs 8004 and 8007, which have unconditional minimums within the proposed General Rating Formula, VA proposes Note (1) to direct the rater to grant a minimum evaluation of 30 percent for Parkinson’s disease (8004), regardless of examination findings. VA proposes Note (2) to direct the rater to grant a minimum evaluation of 10 percent for stroke residuals (8007), regardless of examination findings. No minimum evaluations will be available for DCs 8026, 8027, and 8028. Conditional minimum DCs 8000, 8003, 8011, 8012, 8019, 8020, 8022, and new 8036 all require ascertainable residuals. Examples of ascertainable residuals to be considered include, but are not limited to, psychotic manifestations, loss of use of an extremity (partial or complete), as well as abnormal speech, vision, gait, or coordination. Finally, in the portion of the instruction addressing determinations as to the presence of residuals not capable of objective verification, VA proposes to specify that such determinations must be approached on the basis of disability related to the diagnosis recorded, rather than simply the diagnosis recorded, as the current instruction provides. The revised language is more consistent with 38 CFR 4.1, which provides that the rating schedule is primarily a guide in the evaluation of disability resulting from diseases and injuries encountered as a result of or incident to military service. In regard to peripheral nerves and paralysis, VA proposes to replace the reference to mild, moderate, severe, or complete paralysis of peripheral nerves with a reference to complete or incomplete paralysis to account for changes in the way paralysis of peripheral nerves will be evaluated as referenced above. With respect to ratings in excess of the prescribed minimum ratings, VA proposes to replace the current language directing raters to cite the diagnostic codes utilized as bases of evaluation in addition to the codes identifying the diagnoses with a reference to § 4.27, as that section includes instructions for the use of diagnostic code numbers when a disease is rated on the basis of residual conditions. C. Diagnostic Code 8000, Encephalitis, Infectious Current DC 8000 is titled ‘‘Encephalitis, epidemic, chronic.’’ The use of the term ‘‘epidemic’’ was used to describe an outbreak of encephalitis lethargica from 1918 to 1930. Dr. R.R. PO 00000 Frm 00015 Fmt 4702 Sfmt 4702 Dourmashkin, ‘‘What Caused the 1918– 1930 Epidemic of Encephalitis Lethargica?,’’ 90 Journal of the Royal Society of Medicine 515, 515–520 (1997). Since that outbreak, a recurrence of the epidemic has not been reported. ‘‘Encephalitis Lethargica Information Page,’’ National Institute of Health— National Institute of Neurological Disorders and Stroke, https:// www.ninds.nih.gov/health-information/ disorders/encephalitis (last visited September 18, 2024). Given the infrequency with which this specific type of encephalitis occurs, VA proposes to rename DC 8000 as ‘‘Encephalitis, infectious’’ to better reflect the disabilities currently evaluated under this DC. As a broader disease category, infectious encephalitis refers to an irritation and swelling of the brain caused by viral, bacterial, fungal, or parasitic infection. Symptoms of this disease can be quite severe and include loss of consciousness, seizures, paralysis, and sudden change in mental functions. The residuals of infectious encephalitis vary from full recovery to permanent disabilities and, in some cases, death. ‘‘Encephalitis,’’ National Institute of Health—U.S. National Library of Medicine (Aug. 31, 2016), https://medlineplus.gov/ency/article/ 001415.htm (last visited April 3, 2018). No changes to the evaluation criteria are proposed. D. Diagnostic Code 8002, Brain, New Growth of, Malignant and Diagnostic Code 8003, Brain, New Growth of, Benign Current DC 8002 is titled ‘‘Malignant,’’ and current DC 8003 is titled ‘‘Benign, minimum.’’ VA proposes changes to these diagnostic codes to correct current poor formatting. Both are intended to be read in conjunction with the general category of ‘‘Brain, new growth of.’’ To clarify the conditions covered under these DCs, VA proposes to rename these disabilities as DC 8002, ‘‘Brain, new growth of, malignant,’’ and DC 8003, ‘‘Brain, new growth of, benign.’’ Current DC 8002 also contains a note that is located between the 100 percent and the 30 percent evaluation levels. Previously, this diagnostic code had a 100 percent evaluation level and its note contained information regarding the 30 percent minimum rating. See 43 FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have placed the note between the 100 percent and the 30 percent evaluation levels. Notes are typically found after evaluative criteria. Therefore, VA proposes to relocate this note after the 30 percent evaluation E:\FR\FM\12NOP1.SGM 12NOP1 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules khammond on DSKJM1Z7X2PROD with PROPOSALS level and to revise it to ensure that rating personnel understand how it applies to the both the 100 percent and 30 percent evaluation levels. Current DC 8003 provides a minimum evaluation of 60 percent in the presence of a benign growth of the brain and then directs raters to evaluate based upon residuals, with a minimum evaluation of 10 percent. VA proposes to clarify the 60 percent evaluation by indicating that it applies during the presence of an active benign growth of the brain or during active treatment. By adding this additional information to the 60 percent evaluation criteria, VA will promote consistency of evaluations and avoid premature re-evaluation of the disability prior to successful treatment of the benign growth. VA proposes no other changes to these diagnostic codes. E. Diagnostic Code 8004, Parkinson’s Disease (Paralysis Agitans) Current DC 8004 is titled ‘‘Paralysis agitans,’’ which is Latin for shaking palsy. While these terms are accurate descriptors of the disability, the more commonly used and accepted medical terminology is Parkinson’s disease (PD). To clarify the disability evaluated under this diagnostic code as well as to make the VASRD more user-friendly to nonmedical personnel, VA proposes to rename this diagnostic code ‘‘Parkinson’s disease.’’ VA proposes to preserve the historical reference in parentheses. VA also proposes to adopt evaluation criteria that reflect a modern understanding of this condition within a proposed general rating formula (GRF). VA proposes the creation of a GRF for certain movement disorders within the neurological body system due to the similarities of disabling effects and high frequency of misdiagnosis. By implementing a GRF, the rating process will be standardized as well as simplified based on disability presentation for a group of conditions. Additionally, the use of a GRF for these movement disorders will ensure the avoidance of pyramiding when more than one movement disorder is service connected. Pyramiding occurs when two or more evaluation percentages are awarded for the same disability under various diagnoses. In accordance with 38 CFR 4.14, pyramiding must be avoided. When two or more movement disorders are service-connected, unless none of the symptomatology of a movement disorder is duplicative of or overlapping with the symptomatology of another movement disorder, one evaluation percentage will be awarded based on the highest level of disability represented by the rating criteria that VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 more nearly approximates the disability picture attributable to the serviceconnected movement disorders. 38 CFR 4.7. VA proposes to title the GRF ‘‘General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028)’’. VA proposes 0, 10, 30, 60, and 100 percent evaluations to the newly proposed GRF, and it will be placed immediately below DC 8004. Lastly, specific to PD, VA proposes to continue the minimum 30 percent evaluation for a formal diagnosis of PD, as explained in the first note following the proposed GRF. Recent advances in the understanding of PD have produced several assessment scales that describe discrete levels of increasing disability. The Revised Unified Parkinson’s Disease Rating Scale (2008) is a sophisticated, complex scale widely used by clinicians. The level of sophistication and specificity, however, is not required to describe occupationally significant disability. The Hoehn-Yahr Parkinson’s Disease scale, which has been in use since 1967, is far simpler to use and apply. VA proposes to base the disability criteria on this scale with direct reference to Hoehn-Yahr stages and descriptions of functional limitation associated with that severity of disease. VA recognizes that this scale was specifically developed for PD. However, other movement disorder evaluation tools are similar to Hoehn-Yahr. Thus, it was determined this was a reliable tool to adapt to multiple movement disorders. Parkinson’s Resource Organization, The Five Stages of Parkinson’s Disease, https://www.parkinsonsresource.org/wpcontent/uploads/2012/01/The-FIVEStages-of-Parkinsons-Disease.pdf, May 2002. In addition, where appropriate, VA considered and incorporated features of other movement disorder scales. Those additions are noted under the specific movement disorder discussions below. The GRF will list the evaluation criteria first, followed by several notes. The first note will direct raters to evaluate all cases of PD with a minimum rating of 30 percent. A second note is specific to stroke residuals rated under DC 8007 and directs raters to evaluate stroke residuals with a minimum rating of 10 percent. A third note defines activities of daily living. A fourth note instructs the rater how to evaluate symptoms versus separate and distinct diagnoses. For example, when an impairment such as depression is noted as a symptom versus a formal diagnosis, then it will be evaluated using the GRF for Specified Neurologic Conditions. Conversely, if there is a formal diagnosis, then the disorder will PO 00000 Frm 00016 Fmt 4702 Sfmt 4702 88921 be evaluated separately under § 4.130 (Schedule of ratings—mental disorders). These instructions mirror the current instructions related to the Residuals of Traumatic Brain Injury. The fifth note addresses overlap of manifestations. It instructs rating specialists to evaluate comorbid conditions together when they cannot be delineated. These instructions also mirror the current instructions related to the Residuals of Traumatic Brain Injury. The sixth note reminds raters to consider special monthly compensation. VA proposes the rating criteria under the GRF to consist of the following. A 100 percent evaluation will be given for ‘‘Hoehn-Yahr stage 4 or stage 5, or; the inability to live independently because of neurologically-related disability.’’ A 60 percent evaluation will be given for ‘‘Impairment of mobility (e.g., transfers, balance, or gait) requiring daily use of an assistive device such as a wheelchair, brace(s), crutch(es), cane(s), or walker.’’ A 30 percent evaluation will be given for ‘‘Hoehn-Yahr stage 3, or; impairment of mobility (e.g., transfers, balance, or gait) requiring less than daily use of an assistive device such as a wheelchair, brace(s), crutch(es), cane(s), or walker.’’ A 10 percent evaluation will be given for ‘‘Hoehn-Yahr stage 2, or; impairment in at least one of the following areas: facial expression (e.g., masking, blinking, or eye motion abnormalities); speech (e.g., soft voice, slurring, difficulty speaking or swallowing); posture (e.g., stooping, instability); mobility not requiring an assistive device (e.g., decreased speed with transfers, gait ataxia, unstable balance); problems initiating or controlling motor movements (e.g., stiffness, tremors); cognitive (e.g., memory or executive problems); mental (e.g., anxiety, depression, social phobia); sensory abnormalities (e.g., olfactory deficits); involuntary muscle contractions resulting in pain and impairment, such as but not limited to, spontaneous neck turning or writing difficulty.’’ A 0 percent evaluation will be given for ‘‘Hoehn-Yahr stage 1, or; formal diagnosis without impairment.’’ F. Diagnostic Code 8007, Stroke (Ischemic, Hemorrhagic, or Thrombotic), Including Cerebral Infarction or Cerebrovascular Accident (Brain, Vessels, Embolism, Thrombosis, and Hemorrhage); Diagnostic Code 8008 Brain, Vessels, Thrombosis of (Delete); Diagnostic Code 8009 Brain, Vessels, Hemorrhage From (Delete) VA proposes to combine three DCs (8007, Brain, vessels, embolism of; 8008, Brain, vessels, thrombosis of; and 8009, Brain, vessels, hemorrhage from) under E:\FR\FM\12NOP1.SGM 12NOP1 khammond on DSKJM1Z7X2PROD with PROPOSALS 88922 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules DC 8007 and rename it as ‘‘Stroke (ischemic, hemorrhagic, or thrombotic), including cerebral infarction or cerebrovascular accident (Brain, vessels, embolism, thrombosis, and hemorrhage).’’ Since most clinicians document the condition as ‘‘stroke’’ rather than embolism, thrombosis, or hemorrhage, raters are unable to distinguish which title most accurately aligns with ‘‘stroke,’’ which means there is a risk that rating specialists will not consistently apply these DCs. For example, three raters evaluate three veterans diagnosed with residuals of a stroke. One rater chooses to use DC 8007; another uses DC 8008; and the other uses DC 8009. All three disabilities currently have the same evaluation criteria. Therefore, the veterans are not at a disadvantage from receiving one DC over the other. However, for statistical purposes, combining these three DCs would promote consistency in future research associated with stroke residuals. Because all three of the current diagnostic codes evaluate stroke residuals in the same way, VA proposes to combine them in order to create diagnostic code application consistency. Additionally, while the distinction concerning the type of stroke is a medical necessity for treatment purposes, it is irrelevant for rating purposes. This proposed update will create more consistent data tracking for disability compensation research purposes. Currently, rating personnel grant a 100 percent evaluation for the first six months, then assign a minimum rating of 10 percent for stroke residuals, unless an evaluation of residuals under separate body systems results in a higher evaluation. Under the proposed changes, whenever diagnostic imaging, which is part of standard care for a stroke, identifies a stroke, rating personnel will continue to grant a 100 percent evaluation for the first six months; they will also continue to assign a minimum 10 percent for stroke residuals regardless of examination findings. Rating personnel will assign evaluations higher than the minimum in accordance with the General Rating Formula for Specified Neurologic Conditions (GRF). As explained in the fourth note of the GRF, if a residual is a symptom of the stroke, it will be evaluated as such. Contrarily, if a residual has a separate and distinct formal diagnosis, it will be service connected and evaluated separately. For example, if depression is noted as a symptom, it will be evaluated as part of the minimum 10 percent evaluation. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 However, if depression is a separate and distinct formal diagnosis, it will be service connected on a secondary basis and evaluated under § 4.130 (Schedule of ratings—mental disorders). See DC 8004 for details about the GRF. G. Diagnostic Code 8018, Multiple Sclerosis and Other Demyelinating Diseases of the Central Nervous System VA proposes to revise the title for this diagnostic code. The new title will be Multiple sclerosis (MS) and other demyelinating diseases of the Central Nervous System. The underlying basis for this revision is the existence of two conditions which present with disabilities similar to MS. VA proposes to evaluate neuromyelitis optica spectrum disorder (NMOSD) under this DC. Previously, NMOSD was rated analogously with DC 8010, Myelitis. Myelin oligodendrocyte glycoprotein antibody—associated disease (MOGAD) is the other condition to be captured with this DC. Like NMOSD, MOGAD also presents with a similar disability picture to MS. Wu, H. and Fisher, K., Current Diagnosis & Treatment Pediatric Neurology, Chapter 35. 2023. H. Diagnostic Code 8021, Spinal Cord, New Growths of, Malignant and Diagnostic Code 8022, Spinal Cord, New Growths of, Benign Current DC 8021 is titled ‘‘Malignant,’’ and current DC 8022 is titled ‘‘Benign.’’ VA proposes changes to these DCs to correct current poor formatting. Both were intended to be read in conjunction with the general category ‘‘Spinal cord, new growths of.’’ For the same reasons set forth above in the discussion for DC 8002, VA proposes to rename DC 8021 ‘‘Spinal cord, new growths of, malignant,’’ and DC 8022 ‘‘Spinal cord, new growths of, benign.’’ VA also proposes to clarify the 60 percent evaluation criteria for DC 8022 for the same reasons set forth in the discussion for DC 8003. Additionally, current DC 8021 also contains a note that is located between the 100 percent and the 30 percent evaluation levels. Previously, this DC had a 100 percent evaluation level and its note contained information regarding the 30 percent minimum rating. See 43 FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have placed the note between the 100 percent and the 30 percent evaluation levels. Notes are typically found after evaluative criteria. Therefore, VA proposes to relocate this note after the 30 percent evaluation level and to revise it to ensure that rating personnel understand how it applies to the both the 100 percent and 30 percent PO 00000 Frm 00017 Fmt 4702 Sfmt 4702 evaluation levels. VA proposes no other changes to these DCs. I. Diagnostic Code 8025, Myasthenia Gravis VA proposes to relocate and modify the note currently located directly below the rating criteria of DC 8025. It will be relocated to the introductory instruction under § 4.124. Refer to the above section, ‘‘B. Organic diseases of the central nervous system,’’ and § 4.124 for further details concerning this instruction. J. New Diagnostic Code 8026, Parkinson’s Plus, or Secondary Parkinsonism Syndromes VA proposes to add a new DC 8026, titled ‘‘Parkinson’s plus, or secondary parkinsonism syndromes,’’ in order to account for impairment due to this condition in the veteran population. Parkinson’s plus syndromes cause similar symptoms and impairment to Parkinson’s disease, but have other features that make them different. Parkinson’s plus syndromes have several causes, which include but are not limited to different location of protein buildup, brain injury, encephalitis, meningitis, stroke, medications, and chemical poisonings. Parkinson’s plus syndromes can cause impairment in facial expressions, problems with initiating or controlling motor movements, paralysis, vocal impairment, stiffness, and tremor. Treatment for Parkinson’s plus syndromes, as well as the likelihood and extent of residual disability, depends on the underlying cause of the disorder. This is in contrast to primary Parkinson’s, or Parkinson’s disease, where there is a predictable progression. For this reason, Parkinson’s plus syndrome will not have a minimum evaluation. ‘‘Secondary Parkinsonism,’’ National Institute of Health—U.S. National Library of Medicine (Jan. 19, 2018), https://medlineplus.gov/ency/ article/000759.htm (last visited April 3, 2018). VA is proposing a specific diagnostic code for Parkinson’s plus syndromes to allow for proper tracking of Parkinson’s plus and Parkinson’s disease in the veteran population. Parkinson’s plus will be evaluated under the General Rating Formula for Specified Neurologic Conditions (GRF). See DC 8004 for details about the GRF. K. New Diagnostic Code 8027, Essential Tremor VA proposes to add a new DC 8027, titled ‘‘Essential tremor,’’ in order to account for impairment due to this condition. There is currently no standalone diagnostic code to account E:\FR\FM\12NOP1.SGM 12NOP1 khammond on DSKJM1Z7X2PROD with PROPOSALS Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules for essential tremor, forcing rating personnel to rely on analogous coding and leading to inconsistent evaluations. ‘‘Tremor is defined as a rhythmical, involuntary, oscillatory movement of a body part and is one of the most frequent movement disorders.’’ Teive, H.A.G., ‘‘Essential Tremor: phenotypes,’’ (18) S1, pp 140–142, 140, Parkinsonism and Related Disorders (2012). ‘‘Essential tremor (ET) is one of the most common neurological diseases and the [most common] cause of pathological tremor.’’ Id. ‘‘Historically[,] ET was defined as a benign entity.’’ Id. However, recently it ‘‘was suggested that it is time to remove the ‘benign’ from the ET label, as it has been shown to be progressive in nature and quite disabling for most patients.’’ Id. ‘‘In the last [several] years[,] ET has evolved into two different meanings.’’ Id. First, ‘‘the classical ET, as a monosymptomatic disorder, and second, a heterogeneous disorder, the Essential Tremors, or a family of diseases.’’ Id. Currently, ‘‘ET can be classified with both motor and nonmotor elements. Tremor may occur also in the legs, feet, trunk, jaw, chin, tongue, and voice. Although postural and kinetic tremors are the main features of ET, intentional tremor and tremor at rest may also occur in some patients. Other motor features described in patients with ET are gait ataxia, postural instability[,] and eye-motion abnormalities. Non-motor features include cognitive (memory and executive problems and dementia), psychiatric (anxiety, depression[,] and social phobia), and sensory abnormalities (olfactory deficits [and] hearing loss).’’ Id. In developing evaluation criteria for ET, one of the most significant challenges is little, if any, outcomes research that would assist in criteria development. However, there are two well-recognized tools VA used to research this condition. The first tool is the International Classification of Functioning, Disability, and Health (2001), published by the World Health Organization, that provided terminology and definitions. According to this resource, ET involves the dysfunction of specific elements within the central nervous system. The tremors with ET are the impairments resulting from that nervous system dysfunction. Those tremors cause activity limitations and participation restrictions that can lead to earnings loss. The second tool is the 6th Edition Guides to the Evaluation of Permanent Impairment (2008), published by the American Medical Association. The guide has impairment tables for the upper extremities, gait, VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 and station. These tools were considered in the creation of a general rating formula. Another significant challenge in developing evaluation criteria for ET is the high rate of misdiagnosis with other movement disorders, such as dystonia and Parkinson’s disease. Misdiagnosis occurs in up to 50 percent of cases, with Parkinson’s disease (particularly in elderly patients) and dystonia (tremulous cervical dystonia) being the most common disorders mistaken for ET. Therefore, VA proposes the creation and use of a General Rating Formula for Specified Neurologic Conditions (GRF) for this and other movement disorders, allowing evaluation to focus on the symptoms and impairment present, even when misdiagnosis and/or a change in diagnosis occurs. See diagnostic code 8004 for details about the GRF. Teive, H.A.G., ‘‘Essential Tremor: phenotypes,’’ (18) S1, pp 140– 142, Parkinsonism and Related Disorders (2012). L. New Diagnostic Code 8028, Dystonia VA proposes to add a new DC 8028, titled ‘‘Dystonia,’’ in order to account for impairment due to this condition. There is currently no standalone diagnostic code to account for dystonia, forcing rating personnel to rely on analogous coding and leading to inconsistent evaluations. Dystonia causes involuntary muscle contractions that lead to slow, repetitive, and sometimes painful movement or abnormal posture. Dystonia can affect only one muscle, groups of muscles (torticollis), or muscles throughout the entire body. The specific symptoms and impairment experienced depend highly on the type of dystonia and the muscles affected, but can include difficulty walking, involuntary neck turning, difficulty speaking, writing, and uncontrollable blinking. Some cases of dystonia only affect a muscle group when performing a specific action. ‘‘Dystonias Fact Sheet,’’ National Institute of Health— National Institute of Neurological Disorders and Stroke (June 3, 2014), https://www.ninds.nih.gov/healthinformation/disorders/tremor#tocwhere-can-i-find-more-informationabout-tremor- (last visited September 18, 2024). The Dystonia Study Group composed of renowned international movement disorder experts developed the unified dystonia rating scale and the global dystonia rating scale to serve as instruments to medically assess dystonia severity. ‘‘Rating Scales for Dystonia: A Multicenter Assessment,’’ Comella C et al., 2003 Movement PO 00000 Frm 00018 Fmt 4702 Sfmt 4702 88923 Disorders 18 No.3 pp 303–12. These scales were considered during the creation of the general rating formula. Due to similarity and overlap of symptoms with other movement disorders, along with the high prevalence of misdiagnosis, VA proposes application of a General Rating Formula for Specified Neurologic Conditions (GRF). See DC 8004 for details about the GRF. M. New Diagnostic Code 8036, Primary Lateral Sclerosis VA proposes to add a new DC 8036, titled ‘‘Primary lateral sclerosis,’’ in order to account for impairment due to this condition. There is currently no standalone diagnostic code to account for primary lateral sclerosis (PLS). A standalone diagnostic code will permit more accurate tracking of this condition, and its associated disability. PLS is a motor neuron disease that affects the upper motor neurons in the arms, legs, and face. Individuals with PLS first experience loss of muscle control in the feet and legs, then the disease progresses up the trunk and into the arms, hands, and the muscles that control speech, swallowing, and chewing. PLS can be differentiated from amyotrophic lateral sclerosis in that it only affects the upper motor neurons and progresses gradually. While there is no cure for PLS, it is not considered a fatal disease, and many individuals maintain the ability to walk without assistance, although they may eventually need a cane or walker due to the development of high degrees of spasticity. Due to the wide range of symptoms and severity upon confirmation of diagnosis, VA proposes to evaluate PLS according to the residual impairment under the appropriate diagnostic code with a minimum rating of 10 percent when there are ascertainable residuals. See R. Ramanathan, et al., ‘‘Demographics and clinical characteristics of primary lateral sclerosis: case series and a review of literature,’’ Neurodegener. Dis. Manag., vol 8(1), pp 17–23. 2018. N. Diagnostic Code 8103, Hemifacial Spasm (Tic, Convulsive) Current DC 8103 is titled ‘‘Tic, convulsive,’’ a facial nerve disorder that causes involuntary spasms and contractions of the facial nerves. For consistency, clarity, and ease of use of the VASRD by non-medical personnel, VA proposes to rename this diagnostic code ‘‘Hemifacial spasm.’’ Hemifacial spasm, an alternative name for convulsive tic, provides a much more explicit indication as to the condition to be evaluated under this diagnostic code E:\FR\FM\12NOP1.SGM 12NOP1 88924 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules in terms of the anatomical location to be considered. VA proposes to preserve the historical reference to the nomenclature in parentheses. VA proposes no other changes to this diagnostic code. O. Diagnostic Code 8104, Paramyoclonus Multiplex (Convulsive State, Myoclonic Type) The current evaluation criteria for DC 8104, Paramyoclonus multiplex (convulsive state, myoclonic type), directs rating personnel to rate this condition as convulsive tic, which is DC 8103. As discussed above, VA is updating this term to hemifacial spasm Diagnostic code 8514 8518 8521 8522 8523 8524 8526 8527 8529 ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... in order to reflect current medical terminology. As such, VA proposes to replace ‘‘tic; convulsive’’ in the evaluation criteria of DC 8104 to maintain consistency throughout this portion of the VASRD. VA proposes no other changes to this DC. Sydenham’s chorea, matching the title of the DC that provides the appropriate evaluation criteria. VA proposes no other changes to this DC. P. Diagnostic Code 8107, Athetosis, Acquired Current DC 8107, Athetosis, acquired, directs rating personnel to evaluate this condition as chorea. To clarify these instructions and promote consistency in evaluations, VA proposes to specify that this condition should be evaluated as To reflect current medical terminology, VA proposes to update the names of the following peripheral nerves. The proposed titles are the current accepted nomenclature to describe these nerves. VA proposes to preserve the historical reference to the nomenclature in parentheses. Q. Title Changes to Certain Peripheral Nerves Current title for nerve Proposed title for nerve Musculospiral nerve (radial nerve) .................................. Circumflex nerve ............................................................. External popliteal nerve (common peroneal) .................. Musculocutaneous nerve (superficial peroneal) ............. Anterior tibial nerve (deep peroneal) .............................. Internal popliteal nerve (tibial) ......................................... Anterior crural nerve (femoral) ........................................ Internal saphenous nerve ............................................... External cutaneous nerve of thigh .................................. 1 ‘‘Dorland’s Illustrated Medical Dictionary,’’ 1123 (Douglas M. Anderson et al. eds., J., ‘‘Segmental Neurology’’, page 20, 1981. 3 ‘‘Common Peroneal Nerve Dysfunction,’’ National Institute of Health—U.S. medlineplus.gov/ency/article/000791.htm (last visited April 3, 2018). 4 ‘‘Dorland’s Illustrated Medical Dictionary,’’ 1124 (Douglas M. Anderson et al. eds., 5 ‘‘Dorland’s Illustrated Medical Dictionary,’’ 1120 (Douglas M. Anderson et al. eds., Radial nerve (musculospiral).1 Axillary nerve (circumflex).2 Common peroneal nerve (external popliteal).3 Superficial peroneal nerve (musculocutaneous).1 Deep peroneal nerve (anterior tibial).1 Tibial nerve (internal popliteal).4 Femoral nerve (anterior crural).5 Saphenous nerve (internal saphenous).1 Lateral cutaneous nerve of the thigh (external cutaneous).5 27th ed. 1988). 2 Wolf, R. Diagnostic Code 8514, Paralysis of the Musculospiral (Radial) Nerve khammond on DSKJM1Z7X2PROD with PROPOSALS Current DC 8514 addresses motor impairment from diseases affecting the musculospiral nerve. The current evaluation criteria include a note that references dissociation of extensor communis digitorum and paralysis below the extensor communis digitorum, as well as instructing evaluations of these findings should not exceed a moderate rating. As stated previously, this nerve will be retitled as the radial nerve. Additionally, the note will be revised, as the evaluation criteria will be revised to employ the grade of muscle strength as the means to distinguish evaluation levels, with the maximum evaluation level corresponding to Grade 3 muscle strength for dissociation of extensor communis digitorum and paralysis below the extensor communis digitorum. S. Diagnostic Code 8520, Paralysis of the Sciatic Nerve Current DC 8520 addresses motor impairment due to diseases of the sciatic nerve. The nerve referenced by this diagnostic code stimulates the muscles of the entire lower extremity. While all other peripheral nerve criteria VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 National Library of Medicine (Aug. 7, 2017), https:// 27th ed. 1988). 27th ed. 1988). consist of mild, moderate, and severe, this one includes an extra category labeled moderately severe. In order to preserve the current evaluation levels and account for this extra category, VA proposes to revise the incomplete paralysis criteria at the 60 percent, 40 percent, 20 percent, and 10 percent levels. A 60 percent evaluation will be granted for muscles that have grade 2 strength (previously labeled severe). A 40 percent evaluation will be granted for muscles that have grade 2+ strength (previously labeled moderately severe). A 20 percent evaluation will be granted for muscles that have grade 3 strength (previously labeled moderate). A 10 percent evaluation will be granted for muscles that have grade 4 strength (previously labeled mild). Refer to the discussion above regarding § 4.123 for further details concerning the grading scale for motor impairment. T. Diagnostic Code 8527, Sensory Neuropathy of the Internal Saphenous Nerve Current DC 8527 addresses paralysis of the internal saphenous nerve. Paralysis refers to the lack of muscle function in muscle fibers. Posterior roots of the spinal nerves, including the saphenous nerve, do not have motor fibers, making it a pure sensory nerve. PO 00000 Frm 00019 Fmt 4702 Sfmt 4702 M. De Maeseneer, et al., ‘‘Normal Anatomy and Compression Areas of Nerves of the Foot and Ankle: US and MR Imaging With Anatomic Correlation,’’ Radiographics, vol 35, 1474–1475, 1469–1482 (2015). As a purely sensory nerve, the saphenous nerve has no muscle involvement and therefore using paralysis to describe impairment of this nerve is medically inaccurate. VA proposes to retitle DC 8527 to improve medical accuracy, and motor neuropathy will not be included in the criteria for this nerve. Because this nerve currently has a compensable rating only at the severe to complete paralysis level and sensory neuropathy, wholly sensory evaluations, will only be rated up to the moderate level, this nerve will no longer have a compensable rating. U. Diagnostic Code 8529, Sensory Neuropathy of the External Cutaneous Nerve of the Thigh Current DC 8529 addresses paralysis of the external cutaneous nerve of the thigh. Current medical terminology refers to this nerve as the lateral cutaneous nerve of the thigh, or LCNT. This nerve is part of the lumbar plexus. ‘‘It functions primarily as a sensory nerve and its composition varies among individuals with several different E:\FR\FM\12NOP1.SGM 12NOP1 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules combinations of lumbar nerves that originate from L1 to L3. The LCNT then emerges at the lateral border of the psoas major, crosses the iliacus, to the anterior superior iliac spine. The nerve then passes under the inguinal ligament and over the sartorius muscle and enters the thigh as it divides into an anterior and posterior branch.’’ Cheatham, S., et al. ‘‘Meralgia Paresthetica: A Review of the Literature,’’ International Journal of Sports Physical Therapy, 8(6): 884, December 2013. Paralysis refers to the lack of muscle function in muscle fibers. This nerve lacks motor fibers. As a purely sensory nerve, it has no muscle involvement and therefore using paralysis to describe impairment of this nerve is medically inaccurate. VA proposes to retitle DC 8529 to improve medical accuracy, and motor neuropathy will not be included in the criteria for this nerve. Because this nerve currently has a compensable rating only at the severe to complete paralysis level and sensory neuropathy, wholly sensory evaluations, will only be rated up to the moderate level, this nerve will no longer have a compensable rating. V. Diagnostic Code 8540, Soft Tissue Sarcoma of Neurogenic Origin VA proposes to place a section subheading, ‘‘Other Neoplasms of the Neurological System,’’ just above this diagnostic code as a separator between diagnostic codes for peripheral nerves and other neoplasms of the neurological system. No other changes are proposed for this DC. khammond on DSKJM1Z7X2PROD with PROPOSALS W. Diagnostic Code 8910, Epilepsy, Grand Mal (Including Tonic-Clonic Seizures) Current DC 8910 is titled ‘‘Epilepsy, grand mal.’’ VA proposes to update the title of this code to indicate that this includes tonic-clonic seizures. Tonicclonic seizures involve the entire body, and the terminology is synonymous with grand mal seizures. ‘‘Generalized tonic-clonic seizure,’’ National Institute of Health—U.S. National Library of Medicine (September 3, 2019), https:// medlineplus.gov/ency/article/ 000695.htm (last visited September 10, 2019). VA proposes no other changes to this DC. X. Diagnostic Code 8911, Epilepsy, Petit Mal (Including Absence Seizures) Current DC 8911 is titled ‘‘Epilepsy, petit mal.’’ VA proposes to update the title of this code to indicate that this includes absence seizures. Absence seizures typically last only a few seconds and may involve staring episodes, also called absence spells. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 Absence seizure is used synonymously with petit mal seizures. ‘‘Absence Seizure,’’ National Institute of Health— U.S. National Library of Medicine (September 3, 2019), https:// www.nlm.nih.gov/medlineplus/ency/ article/000696.htm (last visited September 10, 2019). VA proposes no other changes to this DC. Y. Non-Substantial Changes to Relocated 38 CFR 4.124a VA will also make some nonsubstantial changes to relocated 38 CFR 4.124a. In 2008, DC 8045, Residuals of traumatic brain injury (TBI), was revised to include a table titled ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.’’ See 73 FR 54693, 54705– 54708 (September 23, 2008). This table was added after the table titled ‘‘Organic Diseases of the Central Nervous System.’’ This had the effect of placing DC 8046, Cerebral arteriosclerosis, between the evaluation criteria of DC 8045, Residuals of traumatic brain injury, and the newly added table for TBI residuals. To improve readability and ease of use for both DCs 8045 and 8046, VA proposes to relocate the table titled ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified’’ directly below the evaluation criteria for DC 8045. Z. Military Occupational Blast Exposure VA is currently in the process of investigating the potential neurological residuals of repeated exposure to lowlevel military occupational blasts or Military Occupational Blast Exposure. VA invites public comment on this subject. Executive Orders 12866, 13563 and 14094 Executive Order 12866 (Regulatory Planning and Review) directs 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 14094 (Executive Order on Modernizing Regulatory Review) supplements and reaffirms the principles, structures, and definitions governing contemporary regulatory review established in PO 00000 Frm 00020 Fmt 4702 Sfmt 4702 88925 Executive Order 12866 of September 30, 1993 (Regulatory Planning and Review), and Executive Order 13563 of January 18, 2011 (Improving Regulation and Regulatory Review). The Office of Information and Regulatory Affairs has determined that this rulemaking is a significant regulatory action under Executive Order 12866, Section 3(f)(1), as amended by Executive Order 14094. The Regulatory Impact Analysis associated with this rulemaking can be found as a supporting document at www.regulations.gov. Regulatory Flexibility Act The Secretary hereby certifies that this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act (5 U.S.C. 601–612). The factual basis for this certification is based on the fact that no small entities or businesses determine the rating criteria revisions or assign evaluations for disability claims. Therefore, pursuant to 5 U.S.C. 605(b), the initial and final regulatory flexibility analysis requirements of 5 U.S.C. 603 and 604 do not apply. Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This proposed rule would have no such effect on State, local, and tribal governments, or on the private sector. Paperwork Reduction Act (PRA) This proposed rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501– 3521). Assistance Listing The Assistance Listing numbers and titles for the programs affected by this document are 64.102, Compensation for Service-Connected Deaths for Veterans’ Dependents; 64.105, Pension to Veterans, Surviving Spouses, and Children; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death. E:\FR\FM\12NOP1.SGM 12NOP1 88926 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules List of Subjects PART 3—ADJUDICATION 38 CFR Part 3 Administrative practice and procedure, Claims, Disability benefits. Subpart A—Pension, Compensation, and Dependency and Indemnity Compensation PART 4—SCHEDULE FOR RATING DISABILITIES Subpart B—Disability Ratings 3. The authority citation for part 4 continues to read as follows: ■ 38 CFR Part 4 Disability benefits, Pensions, Veterans. 1. The authority citation for part 3 continues to read as follows: ■ Signing Authority Denis McDonough, Secretary of Veterans Affairs, approved and signed this document on October 29, 2024, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Luvenia Potts, Regulation Development Coordinator, Office of Regulation Policy & Management, Office of General Counsel, Department of Veterans Affairs. For the reasons stated in the preamble, VA proposes to amend 38 CFR parts 3 and 4 as set forth below: Authority: 38 U.S.C. 1155, unless otherwise noted. Authority: 38 U.S.C. 501(a), unless otherwise noted. 4. In § 4.71a, amend the table The Spine by revising the entry for diagnostic code 5244 under General Rating Formula for Diseases and Injuries of the Spine to read as follows: ■ 2. Amend § 3.809 by revising paragraph (d) to read as follows: ■ § 3.809 Specially adapted housing under 38 U.S.C. 2101(a)(2)(A)(i). * * * * * (d) Amyotrophic lateral sclerosis. VA considers § 3.809(b) satisfied if the veteran or member of the Armed Forces serving on active duty has serviceconnected amyotrophic lateral sclerosis rated 100 percent disabling under 38 CFR 4.124, diagnostic code 8017. * * * * * § 4.71a Schedule of ratings— musculoskeletal system. * * * * * THE SPINE Rating General Rating Formula for Diseases and Injuries of the Spine * * * * * * 5244 Traumatic paralysis, complete: Paraplegia: Rate under diagnostic code 5110. Quadriplegia: Rate separately under diagnostic codes 5109 and 5110 and combine evaluations in accordance with § 4.25. Note: If traumatic paralysis does not cause loss of use of both hands or both feet, it is incomplete paralysis. Evaluate residuals of incomplete traumatic paralysis under the appropriate diagnostic code (e.g., § 4.124, Diseases of the Peripheral Nerves). * ■ * * 5. Revise § 4.120 to read as follows: khammond on DSKJM1Z7X2PROD with PROPOSALS § 4.120 Minimum evaluations for organic diseases of the central nervous system. (a) Necessity of residuals for minimum evaluations. The minimum evaluations for diagnostic codes 8002, 8004, 8007, 8010, 8018, 8021, 8023, 8024, and 8025 do not require ascertainable residuals. However, ascertainable residuals are required to provide the minimum evaluation for diagnostic codes 8000, 8003, 8011, 8012, 8019, 8020, 8022, and 8036. (b) Definition. Ascertainable residuals include, but are not limited to, psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. With partial loss of use of one or more extremities from neurological lesions, rate by comparison VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 * * with complete or incomplete paralysis of peripheral nerves. Determinations as to the presence of subjective residuals not capable of objective verification, e.g., headaches, dizziness, fatigability, must be approached on the basis of disability related to the diagnosis recorded. VA will only accept subjective residuals when they are consistent with the disease and not more likely attributable to another disease or no disease. (c) Ratings in excess of the minimum evaluation. When one or more compensable evaluations assigned for the residuals of the diagnostic codes noted in this section meet or exceed the minimum evaluation for that diagnostic code, then the minimum evaluation for that diagnostic code is no longer applicable. When a rating in excess of the prescribed minimum rating is assigned based on the presence of ascertainable residuals, the diagnostic PO 00000 Frm 00021 Fmt 4702 Sfmt 4702 * * * codes associated with the evaluation of those residuals must be cited in accordance with § 4.27. ■ 6. Revise § 4.123 to read as follows: § 4.123 Cranial and peripheral nerve impairment. (a) General. (1) In rating cranial and peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in movement or muscle strength, and sensory disturbances. (2) Disability from impairments of the first, second, third, fourth, sixth, and eighth cranial nerves will be rated under the Organs of Special Sense. (3) A cranial nerve will be evaluated strictly as a cranial nerve, regardless of any portions which lie outside the cranium (skull). The evaluations in the rating schedule for the cranial nerves are for unilateral involvement; when bilateral, evaluate separately, then E:\FR\FM\12NOP1.SGM 12NOP1 88927 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules combine using § 4.25 but without application of the bilateral factor. (4) The evaluations in the rating schedule for the peripheral nerves are for unilateral involvement; when bilateral, evaluate separately, then combine using § 4.25 with application of the bilateral factor. (b) Motor neuropathy (complete and incomplete paralysis). (1) General. The evaluation criteria for impairment to muscle function, with or without pain, of both cranial and peripheral nerves will be categorized as either complete paralysis or incomplete paralysis. (2) Cranial nerves. Complete paralysis for cranial nerves is characterized by the complete inability to move. Incomplete paralysis is characterized as either movement with difficulty, or attempted movement with inability to complete such movement (muscle twitching present). (3) Peripheral nerves. VA will evaluate peripheral nerve motor neuropathy using the Medical Research Council (MRC) Scale for Muscle Strength (commonly referred to as manual muscle testing). Complete paralysis for peripheral nerves will be identified as Grade 0 or Grade 1 muscle strength (no movement for Grade 0 and a flicker or trace of contraction for Grade 1). Incomplete paralysis will be determined by the following muscle strength grades: Grade 2 (only able to move if gravity is eliminated; unable to move at all against gravity), Grade 2+, which only applies to DC 8520 Sciatic nerve, (muscle strength, which, though present, can only partially move against gravity), Grade 3 (only able to move against gravity; unable to move against resistance), or Grade 4 (weakness is present, but able to move against resistance and gravity). If muscle strength falls in between grades (Grade + or ¥) for peripheral nerves other than Grade 2+ for DC 8520, then evaluate as follows: (1). for a¥grade, reduce the grade by one integer (e.g., Grade 3¥ shall be evaluated as Grade 2), and (2.) for a + grade, maintain the current grade (e.g., a Grade 3+ shall be evaluated as Grade 3). The term ‘‘incomplete paralysis,’’ with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied levels of the nerve lesion or to partial regeneration. (4) Mixed nerves. When mixed nerves within a single diagnostic code are involved, an evaluation for both motor and sensory neuropathy is not permitted. The evaluation should be based on motor neuropathy with or without sensory neuropathy involvement. (c) Sensory neuropathy (complete and incomplete). (1) General. Impairments, with or without pain, to the sensory function of the cranial and peripheral nerves may be categorized as either incomplete or complete sensory neuropathy. (2) Complete sensory neuropathy. Complete sensory neuropathy is characterized by the complete absence of sensation in an affected nerve. (3) Incomplete sensory neuropathy. Incomplete sensory neuropathy involves sensation that is impaired, but not absent, or unpleasant sensations experienced by the nerve such as dysesthesia, numbness, or paresthesia. Dysesthesia refers to any unpleasant sensation produced by a stimulus that is normally painless. Numbness refers to a sense of heaviness, weakness, or deadness in part of the body. Paresthesia refers to abnormal spontaneous sensations such as burning, tingling, pins and needles, etc. VA will only accept subjective sensations when they are consistent with the disease and not more likely attributable to another disease or no disease. § 4.124 ■ [Removed] 7. Remove § 4.124. § 4.124a [Redesignated as § 4.124] 8. Redesignate § 4.124a as § 4.124. 9. Revise and republish newly redesignated § 4.124 to read as follows: ■ ■ § 4.124 Schedule of ratings—Neurological conditions and convulsive disorders. ORGANIC DISEASES OF THE CENTRAL NERVOUS SYSTEM khammond on DSKJM1Z7X2PROD with PROPOSALS Rating Guidance for rating organic diseases of the central nervous system is located under § 4.120. 8000 Encephalitis, infectious: As active febrile disease .............................................................................................................................................................. Rate residuals, minimum .............................................................................................................................................................. 8002 Brain, new growth of, malignant .............................................................................................................................................. Minimum rating ............................................................................................................................................................................. Note: The 100 percent evaluation will be continued for 2 years following cessation of surgical, chemotherapeutic or other treatment modality. At this point, if the residuals have stabilized, the rating will be made on neurological residuals according to symptomatology or the minimum rating, whichever results in a higher evaluation. 8003 Brain, new growth of, benign: Minimum during active disease or during a treatment phase ...................................................................................................... Rate residuals, minimum .............................................................................................................................................................. General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028): Hoehn-Yahr stage 4 or stage 5, or; the inability to live independently because of neurologically-related disability .................. Impairment of mobility (e.g., transfers, balance, or gait) requiring daily use of an assistive device such as a wheelchair, brace(s), crutch(es), cane(s), or walker .................................................................................................................................... Hoehn-Yahr stage 3, or; impairment of mobility (e.g., transfers, balance, or gait) requiring less than daily use of an assistive device such as a wheelchair, brace(s), crutch(es), cane(s), or walker .................................................................................... Hoehn-Yahr stage 2, or; impairment in at least one of the following areas: ............................................................................... • facial expression (e.g., masking, blinking, or eye motion abnormalities); • speech (e.g., soft voice, slurring, difficulty speaking or swallowing); • posture (e.g., stooping, instability); • mobility not requiring an assistive device (e.g., decreased speed with transfers, gait ataxia, unstable balance); • problems initiating or controlling motor movements (e.g., stiffness, tremors); • cognitive (e.g., memory or executive problems); • mental (e.g., anxiety, depression, social phobia); • sensory abnormalities (e.g., olfactory deficits); • involuntary muscle contractions resulting in pain and impairment, such as but not limited to, spontaneous neck turning or writing difficulty Hoehn-Yahr stage 1, or; formal diagnosis without impairment .................................................................................................... VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00022 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 100 10 100 30 60 10 100 60 30 10 0 88928 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules ORGANIC DISEASES OF THE CENTRAL NERVOUS SYSTEM—Continued khammond on DSKJM1Z7X2PROD with PROPOSALS Rating Note (1): Regardless of examination findings, the minimum rating for Parkinson’s disease (DC 8004) shall be 30 percent. Note (2): Regardless of examination findings, the minimum rating for stroke residuals (DC 8007) shall be 10 percent. Note (3): Activities of daily living (ADLs) refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): Evaluate any residual under the appropriate body system when there is a formal diagnosis of a condition. When there is no formal diagnosis, evaluate the residual under the General Rating Formula for Specified Neurologic Conditions. For example, evaluate emotional dysfunction under § 4.130 (Schedule of ratings—mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional symptoms under the General Rating Formula for Specified Neurologic Conditions. Note (5): There may be an overlap of manifestations of conditions evaluated under the General Rating Formula for Specified Neurologic Conditions with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (6): Consider the need for special monthly compensation. Note (7): When evaluating a neurological condition under the General Rating Formula for Specified Neurological Conditions based on subjective symptoms and not a Hoehn-Yahr stage, a medical opinion finding that the subjectively reported symptom(s) is consistent with the claimed disease and not another disease or no disease is required. 8004 Parkinson’s disease (paralysis agitans): Rate under the General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028). 8005 Bulbar palsy ............................................................................................................................................................................. 8007 Stroke (ischemic, hemorrhagic, or thrombotic), including cerebral infarction or cerebrovascular accident (Brain, vessels, embolism, thrombosis, and hemorrhage): During and for six months following a stroke, documented by diagnostic imaging .................................................................... Thereafter, rate under the General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028). 8010 Myelitis: Minimum rating ............................................................................................................................................................................. 8011 Poliomyelitis, anterior: As active febrile disease .............................................................................................................................................................. Rate residuals, minimum .............................................................................................................................................................. 8012 Hematomyelia: For 6 months ................................................................................................................................................................................ Rate residuals, minimum .............................................................................................................................................................. 8013 Syphilis, cerebrospinal. 8014 Syphilis, meningovascular. 8015 Tabes dorsalis. Note: Rate upon the severity of convulsions, paralysis, visual impairment or psychotic involvement, etc. 8017 Amyotrophic lateral sclerosis ................................................................................................................................................... Note: Consider the need for special monthly compensation. 8018 Multiple sclerosis and and other demyelinating diseases of the central nervous system: Minimum rating ............................................................................................................................................................................. 8019 Meningitis, cerebrospinal, epidemic: As active febrile disease .............................................................................................................................................................. Rate residuals, minimum .............................................................................................................................................................. 8020 Brain, abscess of: As active disease ......................................................................................................................................................................... Rate residuals, minimum .............................................................................................................................................................. 8021 Spinal cord, new growths of, malignant ................................................................................................................................... Minimum rating ............................................................................................................................................................................. Note: The 100 percent evaluation will be continued for 2 years following cessation of surgical, chemotherapeutic or other treatment modality. At this point, if the residuals have stabilized, the rating will be made on neurological residuals according to symptomatology or the minimum rating, whichever results in a higher evaluation. 8022 Spinal cord, new growths of, benign: Minimum during active disease or during a treatment phase ...................................................................................................... Rate residuals, minimum .............................................................................................................................................................. 8023 Progressive muscular atrophy: Minimum rating ............................................................................................................................................................................. 8024 Syringomyelia: Minimum rating ............................................................................................................................................................................. 8025 Myasthenia gravis: Minimum rating ............................................................................................................................................................................. 8026 Parkinson’s plus, or secondary parkinsonism syndromes. Rate under the General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028). 8027 Essential tremor. Rate under the General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028). 8028 Dystonia. Rate under the General Rating Formula for Specified Neurologic Conditions (DCs 8004, 8007, 8026, 8027, and 8028). 8036 Primary lateral sclerosis: Rate residuals, minimum .............................................................................................................................................................. 8045 Residuals of traumatic brain injury (TBI): VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00023 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 100 100 10 100 10 100 10 100 30 100 10 100 10 100 30 60 10 30 30 30 10 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules 88929 ORGANIC DISEASES OF THE CENTRAL NERVOUS SYSTEM—Continued Rating There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.’’ Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.’’ However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified’’ table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings—mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.’’ Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the ‘‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified’’ table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. EVALUATION OF COGNITIVE IMPAIRMENT AND OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED Facets of cognitive impairment and other residuals of TBI not otherwise classified Level of impairment Memory, attention, concentration, executive functions. 0 No complaints of impairment of memory, attention, concentration, or executive functions. 1 A complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Normal. Mildly impaired judgment. For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. Moderately impaired judgment. For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions. Moderately severely impaired judgment. For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. Severely impaired judgment. For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Social interaction is routinely appropriate. Social interaction is occasionally inappropriate. Social interaction is frequently inappropriate. Social interaction is inappropriate most or all of the time. 2 3 Total Judgment ................................... 0 1 2 khammond on DSKJM1Z7X2PROD with PROPOSALS 3 Total Social interaction ........................ VerDate Sep<11>2014 16:06 Nov 08, 2024 0 1 2 3 Jkt 265001 Criteria PO 00000 Frm 00024 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 88930 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules EVALUATION OF COGNITIVE IMPAIRMENT AND OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED—Continued Facets of cognitive impairment and other residuals of TBI not otherwise classified Level of impairment Orientation .................................. 0 1 2 3 Total Motor activity (with intact motor and sensory system). 0 1 2 3 Total 0 1 Visual spatial orientation ............ 2 3 Total Subjective symptoms ................. 0 1 2 Neurobehavioral effects ............. 0 1 2 3 Communication .......................... 0 1 khammond on DSKJM1Z7X2PROD with PROPOSALS 2 3 Total VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 Criteria Always oriented to person, time, place, and situation. Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation. Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation. Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Motor activity normal. Motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function). Motor activity mildly decreased or with moderate slowing due to apraxia. Motor activity moderately decreased due to apraxia. Motor activity severely decreased due to apraxia. Normal. Mildly impaired. Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system). Moderately impaired. Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system). Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system). Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples are: mild or occasional headaches, mild anxiety. Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light. Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects. One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. One or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language. Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas. Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas. Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs. Complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs. PO 00000 Frm 00025 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules 88931 EVALUATION OF COGNITIVE IMPAIRMENT AND OTHER RESIDUALS OF TBI NOT OTHERWISE CLASSIFIED—Continued Facets of cognitive impairment and other residuals of TBI not otherwise classified Level of impairment Consciousness ........................... Total Criteria Persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. Rating 8046 Cerebral arteriosclerosis: Purely neurological disabilities, such as hemiplegia, cranial nerve paralysis, etc., due to cerebral arteriosclerosis will be rated under the diagnostic codes dealing with such specific disabilities, with citation of a hyphenated diagnostic code (e.g., 8046–8207). Purely subjective complaints such as headache, dizziness, tinnitus, insomnia and irritability, recognized as symptomatic of a properly diagnosed cerebral arteriosclerosis, will be rated 10 percent and no more under diagnostic code 9305. This 10 percent rating will not be combined with any other rating for a disability due to cerebral or generalized arteriosclerosis. Ratings in excess of 10 percent for cerebral arteriosclerosis under diagnostic code 9305 are not assignable in the absence of a diagnosis of multi-infarct dementia with cerebral arteriosclerosis. Note: The ratings under code 8046 apply only when the diagnosis of cerebral arteriosclerosis is substantiated by the entire clinical picture and not solely on findings of retinal arteriosclerosis. Miscellaneous Diseases 8100 Migraine: With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability ...................... With characteristic prostrating attacks occurring on an average once a month over last several months ................................. With characteristic prostrating attacks averaging one in 2 months over last several months .................................................... With less frequent attacks ............................................................................................................................................................ 8103 Hemifacial spasm (tic, convulsive): Severe .......................................................................................................................................................................................... Moderate ....................................................................................................................................................................................... Mild ............................................................................................................................................................................................... Note: Depending upon frequency, severity, muscle groups involved. 8104 Paramyoclonus multiplex (convulsive state, myoclonic type): Rate as hemifacial spasm; severe cases .................................................................................................................................... 8105 Chorea, Sydenham’s: Pronounced, progressive grave types .......................................................................................................................................... Severe .......................................................................................................................................................................................... Moderately severe ........................................................................................................................................................................ Moderate ....................................................................................................................................................................................... Mild ............................................................................................................................................................................................... Note: Consider rheumatic etiology and complications. 8106 Chorea, Huntington’s. Rate as Sydenham’s chorea. This, though a familial disease, has its onset in late adult life, and is considered a ratable disability. 8107 Athetosis, acquired. Rate as Sydenham’s chorea. 8108 Narcolepsy. Rate as for epilepsy, petit mal. 50 30 10 0 30 10 0 60 100 80 50 30 10 khammond on DSKJM1Z7X2PROD with PROPOSALS Diseases of the Cranial Nerves Guidance for rating cranial nerves is located under § 4.123. Fifth (trigeminal) cranial nerve 8205 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Sensory neuropathy, complete or incomplete .............................................................................................................................. Note (1): Tic douloureux may be rated under DC 8205 in accordance with severity, up to complete paralysis. Note (2): Rate dependent upon relative loss of sensation or muscle function. Examples of nerve functions include, but are not limited to, movement and sensation to the scalp, forehead, nose, cheeks, lower eye lid, nasal mucosa, upper lip, upper teeth, palate, anterior tongue, skin over mandible and lower teeth, and muscles of mastication. Seventh (facial) cranial nerve 8207 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Sensory neuropathy, complete, or incomplete ............................................................................................................................. Note: Rate dependent upon relative loss of sensation or muscle function. Examples of nerve functions include, but are not limited to, facial expressions, taste, and production/drainage of tears. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00026 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 50 30 10 10 30 20 10 10 88932 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules Rating Ninth (glossopharyngeal) cranial nerve 8209 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Sensory neuropathy, complete, or incomplete ............................................................................................................................. Note: Rate dependent upon relative loss of ordinary sensation or muscle function. Examples of nerve functions include, but are not limited to, taste and sensing carotid blood pressure. Tenth (pneumogastric, vagus) cranial nerve 8210 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Sensory neuropathy, complete, or incomplete ............................................................................................................................. Note: Rate dependent upon relative loss of sensation or muscle function. Examples of nerve functions include, but are not limited to, speech and taste, along with movement and sensation to the larynx, pharynx, thoracic viscera, and abdominal viscera. Eleventh (spinal accessory, external branch) cranial nerve 8211 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Note: Rate dependent upon relative loss of muscle function. Examples of nerve functions include, but are not limited to, movement of the sternocleidomastoid and trapezius muscles. Twelfth (hypoglossal) cranial nerve 8212 Motor neuropathy (complete and incomplete paralysis): Complete paralysis ....................................................................................................................................................................... Incomplete paralysis: Attempted movement with inability to complete such movement (muscle twitching present) ............................................. Muscle movement intact, but task performed with difficulty ................................................................................................. Sensory neuropathy, complete, or incomplete ............................................................................................................................. Note: Rate dependent upon relative loss of sensation or muscle function. Examples of nerve functions include, but are not limited to, movement and sensation to the tongue. 30 20 10 10 50 30 10 10 30 20 10 50 30 10 10 Rating Schedule of ratings Major Minor khammond on DSKJM1Z7X2PROD with PROPOSALS Diseases of the Peripheral Nerves Guidance for rating peripheral nerves, along with a description of the grading system, is located under § 4.123. Upper radicular group (fifth and sixth cervicals) 8510 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Middle radicular group 8511 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Lower radicular group 8512 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00027 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 70 60 50 40 20 40 20 40 30 20 30 20 70 60 50 40 20 40 20 40 30 20 30 20 70 60 50 40 20 40 20 40 30 20 30 20 88933 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules Rating Schedule of ratings khammond on DSKJM1Z7X2PROD with PROPOSALS Major All radicular groups 8513 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Radial nerve (musculospiral) 8514 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Note: Lesions involving only ‘‘dissociation of extensor communis digitorum’’ and ‘‘paralysis below the extensor communis digitorum,’’ will not exceed Grade 3 for diagnostic code 8514. The median nerve 8515 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. The ulnar nerve 8516 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Musculocutaneous nerve 8517 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Axillary nerve (circumflex) 8518 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Long thoracic nerve 8519 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ........................................................................................................................................... Incomplete paralysis: Grade 2 ............................................................................................................................................................................. Grade 3 ............................................................................................................................................................................. Grade 4 ............................................................................................................................................................................. Sensory neuropathy, complete ................................................................................................................................................. Sensory neuropathy, incomplete .............................................................................................................................................. Note (1): Not to be combined with lost motion above shoulder level. Note (2): Combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00028 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 Minor 90 80 70 40 20 40 20 60 30 20 30 20 70 60 50 30 20 30 20 40 20 20 20 20 70 60 50 30 10 30 10 40 20 10 20 10 60 50 40 30 10 30 10 30 20 10 20 10 30 20 20 10 0 10 0 20 10 0 10 0 50 40 30 10 0 10 0 20 10 0 10 0 30 20 20 10 0 10 0 20 10 0 10 0 88934 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules khammond on DSKJM1Z7X2PROD with PROPOSALS Rating Sciatic nerve 8520 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 2+ ............................................................................................................................................................................... Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Common peroneal nerve (external popliteal) 8521 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Superficial peroneal nerve (musculocutaneous) 8522 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Deep peroneal nerve (anterior tibial) 8523 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Tibial nerve (internal popliteal) 8524 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Posterior tibial nerve 8525 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 or Grade 4 ............................................................................................................................................................... Sensory neuropathy, complete or incomplete .............................................................................................................................. Femoral nerve (anterior crural) 8526 Motor neuropathy (complete and incomplete paralysis): Complete paralysis (Grade 0 or 1) ............................................................................................................................................... Incomplete paralysis: Grade 2 ................................................................................................................................................................................. Grade 3 ................................................................................................................................................................................. Grade 4 ................................................................................................................................................................................. Sensory neuropathy, complete ..................................................................................................................................................... Sensory neuropathy, incomplete .................................................................................................................................................. Saphenous nerve (internal saphenous) 8527 Sensory neuropathy, complete or incomplete ......................................................................................................................... Obturator nerve 8528 Motor neuropathy (complete and incomplete paralysis): Grade 0, Grade 1, or Grade 2 .............................................................................................................................................. Grade 3 or Grade 4 ............................................................................................................................................................... Sensory neuropathy, complete or incomplete .............................................................................................................................. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00029 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 80 60 40 20 10 20 10 40 30 20 10 20 10 30 20 10 0 10 0 30 20 10 0 10 0 40 30 20 10 20 10 30 20 10 10 40 30 20 10 20 10 0 10 0 0 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules 88935 Rating Lateral cutaneous nerve of the thigh (external cutaneous) Sensory neuropathy, complete or incomplete ......................................................................................................................... Ilio-inguinal nerve 8530 Motor neuropathy (complete and incomplete paralysis): Grade 0, Grade 1, or Grade 2 .............................................................................................................................................. Grade 3 or Grade 4 ............................................................................................................................................................... Sensory neuropathy, complete or incomplete .............................................................................................................................. 8529 0 10 0 0 Other Neoplasms of the Neurological System 8540 Soft-tissue sarcoma (of neurogenic origin) .............................................................................................................................. Note: The 100 percent rating will be continued for 6 months following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. At this point, if there has been no local recurrence or metastases, the rating will be made on residuals. 100 khammond on DSKJM1Z7X2PROD with PROPOSALS The Epilepsies A thorough study of all material in §§ 4.121 and 4.122 of the preface and under the ratings for epilepsy is necessary prior to any rating action. 8910 Epilepsy, grand mal (including tonic-clonic seizures). Rate under the general rating formula for major seizures. 8911 Epilepsy, petit mal (including absence seizures). Rate under the general rating formula for minor seizures. Note (1): A major seizure is characterized by the generalized tonic-clonic convulsion with unconsciousness. Note (2): A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head (‘‘pure’’ petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type) or sudden loss of postural control (akinetic type). General Rating Formula for Major and Minor Epileptic Seizures: Averaging at least 1 major seizure per month over the last year ............................................................................................... 100 Averaging at least 1 major seizure in 3 months over the last year; or more than 10 minor seizures weekly ............................ 80 Averaging at least 1 major seizure in 4 months over the last year; or 9–10 minor seizures per week ..................................... 60 At least 1 major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly .......... 40 At least 1 major seizure in the last 2 years; or at least 2 minor seizures in the last 6 months .................................................. 20 A confirmed diagnosis of epilepsy with a history of seizures ...................................................................................................... 10 Note (1): When continuous medication is shown necessary for the control of epilepsy, the minimum evaluation will be 10 percent. This rating will not be combined with any other rating for epilepsy. Note (2): In the presence of major and minor seizures, rate the predominating type. Note (3): There will be no distinction between diurnal and nocturnal major seizures. 8912 Epilepsy, Jacksonian and focal motor or sensory. 8913 Epilepsy, diencephalic. Rate as minor seizures, except in the presence of major and minor seizures, rate the predominating type. 8914 Epilepsy, psychomotor. Major seizures: Psychomotor seizures will be rated as major seizures under the general rating formula when characterized by automatic states and/or generalized convulsions with unconsciousness. Minor seizures: Psychomotor seizures will be rated as minor seizures under the general rating formula when characterized by brief transient episodes of random motor movements, hallucinations, perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances. Mental Disorders in Epilepsies: A nonpsychotic organic brain syndrome will be rated separately under the appropriate diagnostic code (e.g., 9304 or 9326). In the absence of a diagnosis of non-psychotic organic psychiatric disturbance (psychotic, psychoneurotic or personality disorder) if diagnosed and shown to be secondary to or directly associated with epilepsy will be rated separately. The psychotic or psychroneurotic disorder will be rated under the appropriate diagnostic code. The personality disorder will be rated as a dementia (e.g., diagnostic code 9304 or 9326). Epilepsy and Unemployability: (1) Rating specialists must bear in mind that the epileptic, although his or her seizures are controlled, may find employment and rehabilitation difficult of attainment due to employer reluctance to the hiring of the epileptic. (2) Where a case is encountered with a definite history of unemployment, full and complete development should be undertaken to ascertain whether the epilepsy is the determining factor in his or her inability to obtain employment. (3) The assent of the claimant should first be obtained for permission to conduct this economic and social survey. The purpose of this survey is to secure all the relevant facts and data necessary to permit of a true judgment as to the reason for his or her unemployment and should include information as to: (a) Education; (b) Occupations prior and subsequent to service; (c) Places of employment and reasons for termination; (d) Wages received; (e) Number of seizures. (4) Upon completion of this survey and current examination, the case should have rating board consideration. Where in the judgment of the rating board the veteran’s unemployability is due to epilepsy and jurisdiction is not vested in that body by reason of schedular evaluations, the case should be submitted to the Compensation Service or the Director, Pension and Fiduciary Service. VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00030 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 88936 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules (Authority: 38 U.S.C. 1155) c. Redesignating the entries for § 4.124a (all diagnostic codes listed under § 4.124a) as new entries for § 4.124; ■ d. Revising and republishing newly redesignated § 4.124; and ■ 10. Amend Appendix A to part 4 by: a. Revising the entry for diagnostic code 5244; ■ b. Adding, in numerical order, entries for §§ 4.120 and 4.123; ■ ■ e. Adding, in numerical order, a new entry for § 4.124a. The revisions and additions read as follows: ■ APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946 Sec. * Diagnostic code No. * * 5244 khammond on DSKJM1Z7X2PROD with PROPOSALS * * * 4.120 ..................................... .................................... 4.123 ..................................... .................................... 4.124 ..................................... .................................... 8000 8002 8003 8004 8007 8008 8009 8018 8021 8022 8025 8026 8027 8028 8036 8045 8046 8100 8103 8104 8107 8205 8207 8209 8210 8211 8212 8305 8307 8309 8310 8311 8312 8405 8407 8409 8410 8411 8412 8510 8511 8512 8513 8514 8515 8516 8517 8518 8519 8520 8521 8522 8523 8524 8525 VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 PO 00000 * * * Added February 7, 2021; note [Effective date of final rule]. * * * * * Title and revised [Effective date of final rule]. Title and revised [Effective date of final rule]. Re-designated from § 4.124a [Effective date of final rule]. Title [Effective date of final rule]. Criteria September 22, 1978; title, note [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria, notes [Effective date of final rule]. Title, criteria [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Title [Effective date of final rule]. Criteria September 22, 1978; criteria October 1, 1961; criteria March 10, 1976; criteria March 1, 1989; title, note [Effective date of final rule]. Title, criteria [Effective date of final rule]. Note removed [Effective date of final rule]. Added [Effective date of final rule]. Added [Effective date of final rule]. Added [Effective date of final rule]. Added [Effective date of final rule]. Criterion and evaluation October 23, 2008. Added October 1, 1961; criterion March 10, 1976; criterion March 1, 1989. Evaluation June 9, 1953. Title [Effective date of final rule]. Criteria [Effective date of final rule]. Criteria [Effective date of final rule]. Title, criteria, notes [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria, note [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria, notes [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Frm 00031 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 88937 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules APPENDIX A TO PART 4—TABLE OF AMENDMENTS AND EFFECTIVE DATES SINCE 1946—Continued Sec. Diagnostic code No. 4.124a ................................... 8526 8527 8528 8529 8530 8610 8611 8612 8613 8614 8615 8616 8617 8618 8619 8620 8621 8622 8623 8624 8625 8626 8627 8628 8629 8630 8710 8711 8712 8713 8714 8715 8716 8717 8718 8719 8720 8721 8722 8723 8724 8725 8726 8727 8728 8729 8730 8910 8911 8912 8913 8914 .................................... * * * 11. Amend Appendix B to part 4 by revising and republishing the entries in khammond on DSKJM1Z7X2PROD with PROPOSALS ■ VerDate Sep<11>2014 17:29 Nov 08, 2024 Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Title, criteria [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Removed [Effective date of final rule]. Added October 1, 1961; evaluation September 9, 1975; title [Effective date of final rule]. Added October 1, 1961; evaluation September 9, 1975; title [Effective date of final rule]. Added October 1, 1961; evaluation September 9, 1975. Added October 1, 1961; evaluation September 9, 1975. Added October 1, 1961; evaluation September 9, 1975. Re-designated as § 4.124 [Effective date of final rule]. Jkt 265001 * * the table under ‘‘Neurological PO 00000 Frm 00032 Fmt 4702 Sfmt 4702 * * Conditions and Convulsive Disorders’’ to read as follows: E:\FR\FM\12NOP1.SGM 12NOP1 88938 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES Diagnostic code No. * * * * * * Neurological Conditions and Convulsive Disorders Organic Diseases of the Central Nervous System 8000 8002 8003 8004 8005 8007 8010 8011 8012 8013 8014 8015 8017 8018 8019 8020 8021 8022 8023 8024 8025 8026 8027 8028 8036 8045 8046 ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... Encephalitis, infectious. Brain, new growth of, malignant. Brain, new growth of, benign. Parkinson’s disease (paralysis agitans). Bulbar palsy. Stroke (ischemic, hemorrhagic, or thrombotic), including cerebral infarction or cerebrovascular accident. Myelitis. Poliomyelitis, anterior. Hematomyelia. Syphilis, cerebrospinal. Syphilis, meningovascular Tabes dorsalis. Amyotrophic lateral sclerosis. Multiple sclerosis and neuromyelitis optica spectrum disorder (NMOSD). Meningitis, cerebrospinal, epidemic. Brain, abscess. Spinal cord, new growths of, malignant. Spinal cord, new growths of, benign. Progressive muscular atrophy. Syringomyelia. Myasthenia gravis. Parkinson’s plus, or secondary parkinsonism syndromes. Essential tremor. Dystonia. Primary lateral sclerosis. Residuals of traumatic brain injury (TBI). Cerebral arteriosclerosis. Miscellaneous Diseases 8100 8103 8104 8105 8106 8107 8108 ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... Migraine. Hemifacial spasm (tic, convulsive). Paramyoclonus multiplex (convulsive state, myoclonic type). Chorea, Sydenham’s. Chorea, Huntington’s. Athetosis, acquired. Narcolepsy. The Cranial Nerves 8205 8207 8209 8210 8211 8212 ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... Fifth (trigeminal), motor neuropathy. Seventh (facial), motor neuropathy. Ninth (glossopharyngeal), motor neuropathy. Tenth (pneumogastric, vagus), motor neuropathy. Eleventh (spinal accessory, external branch), motor neuropathy. Twelfth (hypoglossal), motor neuropathy. khammond on DSKJM1Z7X2PROD with PROPOSALS Peripheral Nerves 8510 8511 8512 8513 8514 8515 8516 8517 8518 8519 8520 8521 8522 8523 8524 8525 8526 8527 ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... ...................................... VerDate Sep<11>2014 17:29 Nov 08, 2024 Upper radicular group, motor neuropathy. Middle radicular group, motor neuropathy. Lower radicular group, motor neuropathy. All radicular groups, motor neuropathy. Radial nerve (musculospiral), motor neuropathy. Median nerve, motor neuropathy. Ulnar nerve, motor neuropathy. Musculocutaneous nerve, motor neuropathy. Axillary nerve (circumflex), motor neuropathy. Long thoracic nerve, motor neuropathy. Sciatic nerve, motor neuropathy. Common peroneal nerve (external popliteal), motor neuropathy. Superficial peroneal nerve (musculocutaneous), motor neuropathy. Deep peroneal nerve (anterior tibial), motor neuropathy. Tibial nerve (internal popliteal), motor neuropathy. Posterior tibial nerve, motor neuropathy. Femoral nerve (anterior crural), motor neuropathy. Saphenous nerve (internal saphenous), sensory neuropathy. Jkt 265001 PO 00000 Frm 00033 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 * 88939 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules APPENDIX B TO PART 4—NUMERICAL INDEX OF DISABILITIES—Continued Diagnostic code No. 8528 ...................................... 8529 ...................................... 8530 ...................................... Obturator nerve, motor neuropathy. Lateral cutaneous nerve of the thigh (external cutaneous), sensory neuropathy. Ilio-inguinal nerve, motor neuropathy. Other Neoplasms of the Neurological System 8540 ...................................... Soft tissue sarcoma (Neurogenic origin). The Epilepsies 8910 8911 8912 8913 8914 ...................................... ...................................... ...................................... ...................................... ...................................... * Epilepsy, grand mal (includes tonic-clonic seizures). Epilepsy, petit mal (includes absence seizures). Jacksonian and focal motor or sensory. Diencephalic. Psychomotor. * * 12. Amend Appendix C to part 4 by: a. Adding, in alphabetical order, an entry for ‘‘Dystonia’’; ■ b. Removing the entry for ‘‘Embolism, brain’’; ■ c. Revising the entry for ‘‘Encephalitis, epidemic’’; ■ d. Under the entry for ‘‘Epilepsies’’, revising the entries for ‘‘Grand mal’’ and ‘‘Petit mal’’; ■ e. Adding, in alphabetical order, entries for ‘‘Essential tremor’’ and ‘‘Hemifacial spasm (tic, convulsive)’’; ■ f. Removing the entry for ‘‘Hemorrhage’’; ■ ■ * * g. Adding, in alphabetical order, an entry for ‘‘Intraocular hemorrhage’’; ■ h. Adding, in alphabetical order, an entry for ‘‘Motor/sensory neuropathy’’; ■ i. Revising the entry for ‘‘Multiple sclerosis’’; ■ j. Removing the entry for ‘‘Neuralgia’’; ■ k. Removing the entry for ‘‘Neuritis’’; ■ l. Adding an entry for ‘‘Optic neuropathy’’; ■ m. Under the entry for ‘‘Paralysis’’, removing the entry for ‘‘Agitans’’; ■ n. Removing the entry for ‘‘Paralysis, nerve’’; ■ * * o. Revising the entry for ‘‘Paramyoclonus multiplex’’; ■ p. Adding, in alphabetical order, entries for ‘‘Parkinson’s disease (paralysis agitans)’’, ‘‘Parkinson’s plus, or secondary parkinsonism syndromes’’, ‘‘Primary lateral sclerosis’’, and ‘‘Stroke (ischemic, hemorrhagic, or thrombotic), including cerebral infarction or cerebrovascular accident’’; and ■ q. Removing the entries for ‘‘Thrombosis, brain’’ and ‘‘Tic, convulsive’’. The revisions and additions read as follows: ■ APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES khammond on DSKJM1Z7X2PROD with PROPOSALS Diagnostic code No. * * * * * * Dystonia ................................................................................................................................................................................... * * * * * * * Encephalitis, infectious ............................................................................................................................................................ * * Epilepsies: * * * * * * 8028 8000 * * * * * * Grand mal (includes tonic-clonic seizures) ...................................................................................................................... * * * * * * * Petit mal (includes absence seizures) ............................................................................................................................. * * * * * * * Essential tremor ....................................................................................................................................................................... * * * * * * * Hemifacial spasm (tic, convulsive) .......................................................................................................................................... * * * * * * * Intraocular hemorrhage ........................................................................................................................................................... * * * * * * * Motor/sensory neuropathy: Cranial nerves: Eleventh (spinal accessory, external branch) ........................................................................................................... Fifth (trigeminal) ........................................................................................................................................................ Ninth (glossopharyngeal) .......................................................................................................................................... * VerDate Sep<11>2014 17:29 Nov 08, 2024 Jkt 265001 PO 00000 Frm 00034 Fmt 4702 Sfmt 4702 E:\FR\FM\12NOP1.SGM 12NOP1 8910 8911 8027 8103 6007 8211 8205 8209 88940 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Proposed Rules APPENDIX C TO PART 4—ALPHABETICAL INDEX OF DISABILITIES—Continued Diagnostic code No. Seventh (facial) ......................................................................................................................................................... Tenth (pneumogastric, vagus) .................................................................................................................................. Twelfth (hypoglossal) ................................................................................................................................................ Peripheral nerves: All radicular groups ................................................................................................................................................... Axillary (circumflex) ................................................................................................................................................... Common peroneal (external popliteal) ...................................................................................................................... Deep peroneal (anterior tibial) .................................................................................................................................. Femoral (anterior crural) ........................................................................................................................................... Ilio-inguinal ................................................................................................................................................................ Lateral cutaneous nerve of the thigh (external cutaneous) ...................................................................................... Long thoracic ............................................................................................................................................................. Lower radicular group ............................................................................................................................................... Median ....................................................................................................................................................................... Middle radicular group ............................................................................................................................................... Musculocutaneous ..................................................................................................................................................... Obturator ................................................................................................................................................................... Posterior tibial ............................................................................................................................................................ Radial (musculospiral) ............................................................................................................................................... Saphenous (internal saphenous) .............................................................................................................................. Sciatic ........................................................................................................................................................................ Superficial peroneal (musculocutaneous) ................................................................................................................. Tibial (internal popliteal) ............................................................................................................................................ Ulnar .......................................................................................................................................................................... Upper radicular group ............................................................................................................................................... 8513 8518 8521 8523 8526 8530 8529 8519 8512 8515 8511 8517 8528 8525 8514 8527 8520 8522 8524 8516 8510 * * * * * * Multiple sclerosis and other demyelinating diseases of the central nervous system ............................................................. * * * * * * * Optic neuropathy ..................................................................................................................................................................... * * * * * * * Paramyoclonus multiplex (convulsive state, myoclonic type) ................................................................................................. * * * * * * * Parkinson’s disease (paralysis agitans) .................................................................................................................................. Parkinson’s plus, or secondary parkinsonism syndromes ...................................................................................................... * * * * * * * Primary lateral sclerosis .......................................................................................................................................................... * * * * * * * Stroke (ischemic, hemorrhagic, or thrombotic), including cerebral infarction or cerebrovascular accident ........................... * * * * * ACTION: [FR Doc. 2024–25665 Filed 11–8–24; 8:45 am] * Proposed rule. BILLING CODE 8320–01–P The U.S. Environmental Protection Agency (EPA) is proposing to revise the EPA’s regulatory definition of volatile organic compounds (VOC) under the Clean Air Act (CAA). This action proposes to add (Z)-1-chloro2,3,3,3-tetrafluoropropene (also known as HCFO-1224yd(Z); CAS number 111512–60–8) to the list of compounds excluded from the regulatory definition on the basis that this compound makes a negligible contribution to tropospheric ozone (O3) formation. SUMMARY: ENVIRONMENTAL PROTECTION AGENCY 40 CFR Part 51 [EPA–HQ–OAR–2023–0295; FRL–10823–01– OAR] khammond on DSKJM1Z7X2PROD with PROPOSALS 8207 8210 8212 RIN 2060–AW00 Air Quality: Revision to the Regulatory Definition of Volatile Organic Compounds—Exclusion of (Z)-1chloro-2,3,3,3-tetrafluoropropene (HCFO-1224yd(Z)) Environmental Protection Agency (EPA). AGENCY: VerDate Sep<11>2014 16:06 Nov 08, 2024 Jkt 265001 Comments must be received on or before January 13, 2025. DATES: You may send comments, identified by Docket ID No. EPA–HQ– ADDRESSES: PO 00000 Frm 00035 Fmt 4702 Sfmt 4702 * 8018 6026 8104 8004 8026 8036 8007 * OAR–2023–0295, by any of the following methods: • Federal eRulemaking Portal: https://www.regulations.gov/ (our preferred method). Follow the online instructions for submitting comments. • Mail: U.S. Environmental Protection Agency, EPA Docket Center, Docket No. EPA–HQ–OAR–2023–0295, Office of Air and Radiation Docket, Mail Code 28221T, 1200 Pennsylvania Avenue NW, Washington, DC 20460. • Hand Delivery or Courier: EPA Docket Center, WJC West Building, Room 3334, 1301 Constitution Avenue NW, Washington, DC 20004. The Docket Center’s hours of operations are 8:30 a.m.–4:30 p.m., Monday–Friday (except Federal Holidays). Instructions: All submissions received must include the Docket ID No. for this E:\FR\FM\12NOP1.SGM 12NOP1

Agencies

DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 89, Number 218 (Tuesday, November 12, 2024)]
[Proposed Rules]
[Pages 88917-88940]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-25665]



[[Page 88917]]

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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Parts 3 and 4

RIN 2900-AQ73


Schedule for Rating Disabilities: Neurological Conditions and 
Convulsive Disorders

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend the 
portion of the VA Schedule for Rating Disabilities (VASRD or Rating 
Schedule) that addresses neurological conditions and convulsive 
disorders. The purpose of these changes is to incorporate medical 
advancements that have occurred since the last revision, update current 
medical terminology, and provide clear evaluation criteria. The 
proposed rule reflects advances in medical knowledge and 
recommendations contained in the report from the Institute of Medicine, 
part of the National Academy of Sciences, titled ``A 21st Century 
System for Evaluating Veterans for Disability Benefits,'' National 
Academies Press, 2007.

DATES: Comments must be received on or before January 13, 2025.

ADDRESSES: Comments must be submitted through www.regulations.gov. 
Except as provided below, comments received before the close of the 
comment period will be available at www.regulations.gov for public 
viewing, inspection, or copying, including any personally identifiable 
or confidential business information that is included in a comment. We 
post the comments received before the close of the comment period on 
www.regulations.gov as soon as possible after they have been received. 
VA will not post on Regulations.gov public comments that make threats 
to individuals or institutions or suggest that the commenter will take 
actions to harm an individual. VA encourages individuals not to submit 
duplicative comments; however, we will post comments from multiple 
unique commenters even if the content is identical or nearly identical 
to other comments. Any public comment received after the comment 
period's closing date is considered late and will not be considered in 
the final rulemaking. In accordance with the Providing Accountability 
Through Transparency Act of 2023, a plain language summary (not more 
than 100 words in length) of this proposed rule is available at 
www.regulations.gov, under RIN 2900-AQ73.

FOR FURTHER INFORMATION CONTACT: Gary Reynolds, M.D., Medical Officer, 
Part 4 VASRD Staff (218), Compensation Service, Veterans Benefits 
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, 
Washington, DC 20420, [email protected], (202) 461-9700. (This 
is not a toll-free telephone number.)

SUPPLEMENTARY INFORMATION: VA has periodically revised portions of the 
Schedule for Rating Disabilities, to include the Neurological 
Conditions and Convulsive Disorders (herein referred to as the 
Neurological body system), since it was created in 1919. Important 
advances in the neurological sciences--particularly in the areas 
related to biochemistry, genetics, physiopathology, as well as 
electrodiagnosis and imaging of the nervous system--have produced 
drastic changes in the understanding of neurological diseases since the 
second half of the 20th century. The extent and repercussion of these 
advances triggered profound changes in approaches to diagnosis, 
classification of disease, and care of patients with neurological 
illnesses. 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 (38 CFR) Sec. Sec.  4.120 and 4.123-
4.124a, which pertain to the neurological conditions and convulsive 
disorders. The proposed changes will: (1) update the medical 
terminology of certain neurological conditions and convulsive 
disorders; (2) add medical conditions frequently encountered but not 
currently found in the rating schedule; (3) refine evaluation criteria 
based on medical advances that have occurred since the last revision 
and current understanding of functional changes associated with or 
resulting from disease or injury (pathophysiology), and; (4) remove or 
modify certain diagnostic codes (DC) that are outdated or obsolete.

I. Retitle and Revise Sec. Sec.  4.120 Evaluations by Comparison, 4.123 
Neuritis, Cranial or Peripheral, and 4.124 Neuralgia, Cranial or 
Peripheral

    VA proposes to retitle and revise Sec.  4.120, Evaluations by 
comparison, because the approach to evaluating neurologic conditions 
has evolved over the time since this section was included in the 1945 
rating schedule. See 29 FR 6718, 6749-6750 (May 22, 1964). As medical 
understanding has increased, the additional knowledge permits VA to 
develop evaluation criteria within the individual diagnostic codes that 
more accurately consider motor, sensory, and mental impairment. The 
instructions contained in the last sentence of Sec.  4.120, which apply 
to peripheral nerves, will be updated to better align with modern 
medical knowledge and relocated to the revised Sec.  4.123, titled 
``Cranial and peripheral nerve impairment,'' paragraph (a)(1). VA 
proposes to relocate instructions relating to organic diseases of the 
central nervous system to Sec.  4.120. See section II B. Orgranic 
diseases of the central nervous system below for additional detail.
    VA also proposes to retitle and revise Sec. Sec.  4.123 Neuritis, 
cranial or peripheral and 4.124 Neuralgia, cranial or peripheral. These 
sections provide information regarding symptoms and evaluations 
associated with neuritis and neuralgia. Neuritis and neuralgia are used 
to describe symptoms associated with motor and sensory neuropathy 
involving cranial and peripheral nerves. However, VA proposes their 
removal in favor of more objective criteria to assess disability in the 
cranial and peripheral nerves.
    In the 1940s, the term neuritis was advanced by Dr. S.A. Kinnier 
Wilson as an all-encompassing term for most peripheral nerve 
conditions. Dr. S.A. Kinnier Wilson, ``Neurology,'' 279 (Ninian Bruce 
ed., 1970). As the field of peripheral neuropathology evolved, it 
became apparent that use of the term neuritis was obsolete and should 
be replaced by neuropathy, the preferred term for peripheral nerve 
diseases. While neuritis is sometimes used as a synonym for neuropathy, 
this use is erroneous and should only be used for certain specified 
inflammatory diseases. Drs. A.K. Asbury & Peter Johnson, ``Neurology,'' 
258 (James Bennington ed., 1978). While the term neuragia is still used 
today, for compensation purposes, VA evaluates nerves affected by 
neuralgia by the sensory impairment caused by neuralgia, not the 
diagnosis itself. To that end, and as discussed in more detail below, 
VA proposes to remove neuritis as a separate ratable condition for both 
cranial nerves (DC series 8300) and peripheral nerves (DC series 8600) 
and neuralgia as a separate ratable condition for both cranial nerves 
(DC series 8400) and peripheral nerves (DC series 8700). VA will 
address evaluations for motor neuropathy and sensory neuropathy in 
revised Sec.  4.123, as discussed below.
    The underlying purpose behind the Sec.  4.123 revision is to 
provide a central location for instructions specific to cranial and 
peripheral nerve conditions. This revision will promote rating

[[Page 88918]]

quality and consistency. First, VA proposes to retitle the section as 
``Cranial and peripheral nerve impairment.'' Next, VA proposes 
informational language explaining, generally, how disabilities from 
cranial and peripheral nerve impairment are evaluated. After that, VA 
proposes to describe how disability from motor neuropathy (complete and 
incomplete paralysis) will be evaluated. Finally, VA proposes to 
describe how disability from sensory neuropathy will be evaluated.
    Concerning the general instructions described in the revised Sec.  
4.123, VA proposes to relocate to this section several instructions 
that are currently located in multiple areas. The current VASRD 
contains an instruction directly above diagnostic code 8205; this 
instruction explains that disability from lesions of peripheral 
portions of first, second, third, fourth, sixth, and eighth nerves are 
rated under the Organs of Special Sense. Additionally, it explains that 
the ratings for the cranial nerves are for unilateral involvement; when 
bilateral, combine but without the bilateral factor. VA proposes to 
revise these two sentences, add an additional sentence, and include 
them in Sec.  4.123. Specifically, proposed Sec.  4.123(a)(3) explains 
that a cranial nerve will be evaluated strictly as a cranial nerve, 
regardless of any portions which lie outside the cranium (skull). This 
is consistent with current medical practice which considers cranial 
nerves outside of the cranium as separate and distinct from other 
peripheral nerves. Proposed Sec.  4.123(a)(3) further explains that the 
evaluations in the rating schedule for the cranial nerves are for 
unilateral involvement; when bilateral involvement occurs, evaluate 
separately, then combine under Sec.  4.25 without using the bilateral 
factor. While all cranial nerves begin inside the cranium, most exit 
the cranium to insert at various destinations, where they function in a 
manner similar to peripheral nerves. Nevertheless, VA proposes to 
evaluate the entire nerve, uniformly, as a cranial nerve. Proposed 
Sec.  4.123(a)(2) explains that disability from impairments of the 
first, second, third, fourth, sixth, and eighth cranial nerves will be 
rated under the Organs of Special Sense. Additionally, the current 
VASRD contains an instruction directly above diagnostic code 8510; this 
instruction states, in part, that ratings for the peripheral nerves are 
for unilateral involvement; when bilateral, combine with application of 
the bilateral factor. VA will add a reference to evaluate bilateral 
disabilities separately, then combine using Sec.  4.25 whenever 
bilateral involvement occurs; this will specify, as opposed to merely 
imply, how bilateral disabilities are to be evaluated. Additionally, VA 
will move the instruction to Sec.  4.123(a)(4) because it is a general 
instruction since it applies to both motor and sensory impairment. 
Section 4.120 currently includes a sentence explaining that when rating 
peripheral nerve injuries and their residuals, attention should be 
given to the site and character of the injury, the relative impairment 
in motor function, trophic changes, or sensory disturbances. VA 
proposes the following changes to this sentence: clarify that the 
sentence applies to cranial and peripheral nerves; remove the reference 
to trophic changes, which do not consistently correlate to disability; 
replace the reference to motor function with a reference to movement or 
muscle strength, corresponding with the proposed evaluation criteria 
for cranial and peripheral motor nerve function, respectively; and 
relocate the sentence to Sec.  4.123(a)(1). The purpose of these 
changes is to remedy confusion and inconsistent application of the 
instructions caused by the current placement of instructions in 
multiple locations. Therefore, VA proposes to combine them into a 
centralized location.
    Motor nerve impairment affects muscle function (typically by 
decreased muscle strength), which can have a significant impact on 
movement activities, including, but not limited to, walking and 
grasping. Therefore, VA proposes to focus the complete and incomplete 
paralysis sections of each cranial and peripheral nerve on motor nerve 
impairment.
    Concerning incomplete paralysis of cranial motor nerves, VA 
proposes to evaluate disability by replacing the current ``severe'' 
with ``[a]ttempted movement with inability to complete such movement 
(muscle twitching present).'' Additionally, VA proposes to revise the 
cranial evaluation criteria for ``moderate'' incomplete paralysis with 
``[m]uscle movement intact, but task performed with difficulty.'' The 
proposed revisions replace subjective criteria with objective and 
measurable criteria, which will promote rating consistency and 
accuracy.
    Regarding cranial nerve notes, in the current VASRD, each cranial 
nerve criteria set contains a note describing functions of that 
particular nerve. These notes are currently placed after the 
``paralysis, incomplete'' diagnostic code section of the individual 
nerve. VA proposes to update the notes to provide more detailed 
examples of affected nerve functions and move them, placing them below 
the evaluation criteria of each individual cranial nerve. VA proposes 
this change because each note applies to both sensory and motor 
impairment of the particular cranial nerve.
    Concerning peripheral motor nerves, VA proposes to evaluate 
disability by replacing the current rating criteria, which refer to 
complete and incomplete paralysis at the severe, moderate, and mild 
incomplete paralysis level, with criteria that align with the Medical 
Research Council (MRC) Scale for Muscle Strength (this is also commonly 
referred to as manual muscle testing). This scale is universally known 
and used throughout the medical community to evaluate peripheral 
nerves. ``How to Assess Muscle Strength,'' Merck Manual, https://www.merckmanuals.com/professional/neurologic-disorders/neurologic-examination/how-to-assess-muscle-strength?query=Medical, (last reviewed 
February 2018). The MRC grades muscle strength on a range from ``0'' 
(completely paralyzed) to ``5'' (normal muscle function). ``To 
distinguish among the various degrees of muscle strength within a given 
level, this scale has been modified with the addition of intermediate 
levels (e.g., 4+ and 4-).'' Frontera, W.R. ``Delisa's Physical Medicine 
& Rehabilitation: Principles and Practice,'' 5th Edition, p 74 (2010).
    Instead of ``mild,'' VA will use Grade 4 muscle strength. This 
represents measurable muscle weakness. Instead of ``moderate,'' VA will 
use Grade 3 muscle strength. This represents muscle strength that can 
oppose gravity, but cannot oppose resistance greater than gravity. 
Instead of ``moderately severe,'' VA will use Grade 2+ muscle strength. 
This represents muscle strength that is unable to oppose gravity 
completely, though muscle strength with gravity eliminated is present. 
That is, muscle strength that is greater than Grade 2, but less than 
Grade 3. Only the sciatic nerve has a ``moderately severe'' category. 
Instead of ``severe,'' VA will use Grade 2 muscle strength. This 
represents muscle strength that, though present, cannot oppose gravity 
at all. Complete paralysis will be identified as Grade 0 muscle 
strength (no muscle contraction or complete paralysis) or Grade 1 
muscle strength (meaning a flicker or trace of contraction). Id. The 
proposed revisions replace subjective criteria with objective and 
measurable criteria, which will promote rating consistency and 
accuracy.
    Regarding peripheral nerve instructions, in the current VASRD, 
there is a three-sentence instruction

[[Page 88919]]

directly above DC 8510; this instruction explains, in part, that 
incomplete paralysis with peripheral nerve injuries indicates a degree 
of impaired function substantially less than the type picture for 
complete paralysis, whether due to varied level of the nerve lesion or 
to partial regeneration. VA proposes to leave this sentence intact with 
two aesthetic revisions. These revisions involve changing ``picture'' 
to ``pictured'' and ``level'' to ``levels.'' VA believes these 
revisions will enable the verbiage to flow more smoothly without 
changing the meaning. The third sentence will remain intact, with the 
addition of a reference to Sec.  4.25 in the third sentence, as 
discussed above. Both sentences will be moved to this instructional 
section. The remaining sentence will be removed, as it refers to 
sensory nerve evaluation criteria that VA is proposing to revise. The 
purpose of these changes is to remedy confusion and inconsistent 
application of the instructions caused by the current placement of 
instructions in multiple locations. Therefore, VA proposes to combine 
them into the most appropriate location.
    Currently, each peripheral nerve includes a description in the 
entry for complete paralysis. For example, the entry for complete 
paralysis for DC 8510 for the upper radicular group (fifth and sixth 
cervicals) contains a description of all shoulder and elbow movements 
lost or severely affected, hand and wrist movements not affected. VA 
proposes to remove all peripheral nerve descriptions. Since VA is 
changing the subjective criteria to objective criteria and examiners 
are aware of the muscles affected by each nerve, VA believes the 
descriptions are no longer needed.
    Concerning sensory neuropathy, sensory nerve impairment affects the 
ability to notice sensations, to include but not limited to, sharpness, 
heat, or coldness, and it can also produce abnormal spontaneous 
sensations, to include but not limited to, burning, tingling, and pain 
(pins and needles). Therefore, VA proposes to focus the sensory 
neuropathy sections of each nerve on sensory nerve impairment and 
remove neuritis and neuralgia as separate ratable conditions. Having 
separate diagnostic codes for neuritis and neuralgia requires VA to 
change the diagnostic code a veteran is rated under when the impairment 
associated with the condition changes, which creates additional work 
and complexity with no benefit to the veteran or VA. VA proposes to 
remove the diagnostic codes for neuritis and neuralgia, retitle the 
diagnostic codes addressing paralysis, and address motor and sensory 
impairment as criteria under the retitled diagnostic codes. 
Additionally, in light of the removal of DCs 8619 and 8719, VA proposes 
to number the notes that will appear under DC 8519.
    In the current VASRD, the instructions under Sec.  4.124, 
Neuralgia, cranial or peripheral, consist of three sentences. The first 
two sentences provide information regarding symptoms associated with 
neuralgia and instructions regarding the maximum evaluations for 
neuralgia. The last sentence provides rating instructions for tic 
douloureux. VA proposes to address sensory impairments in a new 
section, Sec.  4.123(c). Instead of defining neuralgia, Sec.  
4.123(c)(1) will address altered sensation, with or without pain, on 
the basis of incomplete or complete sensory neuropathy. VA proposes to 
delete the last sentence of Sec.  4.124, which addresses tic 
douloureux, because it is redundant. A note under the entry for the 
fifth (trigeminal) cranial nerve provides instructions on how to 
evaluate tic douloureux.
    The current evaluation criteria focus on neuritis, neuralgia, and 
degrees of paralysis, with a maximum rating for neuritis equal to 
severe, incomplete, paralysis of the nerve involved, and a maximum 
rating for neuralgia equal to moderate incomplete paralysis. There is 
also an instruction at the beginning of the schedule of ratings for 
diseases of the peripheral nerves indicating that the rating should be 
for the mild, or at most, the moderate degree when the involvement is 
wholly sensory. Certain cranial and all peripheral nerves are evaluated 
using neuritis, neuralgia, and degrees of paralysis, regardless if the 
nerve has only sensory function, only muscle function, or both sensory 
function and muscle function (found in mixed nerves). There are several 
problems with the current approach. While both neuritis and neuralgia 
involve distorted sensation, the disability associated with these 
distorted sensations cannot be quantified by objective diagnostic 
testing and is unpredictable. Furthermore, the evaluation criteria for 
pure sensory nerves are the same as for pure motor nerves and mixed 
nerves, which is incorrect from a medical science perspective. For 
example, the external cutaneous nerve of the thigh and the obturator 
nerve have the same evaluation criteria (varying degrees of paralysis, 
which currently form the basis for rating neuritis and neuralgia), even 
though it is scientifically incorrect to evaluate a pure sensory nerve, 
such as the external cutaneous nerve of the thigh, for paralysis. It is 
this difficulty with measurement, unpredictability, and inappropriate 
application of certain evaluation criteria that VA seeks to remedy with 
the following proposed changes.
    VA proposes to change the sensory evaluation criteria to a more 
easily measured sensory deprivation standard. Impairment of sensory 
function will be quantified as either incomplete or complete sensory 
deprivation. This simplifies the evaluation criteria and is much more 
easily measured during physical examination. These criteria will be 
applied to certain cranial nerves as well as all peripheral nerves. 
Muscle function in certain cranial nerves and all peripheral nerves 
will be evaluated in isolation using the previously discussed methods.
    Using the incomplete/complete characterization of sensory 
deprivation described above, VA proposes to use a more straightforward 
description for disability when sensory neuropathy is involved. VA will 
consider sensory neuropathy as incomplete when sensation is impaired, 
although not absent, or when unpleasant sensations are experienced by 
the nerve such as dysesthesia, numbness, or paresthesia. Dysesthesia 
refers to any unpleasant sensation produced by a stimulus that is 
normally painless. Numbness refers to a sense of heaviness, weakness, 
or deadness in part of the body. Paresthesia refers to abnormal 
spontaneous sensations such as burning, tingling, pins and needles, 
etc. Clinical Neurology, 11th Edition, 2021, Chapter 10: Sensory 
Disorders. editors Greenberg, D.A., Aminoff, M.J., and Simon, R.P.
    VA will consider sensory neuropathy complete when sensation is 
absent. In cranial nerves, which have compensable evaluations at the 
moderate evaluation level, VA will assign an evaluation at the moderate 
evaluation level if there is incomplete or complete sensory neuropathy. 
However, this will not be applied to the eleventh cranial nerve, also 
known as the spinal accessory nerve, because it only has a muscle 
function. For peripheral nerves, which mostly have compensable 
evaluations at the mild evaluation level, VA will assign an evaluation 
similar to the mild evaluation if there is incomplete sensory 
neuropathy. VA will assign an evaluation similar to the moderate 
evaluation if there is complete sensory neuropathy. Where the 
evaluation of a peripheral nerve remains the same whether it is at the 
mild or moderate evaluation level (DCs 8525, 8527, 8528, 8529, and 
8530), VA will assign an evaluation at the moderate evaluation if there 
is incomplete or complete sensory neuropathy.

[[Page 88920]]

II. Schedule of Ratings--Neurological Conditions and Convulsive 
Disorders

A. Location of Section

    Currently, the schedule of ratings for the Neurological body system 
is located in 38 CFR 4.124a. When the 1945 VA Schedule for Rating 
Disabilities was originally published in title 38 of the Code of 
Federal Regulations in 1964, VA organized it such that specific body 
systems started at specific locations. The Musculoskeletal body system, 
for example, began in Sec.  4.40 even though the preceding section was 
Sec.  4.31, leaving sections Sec. Sec.  4.32 through 4.39 without 
content. See 29 FR 6718, 6722 (May 22, 1964). VA also designed the 
Rating Schedule so that the Mental Disorders body system started with 
Sec.  4.125; however, due to the number of sections necessary to 
establish the Neurological body system, which precedes the Mental 
Disorders body system, the schedule of ratings for neurological 
conditions and convulsive disorders was placed in Sec.  4.124a. See 29 
FR 6718, 6749-53 (May 22, 1964). As proposed above, disability 
previously addressed in Sec.  4.124 will now be addressed in the 
revision of Sec.  4.123, which makes Sec.  4.124 available. Therefore, 
VA also proposes to relocate the Schedule of Ratings from Sec.  4.124a 
to Sec.  4.124 and remove Sec.  4.124a. VA proposes corresponding 
revisions to the references to Sec.  4.124a in 38 CFR 3.809(d) and 38 
CFR 4.71a, DC 5244.

B. Organic Diseases of the Central Nervous System

    Currently, the introductory instruction under Sec.  4.124a provides 
guidance concerning how to evaluate residuals of organic diseases of 
the central nervous system. There is a note currently located under DC 
8025, Myasthenia gravis, which also provides guidance concerning how to 
evaluate residuals of organic diseases of the central nervous system. 
VA proposes to consolidate both notes, revising them and relocating 
them to Sec.  4.120. VA further proposes to specify the diagnostic 
codes to which the instructions apply in order to promote consistent 
application of the VASRD.
    First, VA proposes to clarify when ascertainable residuals are 
required. For diagnostic codes 8000-8036, there are 2 categories of 
diagnostic codes that consider minimum evaluations: unconditional and 
conditional minimums. Unconditional minimum diagnostic codes are 8002, 
8004, 8007, 8010, 8018, 8021, 8023, 8024, and 8025. The aforementioned 
diagnostic codes do not require ascertainable residuals for a minimum 
evaluation, and will not require ascertainable residuals in this 
proposed regulation.
    For DCs 8004 and 8007, which have unconditional minimums within the 
proposed General Rating Formula, VA proposes Note (1) to direct the 
rater to grant a minimum evaluation of 30 percent for Parkinson's 
disease (8004), regardless of examination findings. VA proposes Note 
(2) to direct the rater to grant a minimum evaluation of 10 percent for 
stroke residuals (8007), regardless of examination findings. No minimum 
evaluations will be available for DCs 8026, 8027, and 8028.
    Conditional minimum DCs 8000, 8003, 8011, 8012, 8019, 8020, 8022, 
and new 8036 all require ascertainable residuals. Examples of 
ascertainable residuals to be considered include, but are not limited 
to, psychotic manifestations, loss of use of an extremity (partial or 
complete), as well as abnormal speech, vision, gait, or coordination. 
Finally, in the portion of the instruction addressing determinations as 
to the presence of residuals not capable of objective verification, VA 
proposes to specify that such determinations must be approached on the 
basis of disability related to the diagnosis recorded, rather than 
simply the diagnosis recorded, as the current instruction provides. The 
revised language is more consistent with 38 CFR 4.1, which provides 
that the rating schedule is primarily a guide in the evaluation of 
disability resulting from diseases and injuries encountered as a result 
of or incident to military service.
    In regard to peripheral nerves and paralysis, VA proposes to 
replace the reference to mild, moderate, severe, or complete paralysis 
of peripheral nerves with a reference to complete or incomplete 
paralysis to account for changes in the way paralysis of peripheral 
nerves will be evaluated as referenced above.
    With respect to ratings in excess of the prescribed minimum 
ratings, VA proposes to replace the current language directing raters 
to cite the diagnostic codes utilized as bases of evaluation in 
addition to the codes identifying the diagnoses with a reference to 
Sec.  4.27, as that section includes instructions for the use of 
diagnostic code numbers when a disease is rated on the basis of 
residual conditions.

C. Diagnostic Code 8000, Encephalitis, Infectious

    Current DC 8000 is titled ``Encephalitis, epidemic, chronic.'' The 
use of the term ``epidemic'' was used to describe an outbreak of 
encephalitis lethargica from 1918 to 1930. Dr. R.R. Dourmashkin, ``What 
Caused the 1918-1930 Epidemic of Encephalitis Lethargica?,'' 90 Journal 
of the Royal Society of Medicine 515, 515-520 (1997). Since that 
outbreak, a recurrence of the epidemic has not been reported. 
``Encephalitis Lethargica Information Page,'' National Institute of 
Health--National Institute of Neurological Disorders and Stroke, 
https://www.ninds.nih.gov/health-information/disorders/encephalitis 
(last visited September 18, 2024). Given the infrequency with which 
this specific type of encephalitis occurs, VA proposes to rename DC 
8000 as ``Encephalitis, infectious'' to better reflect the disabilities 
currently evaluated under this DC.
    As a broader disease category, infectious encephalitis refers to an 
irritation and swelling of the brain caused by viral, bacterial, 
fungal, or parasitic infection. Symptoms of this disease can be quite 
severe and include loss of consciousness, seizures, paralysis, and 
sudden change in mental functions. The residuals of infectious 
encephalitis vary from full recovery to permanent disabilities and, in 
some cases, death. ``Encephalitis,'' National Institute of Health--U.S. 
National Library of Medicine (Aug. 31, 2016), https://medlineplus.gov/ency/article/001415.htm (last visited April 3, 2018). No changes to the 
evaluation criteria are proposed.

D. Diagnostic Code 8002, Brain, New Growth of, Malignant and Diagnostic 
Code 8003, Brain, New Growth of, Benign

    Current DC 8002 is titled ``Malignant,'' and current DC 8003 is 
titled ``Benign, minimum.'' VA proposes changes to these diagnostic 
codes to correct current poor formatting. Both are intended to be read 
in conjunction with the general category of ``Brain, new growth of.'' 
To clarify the conditions covered under these DCs, VA proposes to 
rename these disabilities as DC 8002, ``Brain, new growth of, 
malignant,'' and DC 8003, ``Brain, new growth of, benign.''
    Current DC 8002 also contains a note that is located between the 
100 percent and the 30 percent evaluation levels. Previously, this 
diagnostic code had a 100 percent evaluation level and its note 
contained information regarding the 30 percent minimum rating. See 43 
FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have 
placed the note between the 100 percent and the 30 percent evaluation 
levels. Notes are typically found after evaluative criteria. Therefore, 
VA proposes to relocate this note after the 30 percent evaluation

[[Page 88921]]

level and to revise it to ensure that rating personnel understand how 
it applies to the both the 100 percent and 30 percent evaluation 
levels.
    Current DC 8003 provides a minimum evaluation of 60 percent in the 
presence of a benign growth of the brain and then directs raters to 
evaluate based upon residuals, with a minimum evaluation of 10 percent. 
VA proposes to clarify the 60 percent evaluation by indicating that it 
applies during the presence of an active benign growth of the brain or 
during active treatment. By adding this additional information to the 
60 percent evaluation criteria, VA will promote consistency of 
evaluations and avoid premature re-evaluation of the disability prior 
to successful treatment of the benign growth. VA proposes no other 
changes to these diagnostic codes.

E. Diagnostic Code 8004, Parkinson's Disease (Paralysis Agitans)

    Current DC 8004 is titled ``Paralysis agitans,'' which is Latin for 
shaking palsy. While these terms are accurate descriptors of the 
disability, the more commonly used and accepted medical terminology is 
Parkinson's disease (PD). To clarify the disability evaluated under 
this diagnostic code as well as to make the VASRD more user-friendly to 
non-medical personnel, VA proposes to rename this diagnostic code 
``Parkinson's disease.'' VA proposes to preserve the historical 
reference in parentheses.
    VA also proposes to adopt evaluation criteria that reflect a modern 
understanding of this condition within a proposed general rating 
formula (GRF). VA proposes the creation of a GRF for certain movement 
disorders within the neurological body system due to the similarities 
of disabling effects and high frequency of misdiagnosis. By 
implementing a GRF, the rating process will be standardized as well as 
simplified based on disability presentation for a group of conditions. 
Additionally, the use of a GRF for these movement disorders will ensure 
the avoidance of pyramiding when more than one movement disorder is 
service connected. Pyramiding occurs when two or more evaluation 
percentages are awarded for the same disability under various 
diagnoses. In accordance with 38 CFR 4.14, pyramiding must be avoided. 
When two or more movement disorders are service-connected, unless none 
of the symptomatology of a movement disorder is duplicative of or 
overlapping with the symptomatology of another movement disorder, one 
evaluation percentage will be awarded based on the highest level of 
disability represented by the rating criteria that more nearly 
approximates the disability picture attributable to the service-
connected movement disorders. 38 CFR 4.7. VA proposes to title the GRF 
``General Rating Formula for Specified Neurologic Conditions (DCs 8004, 
8007, 8026, 8027, and 8028)''. VA proposes 0, 10, 30, 60, and 100 
percent evaluations to the newly proposed GRF, and it will be placed 
immediately below DC 8004. Lastly, specific to PD, VA proposes to 
continue the minimum 30 percent evaluation for a formal diagnosis of 
PD, as explained in the first note following the proposed GRF.
    Recent advances in the understanding of PD have produced several 
assessment scales that describe discrete levels of increasing 
disability. The Revised Unified Parkinson's Disease Rating Scale (2008) 
is a sophisticated, complex scale widely used by clinicians. The level 
of sophistication and specificity, however, is not required to describe 
occupationally significant disability. The Hoehn-Yahr Parkinson's 
Disease scale, which has been in use since 1967, is far simpler to use 
and apply. VA proposes to base the disability criteria on this scale 
with direct reference to Hoehn-Yahr stages and descriptions of 
functional limitation associated with that severity of disease. VA 
recognizes that this scale was specifically developed for PD. However, 
other movement disorder evaluation tools are similar to Hoehn-Yahr. 
Thus, it was determined this was a reliable tool to adapt to multiple 
movement disorders. Parkinson's Resource Organization, The Five Stages 
of Parkinson's Disease, https://www.parkinsonsresource.org/wp-content/uploads/2012/01/The-FIVE-Stages-of-Parkinsons-Disease.pdf, May 2002. In 
addition, where appropriate, VA considered and incorporated features of 
other movement disorder scales. Those additions are noted under the 
specific movement disorder discussions below. The GRF will list the 
evaluation criteria first, followed by several notes.
    The first note will direct raters to evaluate all cases of PD with 
a minimum rating of 30 percent. A second note is specific to stroke 
residuals rated under DC 8007 and directs raters to evaluate stroke 
residuals with a minimum rating of 10 percent. A third note defines 
activities of daily living. A fourth note instructs the rater how to 
evaluate symptoms versus separate and distinct diagnoses. For example, 
when an impairment such as depression is noted as a symptom versus a 
formal diagnosis, then it will be evaluated using the GRF for Specified 
Neurologic Conditions. Conversely, if there is a formal diagnosis, then 
the disorder will be evaluated separately under Sec.  4.130 (Schedule 
of ratings--mental disorders). These instructions mirror the current 
instructions related to the Residuals of Traumatic Brain Injury. The 
fifth note addresses overlap of manifestations. It instructs rating 
specialists to evaluate comorbid conditions together when they cannot 
be delineated. These instructions also mirror the current instructions 
related to the Residuals of Traumatic Brain Injury. The sixth note 
reminds raters to consider special monthly compensation.
    VA proposes the rating criteria under the GRF to consist of the 
following. A 100 percent evaluation will be given for ``Hoehn-Yahr 
stage 4 or stage 5, or; the inability to live independently because of 
neurologically-related disability.'' A 60 percent evaluation will be 
given for ``Impairment of mobility (e.g., transfers, balance, or gait) 
requiring daily use of an assistive device such as a wheelchair, 
brace(s), crutch(es), cane(s), or walker.'' A 30 percent evaluation 
will be given for ``Hoehn-Yahr stage 3, or; impairment of mobility 
(e.g., transfers, balance, or gait) requiring less than daily use of an 
assistive device such as a wheelchair, brace(s), crutch(es), cane(s), 
or walker.'' A 10 percent evaluation will be given for ``Hoehn-Yahr 
stage 2, or; impairment in at least one of the following areas: facial 
expression (e.g., masking, blinking, or eye motion abnormalities); 
speech (e.g., soft voice, slurring, difficulty speaking or swallowing); 
posture (e.g., stooping, instability); mobility not requiring an 
assistive device (e.g., decreased speed with transfers, gait ataxia, 
unstable balance); problems initiating or controlling motor movements 
(e.g., stiffness, tremors); cognitive (e.g., memory or executive 
problems); mental (e.g., anxiety, depression, social phobia); sensory 
abnormalities (e.g., olfactory deficits); involuntary muscle 
contractions resulting in pain and impairment, such as but not limited 
to, spontaneous neck turning or writing difficulty.'' A 0 percent 
evaluation will be given for ``Hoehn-Yahr stage 1, or; formal diagnosis 
without impairment.''

F. Diagnostic Code 8007, Stroke (Ischemic, Hemorrhagic, or Thrombotic), 
Including Cerebral Infarction or Cerebrovascular Accident (Brain, 
Vessels, Embolism, Thrombosis, and Hemorrhage); Diagnostic Code 8008 
Brain, Vessels, Thrombosis of (Delete); Diagnostic Code 8009 Brain, 
Vessels, Hemorrhage From (Delete)

    VA proposes to combine three DCs (8007, Brain, vessels, embolism 
of; 8008, Brain, vessels, thrombosis of; and 8009, Brain, vessels, 
hemorrhage from) under

[[Page 88922]]

DC 8007 and rename it as ``Stroke (ischemic, hemorrhagic, or 
thrombotic), including cerebral infarction or cerebrovascular accident 
(Brain, vessels, embolism, thrombosis, and hemorrhage).'' Since most 
clinicians document the condition as ``stroke'' rather than embolism, 
thrombosis, or hemorrhage, raters are unable to distinguish which title 
most accurately aligns with ``stroke,'' which means there is a risk 
that rating specialists will not consistently apply these DCs. For 
example, three raters evaluate three veterans diagnosed with residuals 
of a stroke. One rater chooses to use DC 8007; another uses DC 8008; 
and the other uses DC 8009. All three disabilities currently have the 
same evaluation criteria. Therefore, the veterans are not at a 
disadvantage from receiving one DC over the other. However, for 
statistical purposes, combining these three DCs would promote 
consistency in future research associated with stroke residuals. 
Because all three of the current diagnostic codes evaluate stroke 
residuals in the same way, VA proposes to combine them in order to 
create diagnostic code application consistency. Additionally, while the 
distinction concerning the type of stroke is a medical necessity for 
treatment purposes, it is irrelevant for rating purposes. This proposed 
update will create more consistent data tracking for disability 
compensation research purposes.
    Currently, rating personnel grant a 100 percent evaluation for the 
first six months, then assign a minimum rating of 10 percent for stroke 
residuals, unless an evaluation of residuals under separate body 
systems results in a higher evaluation. Under the proposed changes, 
whenever diagnostic imaging, which is part of standard care for a 
stroke, identifies a stroke, rating personnel will continue to grant a 
100 percent evaluation for the first six months; they will also 
continue to assign a minimum 10 percent for stroke residuals regardless 
of examination findings. Rating personnel will assign evaluations 
higher than the minimum in accordance with the General Rating Formula 
for Specified Neurologic Conditions (GRF). As explained in the fourth 
note of the GRF, if a residual is a symptom of the stroke, it will be 
evaluated as such. Contrarily, if a residual has a separate and 
distinct formal diagnosis, it will be service connected and evaluated 
separately. For example, if depression is noted as a symptom, it will 
be evaluated as part of the minimum 10 percent evaluation. However, if 
depression is a separate and distinct formal diagnosis, it will be 
service connected on a secondary basis and evaluated under Sec.  4.130 
(Schedule of ratings--mental disorders). See DC 8004 for details about 
the GRF.

G. Diagnostic Code 8018, Multiple Sclerosis and Other Demyelinating 
Diseases of the Central Nervous System

    VA proposes to revise the title for this diagnostic code. The new 
title will be Multiple sclerosis (MS) and other demyelinating diseases 
of the Central Nervous System. The underlying basis for this revision 
is the existence of two conditions which present with disabilities 
similar to MS. VA proposes to evaluate neuromyelitis optica spectrum 
disorder (NMOSD) under this DC. Previously, NMOSD was rated analogously 
with DC 8010, Myelitis. Myelin oligodendrocyte glycoprotein antibody--
associated disease (MOGAD) is the other condition to be captured with 
this DC. Like NMOSD, MOGAD also presents with a similar disability 
picture to MS. Wu, H. and Fisher, K., Current Diagnosis & Treatment 
Pediatric Neurology, Chapter 35. 2023.

H. Diagnostic Code 8021, Spinal Cord, New Growths of, Malignant and 
Diagnostic Code 8022, Spinal Cord, New Growths of, Benign

    Current DC 8021 is titled ``Malignant,'' and current DC 8022 is 
titled ``Benign.'' VA proposes changes to these DCs to correct current 
poor formatting. Both were intended to be read in conjunction with the 
general category ``Spinal cord, new growths of.'' For the same reasons 
set forth above in the discussion for DC 8002, VA proposes to rename DC 
8021 ``Spinal cord, new growths of, malignant,'' and DC 8022 ``Spinal 
cord, new growths of, benign.'' VA also proposes to clarify the 60 
percent evaluation criteria for DC 8022 for the same reasons set forth 
in the discussion for DC 8003.
    Additionally, current DC 8021 also contains a note that is located 
between the 100 percent and the 30 percent evaluation levels. 
Previously, this DC had a 100 percent evaluation level and its note 
contained information regarding the 30 percent minimum rating. See 43 
FR 45348, 45362 (Oct. 2, 1978). However, revisions to Part 4 have 
placed the note between the 100 percent and the 30 percent evaluation 
levels. Notes are typically found after evaluative criteria. Therefore, 
VA proposes to relocate this note after the 30 percent evaluation level 
and to revise it to ensure that rating personnel understand how it 
applies to the both the 100 percent and 30 percent evaluation levels. 
VA proposes no other changes to these DCs.

I. Diagnostic Code 8025, Myasthenia Gravis

    VA proposes to relocate and modify the note currently located 
directly below the rating criteria of DC 8025. It will be relocated to 
the introductory instruction under Sec.  4.124. Refer to the above 
section, ``B. Organic diseases of the central nervous system,'' and 
Sec.  4.124 for further details concerning this instruction.

J. New Diagnostic Code 8026, Parkinson's Plus, or Secondary 
Parkinsonism Syndromes

    VA proposes to add a new DC 8026, titled ``Parkinson's plus, or 
secondary parkinsonism syndromes,'' in order to account for impairment 
due to this condition in the veteran population. Parkinson's plus 
syndromes cause similar symptoms and impairment to Parkinson's disease, 
but have other features that make them different. Parkinson's plus 
syndromes have several causes, which include but are not limited to 
different location of protein buildup, brain injury, encephalitis, 
meningitis, stroke, medications, and chemical poisonings. Parkinson's 
plus syndromes can cause impairment in facial expressions, problems 
with initiating or controlling motor movements, paralysis, vocal 
impairment, stiffness, and tremor. Treatment for Parkinson's plus 
syndromes, as well as the likelihood and extent of residual disability, 
depends on the underlying cause of the disorder. This is in contrast to 
primary Parkinson's, or Parkinson's disease, where there is a 
predictable progression. For this reason, Parkinson's plus syndrome 
will not have a minimum evaluation. ``Secondary Parkinsonism,'' 
National Institute of Health--U.S. National Library of Medicine (Jan. 
19, 2018), https://medlineplus.gov/ency/article/000759.htm (last 
visited April 3, 2018). VA is proposing a specific diagnostic code for 
Parkinson's plus syndromes to allow for proper tracking of Parkinson's 
plus and Parkinson's disease in the veteran population. Parkinson's 
plus will be evaluated under the General Rating Formula for Specified 
Neurologic Conditions (GRF). See DC 8004 for details about the GRF.

K. New Diagnostic Code 8027, Essential Tremor

    VA proposes to add a new DC 8027, titled ``Essential tremor,'' in 
order to account for impairment due to this condition. There is 
currently no standalone diagnostic code to account

[[Page 88923]]

for essential tremor, forcing rating personnel to rely on analogous 
coding and leading to inconsistent evaluations.
    ``Tremor is defined as a rhythmical, involuntary, oscillatory 
movement of a body part and is one of the most frequent movement 
disorders.'' Teive, H.A.G., ``Essential Tremor: phenotypes,'' (18) S1, 
pp 140-142, 140, Parkinsonism and Related Disorders (2012). ``Essential 
tremor (ET) is one of the most common neurological diseases and the 
[most common] cause of pathological tremor.'' Id. ``Historically[,] ET 
was defined as a benign entity.'' Id. However, recently it ``was 
suggested that it is time to remove the `benign' from the ET label, as 
it has been shown to be progressive in nature and quite disabling for 
most patients.'' Id. ``In the last [several] years[,] ET has evolved 
into two different meanings.'' Id. First, ``the classical ET, as a 
monosymptomatic disorder, and second, a heterogeneous disorder, the 
Essential Tremors, or a family of diseases.'' Id. Currently, ``ET can 
be classified with both motor and non-motor elements. Tremor may occur 
also in the legs, feet, trunk, jaw, chin, tongue, and voice. Although 
postural and kinetic tremors are the main features of ET, intentional 
tremor and tremor at rest may also occur in some patients. Other motor 
features described in patients with ET are gait ataxia, postural 
instability[,] and eye-motion abnormalities. Non-motor features include 
cognitive (memory and executive problems and dementia), psychiatric 
(anxiety, depression[,] and social phobia), and sensory abnormalities 
(olfactory deficits [and] hearing loss).'' Id.
    In developing evaluation criteria for ET, one of the most 
significant challenges is little, if any, outcomes research that would 
assist in criteria development. However, there are two well-recognized 
tools VA used to research this condition. The first tool is the 
International Classification of Functioning, Disability, and Health 
(2001), published by the World Health Organization, that provided 
terminology and definitions. According to this resource, ET involves 
the dysfunction of specific elements within the central nervous system. 
The tremors with ET are the impairments resulting from that nervous 
system dysfunction. Those tremors cause activity limitations and 
participation restrictions that can lead to earnings loss. The second 
tool is the 6th Edition Guides to the Evaluation of Permanent 
Impairment (2008), published by the American Medical Association. The 
guide has impairment tables for the upper extremities, gait, and 
station. These tools were considered in the creation of a general 
rating formula.
    Another significant challenge in developing evaluation criteria for 
ET is the high rate of misdiagnosis with other movement disorders, such 
as dystonia and Parkinson's disease. Misdiagnosis occurs in up to 50 
percent of cases, with Parkinson's disease (particularly in elderly 
patients) and dystonia (tremulous cervical dystonia) being the most 
common disorders mistaken for ET. Therefore, VA proposes the creation 
and use of a General Rating Formula for Specified Neurologic Conditions 
(GRF) for this and other movement disorders, allowing evaluation to 
focus on the symptoms and impairment present, even when misdiagnosis 
and/or a change in diagnosis occurs. See diagnostic code 8004 for 
details about the GRF. Teive, H.A.G., ``Essential Tremor: phenotypes,'' 
(18) S1, pp 140-142, Parkinsonism and Related Disorders (2012).

L. New Diagnostic Code 8028, Dystonia

    VA proposes to add a new DC 8028, titled ``Dystonia,'' in order to 
account for impairment due to this condition. There is currently no 
standalone diagnostic code to account for dystonia, forcing rating 
personnel to rely on analogous coding and leading to inconsistent 
evaluations.
    Dystonia causes involuntary muscle contractions that lead to slow, 
repetitive, and sometimes painful movement or abnormal posture. 
Dystonia can affect only one muscle, groups of muscles (torticollis), 
or muscles throughout the entire body. The specific symptoms and 
impairment experienced depend highly on the type of dystonia and the 
muscles affected, but can include difficulty walking, involuntary neck 
turning, difficulty speaking, writing, and uncontrollable blinking. 
Some cases of dystonia only affect a muscle group when performing a 
specific action. ``Dystonias Fact Sheet,'' National Institute of 
Health--National Institute of Neurological Disorders and Stroke (June 
3, 2014), https://www.ninds.nih.gov/health-information/disorders/tremor#toc-where-can-i-find-more-information-about-tremor- (last 
visited September 18, 2024).
    The Dystonia Study Group composed of renowned international 
movement disorder experts developed the unified dystonia rating scale 
and the global dystonia rating scale to serve as instruments to 
medically assess dystonia severity. ``Rating Scales for Dystonia: A 
Multicenter Assessment,'' Comella C et al., 2003 Movement Disorders 18 
No.3 pp 303-12. These scales were considered during the creation of the 
general rating formula. Due to similarity and overlap of symptoms with 
other movement disorders, along with the high prevalence of 
misdiagnosis, VA proposes application of a General Rating Formula for 
Specified Neurologic Conditions (GRF). See DC 8004 for details about 
the GRF.

M. New Diagnostic Code 8036, Primary Lateral Sclerosis

    VA proposes to add a new DC 8036, titled ``Primary lateral 
sclerosis,'' in order to account for impairment due to this condition. 
There is currently no standalone diagnostic code to account for primary 
lateral sclerosis (PLS). A standalone diagnostic code will permit more 
accurate tracking of this condition, and its associated disability.
    PLS is a motor neuron disease that affects the upper motor neurons 
in the arms, legs, and face. Individuals with PLS first experience loss 
of muscle control in the feet and legs, then the disease progresses up 
the trunk and into the arms, hands, and the muscles that control 
speech, swallowing, and chewing. PLS can be differentiated from 
amyotrophic lateral sclerosis in that it only affects the upper motor 
neurons and progresses gradually. While there is no cure for PLS, it is 
not considered a fatal disease, and many individuals maintain the 
ability to walk without assistance, although they may eventually need a 
cane or walker due to the development of high degrees of spasticity. 
Due to the wide range of symptoms and severity upon confirmation of 
diagnosis, VA proposes to evaluate PLS according to the residual 
impairment under the appropriate diagnostic code with a minimum rating 
of 10 percent when there are ascertainable residuals. See R. 
Ramanathan, et al., ``Demographics and clinical characteristics of 
primary lateral sclerosis: case series and a review of literature,'' 
Neurodegener. Dis. Manag., vol 8(1), pp 17-23. 2018.

N. Diagnostic Code 8103, Hemifacial Spasm (Tic, Convulsive)

    Current DC 8103 is titled ``Tic, convulsive,'' a facial nerve 
disorder that causes involuntary spasms and contractions of the facial 
nerves. For consistency, clarity, and ease of use of the VASRD by non-
medical personnel, VA proposes to rename this diagnostic code 
``Hemifacial spasm.'' Hemifacial spasm, an alternative name for 
convulsive tic, provides a much more explicit indication as to the 
condition to be evaluated under this diagnostic code

[[Page 88924]]

in terms of the anatomical location to be considered. VA proposes to 
preserve the historical reference to the nomenclature in parentheses. 
VA proposes no other changes to this diagnostic code.

O. Diagnostic Code 8104, Paramyoclonus Multiplex (Convulsive State, 
Myoclonic Type)

    The current evaluation criteria for DC 8104, Paramyoclonus 
multiplex (convulsive state, myoclonic type), directs rating personnel 
to rate this condition as convulsive tic, which is DC 8103. As 
discussed above, VA is updating this term to hemifacial spasm in order 
to reflect current medical terminology. As such, VA proposes to replace 
``tic; convulsive'' in the evaluation criteria of DC 8104 to maintain 
consistency throughout this portion of the VASRD. VA proposes no other 
changes to this DC.

P. Diagnostic Code 8107, Athetosis, Acquired

    Current DC 8107, Athetosis, acquired, directs rating personnel to 
evaluate this condition as chorea. To clarify these instructions and 
promote consistency in evaluations, VA proposes to specify that this 
condition should be evaluated as Sydenham's chorea, matching the title 
of the DC that provides the appropriate evaluation criteria. VA 
proposes no other changes to this DC.

Q. Title Changes to Certain Peripheral Nerves

    To reflect current medical terminology, VA proposes to update the 
names of the following peripheral nerves. The proposed titles are the 
current accepted nomenclature to describe these nerves. VA proposes to 
preserve the historical reference to the nomenclature in parentheses.

------------------------------------------------------------------------
                                Current title for    Proposed title for
       Diagnostic code                nerve                 nerve
------------------------------------------------------------------------
8514........................  Musculospiral nerve   Radial nerve
                               (radial nerve).       (musculospiral).\1\
8518........................  Circumflex nerve....  Axillary nerve
                                                     (circumflex).\2\
8521........................  External popliteal    Common peroneal
                               nerve (common         nerve (external
                               peroneal).            popliteal).\3\
8522........................  Musculocutaneous      Superficial peroneal
                               nerve (superficial    nerve
                               peroneal).            (musculocutaneous).
                                                     \1\
8523........................  Anterior tibial       Deep peroneal nerve
                               nerve (deep           (anterior
                               peroneal).            tibial).\1\
8524........................  Internal popliteal    Tibial nerve
                               nerve (tibial).       (internal
                                                     popliteal).\4\
8526........................  Anterior crural       Femoral nerve
                               nerve (femoral).      (anterior
                                                     crural).\5\
8527........................  Internal saphenous    Saphenous nerve
                               nerve.                (internal
                                                     saphenous).\1\
8529........................  External cutaneous    Lateral cutaneous
                               nerve of thigh.       nerve of the thigh
                                                     (external
                                                     cutaneous).\5\
------------------------------------------------------------------------
\1\ ``Dorland's Illustrated Medical Dictionary,'' 1123 (Douglas M.
  Anderson et al. eds., 27th ed. 1988).
\2\ Wolf, J., ``Segmental Neurology'', page 20, 1981.
\3\ ``Common Peroneal Nerve Dysfunction,'' National Institute of Health--
  U.S. National Library of Medicine (Aug. 7, 2017), https://medlineplus.gov/ency/article/000791.htm (last visited April 3, 2018).
\4\ ``Dorland's Illustrated Medical Dictionary,'' 1124 (Douglas M.
  Anderson et al. eds., 27th ed. 1988).
\5\ ``Dorland's Illustrated Medical Dictionary,'' 1120 (Douglas M.
  Anderson et al. eds., 27th ed. 1988).

R. Diagnostic Code 8514, Paralysis of the Musculospiral (Radial) Nerve

    Current DC 8514 addresses motor impairment from diseases affecting 
the musculospiral nerve. The current evaluation criteria include a note 
that references dissociation of extensor communis digitorum and 
paralysis below the extensor communis digitorum, as well as instructing 
evaluations of these findings should not exceed a moderate rating. As 
stated previously, this nerve will be retitled as the radial nerve. 
Additionally, the note will be revised, as the evaluation criteria will 
be revised to employ the grade of muscle strength as the means to 
distinguish evaluation levels, with the maximum evaluation level 
corresponding to Grade 3 muscle strength for dissociation of extensor 
communis digitorum and paralysis below the extensor communis digitorum.

S. Diagnostic Code 8520, Paralysis of the Sciatic Nerve

    Current DC 8520 addresses motor impairment due to diseases of the 
sciatic nerve. The nerve referenced by this diagnostic code stimulates 
the muscles of the entire lower extremity. While all other peripheral 
nerve criteria consist of mild, moderate, and severe, this one includes 
an extra category labeled moderately severe. In order to preserve the 
current evaluation levels and account for this extra category, VA 
proposes to revise the incomplete paralysis criteria at the 60 percent, 
40 percent, 20 percent, and 10 percent levels. A 60 percent evaluation 
will be granted for muscles that have grade 2 strength (previously 
labeled severe). A 40 percent evaluation will be granted for muscles 
that have grade 2+ strength (previously labeled moderately severe). A 
20 percent evaluation will be granted for muscles that have grade 3 
strength (previously labeled moderate). A 10 percent evaluation will be 
granted for muscles that have grade 4 strength (previously labeled 
mild). Refer to the discussion above regarding Sec.  4.123 for further 
details concerning the grading scale for motor impairment.

T. Diagnostic Code 8527, Sensory Neuropathy of the Internal Saphenous 
Nerve

    Current DC 8527 addresses paralysis of the internal saphenous 
nerve. Paralysis refers to the lack of muscle function in muscle 
fibers. Posterior roots of the spinal nerves, including the saphenous 
nerve, do not have motor fibers, making it a pure sensory nerve. M. De 
Maeseneer, et al., ``Normal Anatomy and Compression Areas of Nerves of 
the Foot and Ankle: US and MR Imaging With Anatomic Correlation,'' 
Radiographics, vol 35, 1474-1475, 1469-1482 (2015). As a purely sensory 
nerve, the saphenous nerve has no muscle involvement and therefore 
using paralysis to describe impairment of this nerve is medically 
inaccurate. VA proposes to retitle DC 8527 to improve medical accuracy, 
and motor neuropathy will not be included in the criteria for this 
nerve. Because this nerve currently has a compensable rating only at 
the severe to complete paralysis level and sensory neuropathy, wholly 
sensory evaluations, will only be rated up to the moderate level, this 
nerve will no longer have a compensable rating.

U. Diagnostic Code 8529, Sensory Neuropathy of the External Cutaneous 
Nerve of the Thigh

    Current DC 8529 addresses paralysis of the external cutaneous nerve 
of the thigh. Current medical terminology refers to this nerve as the 
lateral cutaneous nerve of the thigh, or LCNT. This nerve is part of 
the lumbar plexus. ``It functions primarily as a sensory nerve and its 
composition varies among individuals with several different

[[Page 88925]]

combinations of lumbar nerves that originate from L1 to L3. The LCNT 
then emerges at the lateral border of the psoas major, crosses the 
iliacus, to the anterior superior iliac spine. The nerve then passes 
under the inguinal ligament and over the sartorius muscle and enters 
the thigh as it divides into an anterior and posterior branch.'' 
Cheatham, S., et al. ``Meralgia Paresthetica: A Review of the 
Literature,'' International Journal of Sports Physical Therapy, 8(6): 
884, December 2013. Paralysis refers to the lack of muscle function in 
muscle fibers. This nerve lacks motor fibers. As a purely sensory 
nerve, it has no muscle involvement and therefore using paralysis to 
describe impairment of this nerve is medically inaccurate. VA proposes 
to retitle DC 8529 to improve medical accuracy, and motor neuropathy 
will not be included in the criteria for this nerve. Because this nerve 
currently has a compensable rating only at the severe to complete 
paralysis level and sensory neuropathy, wholly sensory evaluations, 
will only be rated up to the moderate level, this nerve will no longer 
have a compensable rating.

V. Diagnostic Code 8540, Soft Tissue Sarcoma of Neurogenic Origin

    VA proposes to place a section subheading, ``Other Neoplasms of the 
Neurological System,'' just above this diagnostic code as a separator 
between diagnostic codes for peripheral nerves and other neoplasms of 
the neurological system. No other changes are proposed for this DC.

W. Diagnostic Code 8910, Epilepsy, Grand Mal (Including Tonic-Clonic 
Seizures)

    Current DC 8910 is titled ``Epilepsy, grand mal.'' VA proposes to 
update the title of this code to indicate that this includes tonic-
clonic seizures. Tonic-clonic seizures involve the entire body, and the 
terminology is synonymous with grand mal seizures. ``Generalized tonic-
clonic seizure,'' National Institute of Health--U.S. National Library 
of Medicine (September 3, 2019), https://medlineplus.gov/ency/article/000695.htm (last visited September 10, 2019). VA proposes no other 
changes to this DC.

X. Diagnostic Code 8911, Epilepsy, Petit Mal (Including Absence 
Seizures)

    Current DC 8911 is titled ``Epilepsy, petit mal.'' VA proposes to 
update the title of this code to indicate that this includes absence 
seizures. Absence seizures typically last only a few seconds and may 
involve staring episodes, also called absence spells. Absence seizure 
is used synonymously with petit mal seizures. ``Absence Seizure,'' 
National Institute of Health--U.S. National Library of Medicine 
(September 3, 2019), https://www.nlm.nih.gov/medlineplus/ency/article/000696.htm (last visited September 10, 2019). VA proposes no other 
changes to this DC.

Y. Non-Substantial Changes to Relocated 38 CFR 4.124a

    VA will also make some non-substantial changes to relocated 38 CFR 
4.124a. In 2008, DC 8045, Residuals of traumatic brain injury (TBI), 
was revised to include a table titled ``Evaluation of Cognitive 
Impairment and Other Residuals of TBI Not Otherwise Classified.'' See 
73 FR 54693, 54705-54708 (September 23, 2008). This table was added 
after the table titled ``Organic Diseases of the Central Nervous 
System.'' This had the effect of placing DC 8046, Cerebral 
arteriosclerosis, between the evaluation criteria of DC 8045, Residuals 
of traumatic brain injury, and the newly added table for TBI residuals. 
To improve readability and ease of use for both DCs 8045 and 8046, VA 
proposes to relocate the table titled ``Evaluation of Cognitive 
Impairment and Other Residuals of TBI Not Otherwise Classified'' 
directly below the evaluation criteria for DC 8045.

Z. Military Occupational Blast Exposure

    VA is currently in the process of investigating the potential 
neurological residuals of repeated exposure to low-level military 
occupational blasts or Military Occupational Blast Exposure. VA invites 
public comment on this subject.

Executive Orders 12866, 13563 and 14094

    Executive Order 12866 (Regulatory Planning and Review) directs 
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 14094 (Executive Order on 
Modernizing Regulatory Review) supplements and reaffirms the 
principles, structures, and definitions governing contemporary 
regulatory review established in Executive Order 12866 of September 30, 
1993 (Regulatory Planning and Review), and Executive Order 13563 of 
January 18, 2011 (Improving Regulation and Regulatory Review). The 
Office of Information and Regulatory Affairs has determined that this 
rulemaking is a significant regulatory action under Executive Order 
12866, Section 3(f)(1), as amended by Executive Order 14094. The 
Regulatory Impact Analysis associated with this rulemaking can be found 
as a supporting document at www.regulations.gov.

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act (5 
U.S.C. 601-612).
    The factual basis for this certification is based on the fact that 
no small entities or businesses determine the rating criteria revisions 
or assign evaluations for disability claims. Therefore, pursuant to 5 
U.S.C. 605(b), the initial and final regulatory flexibility analysis 
requirements of 5 U.S.C. 603 and 604 do not apply.

Unfunded Mandates

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

Paperwork Reduction Act (PRA)

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

Assistance Listing

    The Assistance Listing numbers and titles for the programs affected 
by this document are 64.102, Compensation for Service-Connected Deaths 
for Veterans' Dependents; 64.105, Pension to Veterans, Surviving 
Spouses, and Children; 64.109, Veterans Compensation for Service-
Connected Disability; and 64.110, Veterans Dependency and Indemnity 
Compensation for Service-Connected Death.

[[Page 88926]]

List of Subjects

38 CFR Part 3

    Administrative practice and procedure, Claims, Disability benefits.

38 CFR Part 4

    Disability benefits, Pensions, Veterans.

Signing Authority

    Denis McDonough, Secretary of Veterans Affairs, approved and signed 
this document on October 29, 2024, and authorized the undersigned to 
sign and submit the document to the Office of the Federal Register for 
publication electronically as an official document of the Department of 
Veterans Affairs.

Luvenia Potts,
Regulation Development Coordinator, Office of Regulation Policy & 
Management, Office of General Counsel, Department of Veterans Affairs.

    For the reasons stated in the preamble, VA proposes to amend 38 CFR 
parts 3 and 4 as set forth below:

PART 3--ADJUDICATION

Subpart A--Pension, Compensation, and Dependency and Indemnity 
Compensation

0
1. The authority citation for part 3 continues to read as follows:

    Authority: 38 U.S.C. 501(a), unless otherwise noted.

0
2. Amend Sec.  3.809 by revising paragraph (d) to read as follows:


Sec.  3.809   Specially adapted housing under 38 U.S.C. 
2101(a)(2)(A)(i).

* * * * *
    (d) Amyotrophic lateral sclerosis. VA considers Sec.  3.809(b) 
satisfied if the veteran or member of the Armed Forces serving on 
active duty has service-connected amyotrophic lateral sclerosis rated 
100 percent disabling under 38 CFR 4.124, diagnostic code 8017.
* * * * *

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

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

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

0
4. In Sec.  4.71a, amend the table The Spine by revising the entry for 
diagnostic code 5244 under General Rating Formula for Diseases and 
Injuries of the Spine to read as follows:


Sec.  4.71a   Schedule of ratings--musculoskeletal system.

* * * * *

                                The Spine
------------------------------------------------------------------------
                                                         Rating
------------------------------------------------------------------------
    General Rating Formula for Diseases and
             Injuries of the Spine
 
                              * * * * * * *
5244 Traumatic paralysis, complete:
    Paraplegia: Rate under diagnostic code
     5110.
    Quadriplegia: Rate separately under
     diagnostic codes 5109 and 5110 and
     combine evaluations in accordance with
     Sec.   4.25.
    Note: If traumatic paralysis does not
     cause loss of use of both hands or both
     feet, it is incomplete paralysis.
     Evaluate residuals of incomplete
     traumatic paralysis under the appropriate
     diagnostic code (e.g., Sec.   4.124,
     Diseases of the Peripheral Nerves).
 
                              * * * * * * *
------------------------------------------------------------------------

0
5. Revise Sec.  4.120 to read as follows:


Sec.  4.120   Minimum evaluations for organic diseases of the central 
nervous system.

    (a) Necessity of residuals for minimum evaluations. The minimum 
evaluations for diagnostic codes 8002, 8004, 8007, 8010, 8018, 8021, 
8023, 8024, and 8025 do not require ascertainable residuals. However, 
ascertainable residuals are required to provide the minimum evaluation 
for diagnostic codes 8000, 8003, 8011, 8012, 8019, 8020, 8022, and 
8036.
    (b) Definition. Ascertainable residuals include, but are not 
limited to, psychotic manifestations, complete or partial loss of use 
of one or more extremities, speech disturbances, impairment of vision, 
disturbances of gait, tremors, visceral manifestations, etc., referring 
to the appropriate bodily system of the schedule. With partial loss of 
use of one or more extremities from neurological lesions, rate by 
comparison with complete or incomplete paralysis of peripheral nerves. 
Determinations as to the presence of subjective residuals not capable 
of objective verification, e.g., headaches, dizziness, fatigability, 
must be approached on the basis of disability related to the diagnosis 
recorded. VA will only accept subjective residuals when they are 
consistent with the disease and not more likely attributable to another 
disease or no disease.
    (c) Ratings in excess of the minimum evaluation. When one or more 
compensable evaluations assigned for the residuals of the diagnostic 
codes noted in this section meet or exceed the minimum evaluation for 
that diagnostic code, then the minimum evaluation for that diagnostic 
code is no longer applicable. When a rating in excess of the prescribed 
minimum rating is assigned based on the presence of ascertainable 
residuals, the diagnostic codes associated with the evaluation of those 
residuals must be cited in accordance with Sec.  4.27.
0
6. Revise Sec.  4.123 to read as follows:


Sec.  4.123   Cranial and peripheral nerve impairment.

    (a) General. (1) In rating cranial and peripheral nerve injuries 
and their residuals, attention should be given to the site and 
character of the injury, the relative impairment in movement or muscle 
strength, and sensory disturbances.
    (2) Disability from impairments of the first, second, third, 
fourth, sixth, and eighth cranial nerves will be rated under the Organs 
of Special Sense.
    (3) A cranial nerve will be evaluated strictly as a cranial nerve, 
regardless of any portions which lie outside the cranium (skull). The 
evaluations in the rating schedule for the cranial nerves are for 
unilateral involvement; when bilateral, evaluate separately, then

[[Page 88927]]

combine using Sec.  4.25 but without application of the bilateral 
factor.
    (4) The evaluations in the rating schedule for the peripheral 
nerves are for unilateral involvement; when bilateral, evaluate 
separately, then combine using Sec.  4.25 with application of the 
bilateral factor.
    (b) Motor neuropathy (complete and incomplete paralysis).
    (1) General. The evaluation criteria for impairment to muscle 
function, with or without pain, of both cranial and peripheral nerves 
will be categorized as either complete paralysis or incomplete 
paralysis.
    (2) Cranial nerves. Complete paralysis for cranial nerves is 
characterized by the complete inability to move. Incomplete paralysis 
is characterized as either movement with difficulty, or attempted 
movement with inability to complete such movement (muscle twitching 
present).
    (3) Peripheral nerves. VA will evaluate peripheral nerve motor 
neuropathy using the Medical Research Council (MRC) Scale for Muscle 
Strength (commonly referred to as manual muscle testing). Complete 
paralysis for peripheral nerves will be identified as Grade 0 or Grade 
1 muscle strength (no movement for Grade 0 and a flicker or trace of 
contraction for Grade 1). Incomplete paralysis will be determined by 
the following muscle strength grades: Grade 2 (only able to move if 
gravity is eliminated; unable to move at all against gravity), Grade 
2+, which only applies to DC 8520 Sciatic nerve, (muscle strength, 
which, though present, can only partially move against gravity), Grade 
3 (only able to move against gravity; unable to move against 
resistance), or Grade 4 (weakness is present, but able to move against 
resistance and gravity). If muscle strength falls in between grades 
(Grade + or -) for peripheral nerves other than Grade 2+ for DC 8520, 
then evaluate as follows: (1). for a-grade, reduce the grade by one 
integer (e.g., Grade 3- shall be evaluated as Grade 2), and (2.) for a 
+ grade, maintain the current grade (e.g., a Grade 3+ shall be 
evaluated as Grade 3). The term ``incomplete paralysis,'' with this and 
other peripheral nerve injuries, indicates a degree of lost or impaired 
function substantially less than the type pictured for complete 
paralysis given with each nerve, whether due to varied levels of the 
nerve lesion or to partial regeneration.
    (4) Mixed nerves. When mixed nerves within a single diagnostic code 
are involved, an evaluation for both motor and sensory neuropathy is 
not permitted. The evaluation should be based on motor neuropathy with 
or without sensory neuropathy involvement.
    (c) Sensory neuropathy (complete and incomplete).
    (1) General. Impairments, with or without pain, to the sensory 
function of the cranial and peripheral nerves may be categorized as 
either incomplete or complete sensory neuropathy.
    (2) Complete sensory neuropathy. Complete sensory neuropathy is 
characterized by the complete absence of sensation in an affected 
nerve.
    (3) Incomplete sensory neuropathy. Incomplete sensory neuropathy 
involves sensation that is impaired, but not absent, or unpleasant 
sensations experienced by the nerve such as dysesthesia, numbness, or 
paresthesia. Dysesthesia refers to any unpleasant sensation produced by 
a stimulus that is normally painless. Numbness refers to a sense of 
heaviness, weakness, or deadness in part of the body. Paresthesia 
refers to abnormal spontaneous sensations such as burning, tingling, 
pins and needles, etc. VA will only accept subjective sensations when 
they are consistent with the disease and not more likely attributable 
to another disease or no disease.


Sec.  4.124   [Removed]

0
7. Remove Sec.  4.124.


Sec.  4.124a   [Redesignated as Sec.  4.124]

0
8. Redesignate Sec.  4.124a as Sec.  4.124.
0
9. Revise and republish newly redesignated Sec.  4.124 to read as 
follows:


Sec.  4.124   Schedule of ratings--Neurological conditions and 
convulsive disorders.

             Organic Diseases of the Central Nervous System
------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
Guidance for rating organic diseases of the central
 nervous system is located under Sec.   4.120.
8000 Encephalitis, infectious:
    As active febrile disease...........................             100
    Rate residuals, minimum.............................              10
8002 Brain, new growth of, malignant....................             100
    Minimum rating......................................              30
Note: The 100 percent evaluation will be continued for 2
 years following cessation of surgical, chemotherapeutic
 or other treatment modality. At this point, if the
 residuals have stabilized, the rating will be made on
 neurological residuals according to symptomatology or
 the minimum rating, whichever results in a higher
 evaluation.
8003 Brain, new growth of, benign:
    Minimum during active disease or during a treatment               60
     phase..............................................
    Rate residuals, minimum.............................              10
General Rating Formula for Specified Neurologic
 Conditions (DCs 8004, 8007, 8026, 8027, and 8028):
    Hoehn-Yahr stage 4 or stage 5, or; the inability to              100
     live independently because of neurologically-
     related disability.................................
    Impairment of mobility (e.g., transfers, balance, or              60
     gait) requiring daily use of an assistive device
     such as a wheelchair, brace(s), crutch(es),
     cane(s), or walker.................................
    Hoehn-Yahr stage 3, or; impairment of mobility                    30
     (e.g., transfers, balance, or gait) requiring less
     than daily use of an assistive device such as a
     wheelchair, brace(s), crutch(es), cane(s), or
     walker.............................................
    Hoehn-Yahr stage 2, or; impairment in at least one                10
     of the following areas:............................
         facial expression (e.g., masking,
         blinking, or eye motion abnormalities);
         speech (e.g., soft voice, slurring,
         difficulty speaking or swallowing);
         posture (e.g., stooping, instability);
         mobility not requiring an assistive
         device (e.g., decreased speed with transfers,
         gait ataxia, unstable balance);
         problems initiating or controlling
         motor movements (e.g., stiffness, tremors);
         cognitive (e.g., memory or executive
         problems);
         mental (e.g., anxiety, depression,
         social phobia);
         sensory abnormalities (e.g., olfactory
         deficits);
         involuntary muscle contractions
         resulting in pain and impairment, such as but
         not limited to, spontaneous neck turning or
         writing difficulty
    Hoehn-Yahr stage 1, or; formal diagnosis without                   0
     impairment.........................................

[[Page 88928]]

 
Note (1): Regardless of examination findings, the
 minimum rating for Parkinson's disease (DC 8004) shall
 be 30 percent.
Note (2): Regardless of examination findings, the
 minimum rating for stroke residuals (DC 8007) shall be
 10 percent.
Note (3): Activities of daily living (ADLs) refers to
 basic self-care and includes bathing or showering,
 dressing, eating, getting in or out of bed or a chair,
 and using the toilet.
Note (4): Evaluate any residual under the appropriate
 body system when there is a formal diagnosis of a
 condition. When there is no formal diagnosis, evaluate
 the residual under the General Rating Formula for
 Specified Neurologic Conditions. For example, evaluate
 emotional dysfunction under Sec.   4.130 (Schedule of
 ratings--mental disorders) when there is a diagnosis of
 a mental disorder. When there is no diagnosis of a
 mental disorder, evaluate emotional symptoms under the
 General Rating Formula for Specified Neurologic
 Conditions.
Note (5): There may be an overlap of manifestations of
 conditions evaluated under the General Rating Formula
 for Specified Neurologic Conditions with manifestations
 of a comorbid mental or neurologic or other physical
 disorder that can be separately evaluated under another
 diagnostic code. In such cases, do not assign more than
 one evaluation based on the same manifestations. If the
 manifestations of two or more conditions cannot be
 clearly separated, assign a single evaluation under
 whichever set of diagnostic criteria allows the better
 assessment of overall impaired functioning due to both
 conditions. However, if the manifestations are clearly
 separable, assign a separate evaluation for each
 condition.
Note (6): Consider the need for special monthly
 compensation.
Note (7): When evaluating a neurological condition under
 the General Rating Formula for Specified Neurological
 Conditions based on subjective symptoms and not a Hoehn-
 Yahr stage, a medical opinion finding that the
 subjectively reported symptom(s) is consistent with the
 claimed disease and not another disease or no disease
 is required.
8004 Parkinson's disease (paralysis agitans):
    Rate under the General Rating Formula for Specified
     Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
     and 8028)..........................................
8005 Bulbar palsy.......................................             100
8007 Stroke (ischemic, hemorrhagic, or thrombotic),
 including cerebral infarction or cerebrovascular
 accident (Brain, vessels, embolism, thrombosis, and
 hemorrhage):
    During and for six months following a stroke,                    100
     documented by diagnostic imaging...................
    Thereafter, rate under the General Rating Formula
     for Specified Neurologic Conditions (DCs 8004,
     8007, 8026, 8027, and 8028).
8010 Myelitis:
    Minimum rating......................................              10
8011 Poliomyelitis, anterior:
    As active febrile disease...........................             100
    Rate residuals, minimum.............................              10
8012 Hematomyelia:
    For 6 months........................................             100
    Rate residuals, minimum.............................              10
8013 Syphilis, cerebrospinal.
8014 Syphilis, meningovascular.
8015 Tabes dorsalis.
    Note: Rate upon the severity of convulsions,
     paralysis, visual impairment or psychotic
     involvement, etc.
8017 Amyotrophic lateral sclerosis......................             100
    Note: Consider the need for special monthly
     compensation.
8018 Multiple sclerosis and and other demyelinating
 diseases of the central nervous system:
    Minimum rating......................................              30
8019 Meningitis, cerebrospinal, epidemic:
    As active febrile disease...........................             100
    Rate residuals, minimum.............................              10
8020 Brain, abscess of:
    As active disease...................................             100
    Rate residuals, minimum.............................              10
8021 Spinal cord, new growths of, malignant.............             100
    Minimum rating......................................              30
Note: The 100 percent evaluation will be continued for 2
 years following cessation of surgical, chemotherapeutic
 or other treatment modality. At this point, if the
 residuals have stabilized, the rating will be made on
 neurological residuals according to symptomatology or
 the minimum rating, whichever results in a higher
 evaluation.
8022 Spinal cord, new growths of, benign:
    Minimum during active disease or during a treatment               60
     phase..............................................
    Rate residuals, minimum.............................              10
8023 Progressive muscular atrophy:
    Minimum rating......................................              30
8024 Syringomyelia:
    Minimum rating......................................              30
8025 Myasthenia gravis:
    Minimum rating......................................              30
8026 Parkinson's plus, or secondary parkinsonism
 syndromes.
    Rate under the General Rating Formula for Specified
     Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
     and 8028)..........................................
8027 Essential tremor.
    Rate under the General Rating Formula for Specified
     Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
     and 8028)..........................................
8028 Dystonia.
    Rate under the General Rating Formula for Specified
     Neurologic Conditions (DCs 8004, 8007, 8026, 8027,
     and 8028)..........................................
8036 Primary lateral sclerosis:
    Rate residuals, minimum.............................              10
8045 Residuals of traumatic brain injury (TBI):

[[Page 88929]]

 
    There are three main areas of dysfunction that may
     result from TBI and have profound effects on
     functioning: cognitive (which is common in varying
     degrees after TBI), emotional/behavioral, and
     physical. Each of these areas of dysfunction may
     require evaluation.
    Cognitive impairment is defined as decreased memory,
     concentration, attention, and executive functions
     of the brain. Executive functions are goal setting,
     speed of information processing, planning,
     organizing, prioritizing, self-monitoring, problem
     solving, judgment, decision making, spontaneity,
     and flexibility in changing actions when they are
     not productive. Not all of these brain functions
     may be affected in a given individual with
     cognitive impairment, and some functions may be
     affected more severely than others. In a given
     individual, symptoms may fluctuate in severity from
     day to day. Evaluate cognitive impairment under the
     table titled ``Evaluation of Cognitive Impairment
     and Other Residuals of TBI Not Otherwise
     Classified.''
    Subjective symptoms may be the only residual of TBI
     or may be associated with cognitive impairment or
     other areas of dysfunction. Evaluate subjective
     symptoms that are residuals of TBI, whether or not
     they are part of cognitive impairment, under the
     subjective symptoms facet in the table titled
     ``Evaluation of Cognitive Impairment and Other
     Residuals of TBI Not Otherwise Classified.''
     However, separately evaluate any residual with a
     distinct diagnosis that may be evaluated under
     another diagnostic code, such as migraine headache
     or Meniere's disease, even if that diagnosis is
     based on subjective symptoms, rather than under the
     ``Evaluation of Cognitive Impairment and Other
     Residuals of TBI Not Otherwise Classified'' table.
    Evaluate emotional/behavioral dysfunction under Sec.
       4.130 (Schedule of ratings--mental disorders)
     when there is a diagnosis of a mental disorder.
     When there is no diagnosis of a mental disorder,
     evaluate emotional/behavioral symptoms under the
     criteria in the table titled ``Evaluation of
     Cognitive Impairment and Other Residuals of TBI Not
     Otherwise Classified.''
    Evaluate physical (including neurological)
     dysfunction based on the following list, under an
     appropriate diagnostic code: Motor and sensory
     dysfunction, including pain, of the extremities and
     face; visual impairment; hearing loss and tinnitus;
     loss of sense of smell and taste; seizures; gait,
     coordination, and balance problems; speech and
     other communication difficulties, including aphasia
     and related disorders, and dysarthria; neurogenic
     bladder; neurogenic bowel; cranial nerve
     dysfunctions; autonomic nerve dysfunctions; and
     endocrine dysfunctions.
    The preceding list of types of physical dysfunction
     does not encompass all possible residuals of TBI.
     For residuals not listed here that are reported on
     an examination, evaluate under the most appropriate
     diagnostic code. Evaluate each condition
     separately, as long as the same signs and symptoms
     are not used to support more than one evaluation,
     and combine under Sec.   4.25 the evaluations for
     each separately rated condition. The evaluation
     assigned based on the ``Evaluation of Cognitive
     Impairment and Other Residuals of TBI Not Otherwise
     Classified'' table will be considered the
     evaluation for a single condition for purposes of
     combining with other disability evaluations.
    Consider the need for special monthly compensation
     for such problems as loss of use of an extremity,
     certain sensory impairments, erectile dysfunction,
     the need for aid and attendance (including for
     protection from hazards or dangers incident to the
     daily environment due to cognitive impairment),
     being housebound, etc.
------------------------------------------------------------------------


             Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified
----------------------------------------------------------------------------------------------------------------
    Facets of cognitive impairment and other        Level of
    residuals of TBI not otherwise classified      impairment                       Criteria
----------------------------------------------------------------------------------------------------------------
Memory, attention, concentration, executive                 0  No complaints of impairment of memory, attention,
 functions.                                                     concentration, or executive functions.
                                                            1  A complaint of mild loss of memory (such as
                                                                having difficulty following a conversation,
                                                                recalling recent conversations, remembering
                                                                names of new acquaintances, or finding words, or
                                                                often misplacing items), attention,
                                                                concentration, or executive functions, but
                                                                without objective evidence on testing.
                                                            2  Objective evidence on testing of mild impairment
                                                                of memory, attention, concentration, or
                                                                executive functions resulting in mild functional
                                                                impairment.
                                                            3  Objective evidence on testing of moderate
                                                                impairment of memory, attention, concentration,
                                                                or executive functions resulting in moderate
                                                                functional impairment.
                                                        Total  Objective evidence on testing of severe
                                                                impairment of memory, attention, concentration,
                                                                or executive functions resulting in severe
                                                                functional impairment.
Judgment........................................            0  Normal.
                                                            1  Mildly impaired judgment. For complex or
                                                                unfamiliar decisions, occasionally unable to
                                                                identify, understand, and weigh the
                                                                alternatives, understand the consequences of
                                                                choices, and make a reasonable decision.
                                                            2  Moderately impaired judgment. For complex or
                                                                unfamiliar decisions, usually unable to
                                                                identify, understand, and weigh the
                                                                alternatives, understand the consequences of
                                                                choices, and make a reasonable decision,
                                                                although has little difficulty with simple
                                                                decisions.
                                                            3  Moderately severely impaired judgment. For even
                                                                routine and familiar decisions, occasionally
                                                                unable to identify, understand, and weigh the
                                                                alternatives, understand the consequences of
                                                                choices, and make a reasonable decision.
                                                        Total  Severely impaired judgment. For even routine and
                                                                familiar decisions, usually unable to identify,
                                                                understand, and weigh the alternatives,
                                                                understand the consequences of choices, and make
                                                                a reasonable decision. For example, unable to
                                                                determine appropriate clothing for current
                                                                weather conditions or judge when to avoid
                                                                dangerous situations or activities.
Social interaction..............................            0  Social interaction is routinely appropriate.
                                                            1  Social interaction is occasionally inappropriate.
                                                            2  Social interaction is frequently inappropriate.
                                                            3  Social interaction is inappropriate most or all
                                                                of the time.

[[Page 88930]]

 
Orientation.....................................            0  Always oriented to person, time, place, and
                                                                situation.
                                                            1  Occasionally disoriented to one of the four
                                                                aspects (person, time, place, situation) of
                                                                orientation.
                                                            2  Occasionally disoriented to two of the four
                                                                aspects (person, time, place, situation) of
                                                                orientation or often disoriented to one aspect
                                                                of orientation.
                                                            3  Often disoriented to two or more of the four
                                                                aspects (person, time, place, situation) of
                                                                orientation.
                                                        Total  Consistently disoriented to two or more of the
                                                                four aspects (person, time, place, situation) of
                                                                orientation.
Motor activity (with intact motor and sensory               0  Motor activity normal.
 system).
                                                            1  Motor activity normal most of the time, but
                                                                mildly slowed at times due to apraxia (inability
                                                                to perform previously learned motor activities,
                                                                despite normal motor function).
                                                            2  Motor activity mildly decreased or with moderate
                                                                slowing due to apraxia.
                                                            3  Motor activity moderately decreased due to
                                                                apraxia.
                                                        Total  Motor activity severely decreased due to apraxia.
Visual spatial orientation......................            0  Normal.
                                                            1  Mildly impaired. Occasionally gets lost in
                                                                unfamiliar surroundings, has difficulty reading
                                                                maps or following directions. Is able to use
                                                                assistive devices such as GPS (global
                                                                positioning system).
                                                            2  Moderately impaired. Usually gets lost in
                                                                unfamiliar surroundings, has difficulty reading
                                                                maps, following directions, and judging
                                                                distance. Has difficulty using assistive devices
                                                                such as GPS (global positioning system).
                                                            3  Moderately severely impaired. Gets lost even in
                                                                familiar surroundings, unable to use assistive
                                                                devices such as GPS (global positioning system).
                                                        Total  Severely impaired. May be unable to touch or name
                                                                own body parts when asked by the examiner,
                                                                identify the relative position in space of two
                                                                different objects, or find the way from one room
                                                                to another in a familiar environment.
Subjective symptoms.............................            0  Subjective symptoms that do not interfere with
                                                                work; instrumental activities of daily living;
                                                                or work, family, or other close relationships.
                                                                Examples are: mild or occasional headaches, mild
                                                                anxiety.
                                                            1  Three or more subjective symptoms that mildly
                                                                interfere with work; instrumental activities of
                                                                daily living; or work, family, or other close
                                                                relationships. Examples of findings that might
                                                                be seen at this level of impairment are:
                                                                intermittent dizziness, daily mild to moderate
                                                                headaches, tinnitus, frequent insomnia,
                                                                hypersensitivity to sound, hypersensitivity to
                                                                light.
                                                            2  Three or more subjective symptoms that moderately
                                                                interfere with work; instrumental activities of
                                                                daily living; or work, family, or other close
                                                                relationships. Examples of findings that might
                                                                be seen at this level of impairment are: marked
                                                                fatigability, blurred or double vision,
                                                                headaches requiring rest periods during most
                                                                days.
Neurobehavioral effects.........................            0  One or more neurobehavioral effects that do not
                                                                interfere with workplace interaction or social
                                                                interaction. Examples of neurobehavioral effects
                                                                are: Irritability, impulsivity,
                                                                unpredictability, lack of motivation, verbal
                                                                aggression, physical aggression, belligerence,
                                                                apathy, lack of empathy, moodiness, lack of
                                                                cooperation, inflexibility, and impaired
                                                                awareness of disability. Any of these effects
                                                                may range from slight to severe, although verbal
                                                                and physical aggression are likely to have a
                                                                more serious impact on workplace interaction and
                                                                social interaction than some of the other
                                                                effects.
                                                            1  One or more neurobehavioral effects that
                                                                occasionally interfere with workplace
                                                                interaction, social interaction, or both but do
                                                                not preclude them.
                                                            2  One or more neurobehavioral effects that
                                                                frequently interfere with workplace interaction,
                                                                social interaction, or both but do not preclude
                                                                them.
                                                            3  One or more neurobehavioral effects that
                                                                interfere with or preclude workplace
                                                                interaction, social interaction, or both on most
                                                                days or that occasionally require supervision
                                                                for safety of self or others.
Communication...................................            0  Able to communicate by spoken and written
                                                                language (expressive communication), and to
                                                                comprehend spoken and written language.
                                                            1  Comprehension or expression, or both, of either
                                                                spoken language or written language is only
                                                                occasionally impaired. Can communicate complex
                                                                ideas.
                                                            2  Inability to communicate either by spoken
                                                                language, written language, or both, more than
                                                                occasionally but less than half of the time, or
                                                                to comprehend spoken language, written language,
                                                                or both, more than occasionally but less than
                                                                half of the time. Can generally communicate
                                                                complex ideas.
                                                            3  Inability to communicate either by spoken
                                                                language, written language, or both, at least
                                                                half of the time but not all of the time, or to
                                                                comprehend spoken language, written language, or
                                                                both, at least half of the time but not all of
                                                                the time. May rely on gestures or other
                                                                alternative modes of communication. Able to
                                                                communicate basic needs.
                                                        Total  Complete inability to communicate either by
                                                                spoken language, written language, or both, or
                                                                to comprehend spoken language, written language,
                                                                or both. Unable to communicate basic needs.

[[Page 88931]]

 
Consciousness...................................        Total  Persistently altered state of consciousness, such
                                                                as vegetative state, minimally responsive state,
                                                                coma.
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
8046 Cerebral arteriosclerosis:
    Purely neurological disabilities, such as
     hemiplegia, cranial nerve paralysis, etc., due to
     cerebral arteriosclerosis will be rated under the
     diagnostic codes dealing with such specific
     disabilities, with citation of a hyphenated
     diagnostic code (e.g., 8046-8207).
    Purely subjective complaints such as headache,
     dizziness, tinnitus, insomnia and irritability,
     recognized as symptomatic of a properly diagnosed
     cerebral arteriosclerosis, will be rated 10 percent
     and no more under diagnostic code 9305. This 10
     percent rating will not be combined with any other
     rating for a disability due to cerebral or
     generalized arteriosclerosis. Ratings in excess of
     10 percent for cerebral arteriosclerosis under
     diagnostic code 9305 are not assignable in the
     absence of a diagnosis of multi-infarct dementia
     with cerebral arteriosclerosis.
Note: The ratings under code 8046 apply only when the
 diagnosis of cerebral arteriosclerosis is substantiated
 by the entire clinical picture and not solely on
 findings of retinal arteriosclerosis.
------------------------------------------------------------------------
                         Miscellaneous Diseases
------------------------------------------------------------------------
8100 Migraine:
    With very frequent completely prostrating and                     50
     prolonged attacks productive of severe economic
     inadaptability.....................................
    With characteristic prostrating attacks occurring on              30
     an average once a month over last several months...
    With characteristic prostrating attacks averaging                 10
     one in 2 months over last several months...........
    With less frequent attacks..........................               0
8103 Hemifacial spasm (tic, convulsive):
    Severe..............................................              30
    Moderate............................................              10
    Mild................................................               0
Note: Depending upon frequency, severity, muscle groups
 involved.
8104 Paramyoclonus multiplex (convulsive state,
 myoclonic type):
    Rate as hemifacial spasm; severe cases..............              60
8105 Chorea, Sydenham's:
    Pronounced, progressive grave types.................             100
    Severe..............................................              80
    Moderately severe...................................              50
    Moderate............................................              30
    Mild................................................              10
Note: Consider rheumatic etiology and complications.
8106 Chorea, Huntington's.
    Rate as Sydenham's chorea. This, though a familial
     disease, has its onset in late adult life, and is
     considered a ratable disability.
8107 Athetosis, acquired.
    Rate as Sydenham's chorea.
8108 Narcolepsy.
    Rate as for epilepsy, petit mal.
------------------------------------------------------------------------
                     Diseases of the Cranial Nerves
------------------------------------------------------------------------
Guidance for rating cranial nerves is located under Sec.
   4.123.
 
            Fifth (trigeminal) cranial nerve
 
8205 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              50
    Incomplete paralysis:
        Attempted movement with inability to complete                 30
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Sensory neuropathy, complete or incomplete..........              10
    Note (1): Tic douloureux may be rated under DC 8205
     in accordance with severity, up to complete
     paralysis.
    Note (2): Rate dependent upon relative loss of
     sensation or muscle function. Examples of nerve
     functions include, but are not limited to, movement
     and sensation to the scalp, forehead, nose, cheeks,
     lower eye lid, nasal mucosa, upper lip, upper
     teeth, palate, anterior tongue, skin over mandible
     and lower teeth, and muscles of mastication.
 
             Seventh (facial) cranial nerve
 
8207 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              30
    Incomplete paralysis:
        Attempted movement with inability to complete                 20
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Sensory neuropathy, complete, or incomplete.........              10
    Note: Rate dependent upon relative loss of sensation
     or muscle function. Examples of nerve functions
     include, but are not limited to, facial
     expressions, taste, and production/drainage of
     tears.
 

[[Page 88932]]

 
         Ninth (glossopharyngeal) cranial nerve
 
8209 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              30
    Incomplete paralysis:
        Attempted movement with inability to complete                 20
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Sensory neuropathy, complete, or incomplete.........              10
    Note: Rate dependent upon relative loss of ordinary
     sensation or muscle function. Examples of nerve
     functions include, but are not limited to, taste
     and sensing carotid blood pressure.
 
       Tenth (pneumogastric, vagus) cranial nerve
 
8210 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              50
    Incomplete paralysis:
        Attempted movement with inability to complete                 30
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Sensory neuropathy, complete, or incomplete.........              10
    Note: Rate dependent upon relative loss of sensation
     or muscle function. Examples of nerve functions
     include, but are not limited to, speech and taste,
     along with movement and sensation to the larynx,
     pharynx, thoracic viscera, and abdominal viscera.
 
  Eleventh (spinal accessory, external branch) cranial
                          nerve
 
8211 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              30
    Incomplete paralysis:
        Attempted movement with inability to complete                 20
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Note: Rate dependent upon relative loss of muscle
     function. Examples of nerve functions include, but
     are not limited to, movement of the
     sternocleidomastoid and trapezius muscles.
 
           Twelfth (hypoglossal) cranial nerve
 
8212 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis..................................              50
    Incomplete paralysis:
        Attempted movement with inability to complete                 30
         such movement (muscle twitching present).......
        Muscle movement intact, but task performed with               10
         difficulty.....................................
    Sensory neuropathy, complete, or incomplete.........              10
    Note: Rate dependent upon relative loss of sensation
     or muscle function. Examples of nerve functions
     include, but are not limited to, movement and
     sensation to the tongue.
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                             Rating
                  Schedule of ratings                  -----------------
                                                         Major    Minor
------------------------------------------------------------------------
                    Diseases of the Peripheral Nerves
------------------------------------------------------------------------
Guidance for rating peripheral nerves, along with a
 description of the grading system, is located under
 Sec.   4.123.
 
   Upper radicular group (fifth and sixth cervicals)
 
8510 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       70       60
    Incomplete paralysis:
        Grade 2.......................................       50       40
        Grade 3.......................................       40       30
        Grade 4.......................................       20       20
    Sensory neuropathy, complete......................       40       30
    Sensory neuropathy, incomplete....................       20       20
 
                Middle radicular group
 
8511 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       70       60
    Incomplete paralysis:
        Grade 2.......................................       50       40
        Grade 3.......................................       40       30
        Grade 4.......................................       20       20
    Sensory neuropathy, complete......................       40       30
    Sensory neuropathy, incomplete....................       20       20
 
                 Lower radicular group
 
8512 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       70       60
    Incomplete paralysis:
        Grade 2.......................................       50       40
        Grade 3.......................................       40       30
        Grade 4.......................................       20       20
    Sensory neuropathy, complete......................       40       30
    Sensory neuropathy, incomplete....................       20       20
 

[[Page 88933]]

 
                 All radicular groups
 
8513 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       90       80
    Incomplete paralysis:
        Grade 2.......................................       70       60
        Grade 3.......................................       40       30
        Grade 4.......................................       20       20
    Sensory neuropathy, complete......................       40       30
    Sensory neuropathy, incomplete....................       20       20
 
             Radial nerve (musculospiral)
 
8514 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       70       60
    Incomplete paralysis:
        Grade 2.......................................       50       40
        Grade 3.......................................       30       20
        Grade 4.......................................       20       20
    Sensory neuropathy, complete......................       30       20
    Sensory neuropathy, incomplete....................       20       20
    Note: Lesions involving only ``dissociation of
     extensor communis digitorum'' and ``paralysis
     below the extensor communis digitorum,'' will not
     exceed Grade 3 for diagnostic code 8514.
 
                   The median nerve
 
8515 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       70       60
    Incomplete paralysis:
        Grade 2.......................................       50       40
        Grade 3.......................................       30       20
        Grade 4.......................................       10       10
    Sensory neuropathy, complete......................       30       20
    Sensory neuropathy, incomplete....................       10       10
 
                    The ulnar nerve
 
8516 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       60       50
    Incomplete paralysis:
        Grade 2.......................................       40       30
        Grade 3.......................................       30       20
        Grade 4.......................................       10       10
    Sensory neuropathy, complete......................       30       20
    Sensory neuropathy, incomplete....................       10       10
 
                Musculocutaneous nerve
 
8517 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       30       20
    Incomplete paralysis:
        Grade 2.......................................       20       20
        Grade 3.......................................       10       10
        Grade 4.......................................        0        0
    Sensory neuropathy, complete......................       10       10
    Sensory neuropathy, incomplete....................        0        0
 
              Axillary nerve (circumflex)
 
8518 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       50       40
    Incomplete paralysis:
        Grade 2.......................................       30       20
        Grade 3.......................................       10       10
        Grade 4.......................................        0        0
    Sensory neuropathy, complete......................       10       10
    Sensory neuropathy, incomplete....................        0        0
 
                  Long thoracic nerve
 
8519 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1).................       30       20
    Incomplete paralysis:
        Grade 2.......................................       20       20
        Grade 3.......................................       10       10
        Grade 4.......................................        0        0
    Sensory neuropathy, complete......................       10       10
    Sensory neuropathy, incomplete....................        0        0
    Note (1): Not to be combined with lost motion
     above shoulder level.
    Note (2): Combined nerve injuries should be rated
     by reference to the major involvement, or if
     sufficient in extent, consider radicular group
     ratings.
------------------------------------------------------------------------


[[Page 88934]]


------------------------------------------------------------------------
                                                              Rating
------------------------------------------------------------------------
                      Sciatic nerve
 
8520 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              80
    Incomplete paralysis:
        Grade 2.........................................              60
        Grade 2+........................................              40
        Grade 3.........................................              20
        Grade 4.........................................              10
    Sensory neuropathy, complete........................              20
    Sensory neuropathy, incomplete......................              10
 
       Common peroneal nerve (external popliteal)
 
8521 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              40
    Incomplete paralysis:
        Grade 2.........................................              30
        Grade 3.........................................              20
        Grade 4.........................................              10
    Sensory neuropathy, complete........................              20
    Sensory neuropathy, incomplete......................              10
 
      Superficial peroneal nerve (musculocutaneous)
 
8522 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              30
    Incomplete paralysis:
        Grade 2.........................................              20
        Grade 3.........................................              10
        Grade 4.........................................               0
    Sensory neuropathy, complete........................              10
    Sensory neuropathy, incomplete......................               0
 
          Deep peroneal nerve (anterior tibial)
 
8523 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              30
    Incomplete paralysis:
        Grade 2.........................................              20
        Grade 3.........................................              10
        Grade 4.........................................               0
    Sensory neuropathy, complete........................              10
    Sensory neuropathy, incomplete......................               0
 
            Tibial nerve (internal popliteal)
 
8524 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              40
    Incomplete paralysis:
        Grade 2.........................................              30
        Grade 3.........................................              20
        Grade 4.........................................              10
    Sensory neuropathy, complete........................              20
    Sensory neuropathy, incomplete......................              10
 
                 Posterior tibial nerve
 
8525 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              30
    Incomplete paralysis:
        Grade 2.........................................              20
        Grade 3 or Grade 4..............................              10
    Sensory neuropathy, complete or incomplete..........              10
 
             Femoral nerve (anterior crural)
 
8526 Motor neuropathy (complete and incomplete
 paralysis):
    Complete paralysis (Grade 0 or 1)...................              40
    Incomplete paralysis:
        Grade 2.........................................              30
        Grade 3.........................................              20
        Grade 4.........................................              10
    Sensory neuropathy, complete........................              20
    Sensory neuropathy, incomplete......................              10
 
          Saphenous nerve (internal saphenous)
 
8527 Sensory neuropathy, complete or incomplete.........               0
 
                     Obturator nerve
 
8528 Motor neuropathy (complete and incomplete
 paralysis):
        Grade 0, Grade 1, or Grade 2....................              10
        Grade 3 or Grade 4..............................               0
    Sensory neuropathy, complete or incomplete..........               0
 

[[Page 88935]]

 
     Lateral cutaneous nerve of the thigh (external
                       cutaneous)
 
8529 Sensory neuropathy, complete or incomplete.........               0
 
                   Ilio-inguinal nerve
 
8530 Motor neuropathy (complete and incomplete
 paralysis):
        Grade 0, Grade 1, or Grade 2....................              10
        Grade 3 or Grade 4..............................               0
    Sensory neuropathy, complete or incomplete..........               0
------------------------------------------------------------------------
               Other Neoplasms of the Neurological System
------------------------------------------------------------------------
8540 Soft-tissue sarcoma (of neurogenic origin).........             100
Note: The 100 percent rating will be continued for 6
 months following the cessation of surgical, X-ray,
 antineoplastic chemotherapy or other therapeutic
 procedure. At this point, if there has been no local
 recurrence or metastases, the rating will be made on
 residuals.
------------------------------------------------------------------------
                             The Epilepsies
------------------------------------------------------------------------
A thorough study of all material in Sec.  Sec.   4.121
 and 4.122 of the preface and under the ratings for
 epilepsy is necessary prior to any rating action.
8910 Epilepsy, grand mal (including tonic-clonic
 seizures).
    Rate under the general rating formula for major
     seizures.
8911 Epilepsy, petit mal (including absence seizures).
    Rate under the general rating formula for minor
     seizures.
    Note (1): A major seizure is characterized by the
     generalized tonic-clonic convulsion with
     unconsciousness.
    Note (2): A minor seizure consists of a brief
     interruption in consciousness or conscious control
     associated with staring or rhythmic blinking of the
     eyes or nodding of the head (``pure'' petit mal),
     or sudden jerking movements of the arms, trunk, or
     head (myoclonic type) or sudden loss of postural
     control (akinetic type).
General Rating Formula for Major and Minor Epileptic
 Seizures:
    Averaging at least 1 major seizure per month over                100
     the last year......................................
    Averaging at least 1 major seizure in 3 months over               80
     the last year; or more than 10 minor seizures
     weekly.............................................
    Averaging at least 1 major seizure in 4 months over               60
     the last year; or 9-10 minor seizures per week.....
    At least 1 major seizure in the last 6 months or 2                40
     in the last year; or averaging at least 5 to 8
     minor seizures weekly..............................
    At least 1 major seizure in the last 2 years; or at               20
     least 2 minor seizures in the last 6 months........
    A confirmed diagnosis of epilepsy with a history of               10
     seizures...........................................
    Note (1): When continuous medication is shown
     necessary for the control of epilepsy, the minimum
     evaluation will be 10 percent. This rating will not
     be combined with any other rating for epilepsy.
    Note (2): In the presence of major and minor
     seizures, rate the predominating type.
    Note (3): There will be no distinction between
     diurnal and nocturnal major seizures.
8912 Epilepsy, Jacksonian and focal motor or sensory.
8913 Epilepsy, diencephalic.
    Rate as minor seizures, except in the presence of
     major and minor seizures, rate the predominating
     type.
8914 Epilepsy, psychomotor.
    Major seizures:
        Psychomotor seizures will be rated as major
         seizures under the general rating formula when
         characterized by automatic states and/or
         generalized convulsions with unconsciousness.
    Minor seizures:
        Psychomotor seizures will be rated as minor
         seizures under the general rating formula when
         characterized by brief transient episodes of
         random motor movements, hallucinations,
         perceptual illusions, abnormalities of
         thinking, memory or mood, or autonomic
         disturbances.
Mental Disorders in Epilepsies: A nonpsychotic organic brain syndrome
 will be rated separately under the appropriate diagnostic code (e.g.,
 9304 or 9326). In the absence of a diagnosis of non-psychotic organic
 psychiatric disturbance (psychotic, psychoneurotic or personality
 disorder) if diagnosed and shown to be secondary to or directly
 associated with epilepsy will be rated separately. The psychotic or
 psychroneurotic disorder will be rated under the appropriate diagnostic
 code. The personality disorder will be rated as a dementia (e.g.,
 diagnostic code 9304 or 9326).
Epilepsy and Unemployability: (1) Rating specialists must bear in mind
 that the epileptic, although his or her seizures are controlled, may
 find employment and rehabilitation difficult of attainment due to
 employer reluctance to the hiring of the epileptic.
(2) Where a case is encountered with a definite history of unemployment,
 full and complete development should be undertaken to ascertain whether
 the epilepsy is the determining factor in his or her inability to
 obtain employment.
(3) The assent of the claimant should first be obtained for permission
 to conduct this economic and social survey. The purpose of this survey
 is to secure all the relevant facts and data necessary to permit of a
 true judgment as to the reason for his or her unemployment and should
 include information as to:
    (a) Education;
    (b) Occupations prior and subsequent to service;
    (c) Places of employment and reasons for termination;
    (d) Wages received;
    (e) Number of seizures.
(4) Upon completion of this survey and current examination, the case
 should have rating board consideration. Where in the judgment of the
 rating board the veteran's unemployability is due to epilepsy and
 jurisdiction is not vested in that body by reason of schedular
 evaluations, the case should be submitted to the Compensation Service
 or the Director, Pension and Fiduciary Service.
------------------------------------------------------------------------


[[Page 88936]]

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

0
10. Amend Appendix A to part 4 by:
0
a. Revising the entry for diagnostic code 5244;
0
b. Adding, in numerical order, entries for Sec. Sec.  4.120 and 4.123;
0
c. Redesignating the entries for Sec.  4.124a (all diagnostic codes 
listed under Sec.  4.124a) as new entries for Sec.  4.124;
0
d. Revising and republishing newly redesignated Sec.  4.124; and
0
e. Adding, in numerical order, a new entry for Sec.  4.124a.
    The revisions and additions read as follows:

                    Appendix A to Part 4--Table of Amendments and Effective Dates Since 1946
----------------------------------------------------------------------------------------------------------------
                    Sec.                      Diagnostic code No.
----------------------------------------------------------------------------------------------------------------
 
                                                  * * * * * * *
                                                             5244  Added February 7, 2021; note [Effective date
                                                                    of final rule].
 
                                                  * * * * * * *
4.120......................................  ....................  Title and revised [Effective date of final
                                                                    rule].
4.123......................................  ....................  Title and revised [Effective date of final
                                                                    rule].
4.124......................................  ....................  Re-designated from Sec.   4.124a [Effective
                                                                    date of final rule].
                                                             8000  Title [Effective date of final rule].
                                                             8002  Criteria September 22, 1978; title, note
                                                                    [Effective date of final rule].
                                                             8003  Title, criteria [Effective date of final
                                                                    rule].
                                                             8004  Title, criteria, notes [Effective date of
                                                                    final rule].
                                                             8007  Title, criteria [Effective date of final
                                                                    rule].
                                                             8008  Removed [Effective date of final rule].
                                                             8009  Removed [Effective date of final rule].
                                                             8018  Title [Effective date of final rule].
                                                             8021  Criteria September 22, 1978; criteria October
                                                                    1, 1961; criteria March 10, 1976; criteria
                                                                    March 1, 1989; title, note [Effective date
                                                                    of final rule].
                                                             8022  Title, criteria [Effective date of final
                                                                    rule].
                                                             8025  Note removed [Effective date of final rule].
                                                             8026  Added [Effective date of final rule].
                                                             8027  Added [Effective date of final rule].
                                                             8028  Added [Effective date of final rule].
                                                             8036  Added [Effective date of final rule].
                                                             8045  Criterion and evaluation October 23, 2008.
                                                             8046  Added October 1, 1961; criterion March 10,
                                                                    1976; criterion March 1, 1989.
                                                             8100  Evaluation June 9, 1953.
                                                             8103  Title [Effective date of final rule].
                                                             8104  Criteria [Effective date of final rule].
                                                             8107  Criteria [Effective date of final rule].
                                                             8205  Title, criteria, notes [Effective date of
                                                                    final rule].
                                                             8207  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8209  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8210  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8211  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8212  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8305  Removed [Effective date of final rule].
                                                             8307  Removed [Effective date of final rule].
                                                             8309  Removed [Effective date of final rule].
                                                             8310  Removed [Effective date of final rule].
                                                             8311  Removed [Effective date of final rule].
                                                             8312  Removed [Effective date of final rule].
                                                             8405  Removed [Effective date of final rule].
                                                             8407  Removed [Effective date of final rule].
                                                             8409  Removed [Effective date of final rule].
                                                             8410  Removed [Effective date of final rule].
                                                             8411  Removed [Effective date of final rule].
                                                             8412  Removed [Effective date of final rule].
                                                             8510  Title, criteria [Effective date of final
                                                                    rule].
                                                             8511  Title, criteria [Effective date of final
                                                                    rule].
                                                             8512  Title, criteria [Effective date of final
                                                                    rule].
                                                             8513  Title, criteria [Effective date of final
                                                                    rule].
                                                             8514  Title, criteria, note [Effective date of
                                                                    final rule].
                                                             8515  Title, criteria [Effective date of final
                                                                    rule].
                                                             8516  Title, criteria [Effective date of final
                                                                    rule].
                                                             8517  Title, criteria [Effective date of final
                                                                    rule].
                                                             8518  Title, criteria [Effective date of final
                                                                    rule].
                                                             8519  Title, criteria, notes [Effective date of
                                                                    final rule].
                                                             8520  Title, criteria [Effective date of final
                                                                    rule].
                                                             8521  Title, criteria [Effective date of final
                                                                    rule].
                                                             8522  Title, criteria [Effective date of final
                                                                    rule].
                                                             8523  Title, criteria [Effective date of final
                                                                    rule].
                                                             8524  Title, criteria [Effective date of final
                                                                    rule].
                                                             8525  Title, criteria [Effective date of final
                                                                    rule].

[[Page 88937]]

 
                                                             8526  Title, criteria [Effective date of final
                                                                    rule].
                                                             8527  Title, criteria [Effective date of final
                                                                    rule].
                                                             8528  Title, criteria [Effective date of final
                                                                    rule].
                                                             8529  Title, criteria [Effective date of final
                                                                    rule].
                                                             8530  Title, criteria [Effective date of final
                                                                    rule].
                                                             8610  Removed [Effective date of final rule].
                                                             8611  Removed [Effective date of final rule].
                                                             8612  Removed [Effective date of final rule].
                                                             8613  Removed [Effective date of final rule].
                                                             8614  Removed [Effective date of final rule].
                                                             8615  Removed [Effective date of final rule].
                                                             8616  Removed [Effective date of final rule].
                                                             8617  Removed [Effective date of final rule].
                                                             8618  Removed [Effective date of final rule].
                                                             8619  Removed [Effective date of final rule].
                                                             8620  Removed [Effective date of final rule].
                                                             8621  Removed [Effective date of final rule].
                                                             8622  Removed [Effective date of final rule].
                                                             8623  Removed [Effective date of final rule].
                                                             8624  Removed [Effective date of final rule].
                                                             8625  Removed [Effective date of final rule].
                                                             8626  Removed [Effective date of final rule].
                                                             8627  Removed [Effective date of final rule].
                                                             8628  Removed [Effective date of final rule].
                                                             8629  Removed [Effective date of final rule].
                                                             8630  Removed [Effective date of final rule].
                                                             8710  Removed [Effective date of final rule].
                                                             8711  Removed [Effective date of final rule].
                                                             8712  Removed [Effective date of final rule].
                                                             8713  Removed [Effective date of final rule].
                                                             8714  Removed [Effective date of final rule].
                                                             8715  Removed [Effective date of final rule].
                                                             8716  Removed [Effective date of final rule].
                                                             8717  Removed [Effective date of final rule].
                                                             8718  Removed [Effective date of final rule].
                                                             8719  Removed [Effective date of final rule].
                                                             8720  Removed [Effective date of final rule].
                                                             8721  Removed [Effective date of final rule].
                                                             8722  Removed [Effective date of final rule].
                                                             8723  Removed [Effective date of final rule].
                                                             8724  Removed [Effective date of final rule].
                                                             8725  Removed [Effective date of final rule].
                                                             8726  Removed [Effective date of final rule].
                                                             8727  Removed [Effective date of final rule].
                                                             8728  Removed [Effective date of final rule].
                                                             8729  Removed [Effective date of final rule].
                                                             8730  Removed [Effective date of final rule].
                                                             8910  Added October 1, 1961; evaluation September
                                                                    9, 1975; title [Effective date of final
                                                                    rule].
                                                             8911  Added October 1, 1961; evaluation September
                                                                    9, 1975; title [Effective date of final
                                                                    rule].
                                                             8912  Added October 1, 1961; evaluation September
                                                                    9, 1975.
                                                             8913  Added October 1, 1961; evaluation September
                                                                    9, 1975.
                                                             8914  Added October 1, 1961; evaluation September
                                                                    9, 1975.
4.124a.....................................  ....................  Re-designated as Sec.   4.124 [Effective date
                                                                    of final rule].
 
                                                  * * * * * * *
----------------------------------------------------------------------------------------------------------------

0
11. Amend Appendix B to part 4 by revising and republishing the entries 
in the table under ``Neurological Conditions and Convulsive Disorders'' 
to read as follows:

[[Page 88938]]



          Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
     Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
------------------------------------------------------------------------
            Neurological Conditions and Convulsive Disorders
------------------------------------------------------------------------
             Organic Diseases of the Central Nervous System
------------------------------------------------------------------------
8000.........................  Encephalitis, infectious.
8002.........................  Brain, new growth of, malignant.
8003.........................  Brain, new growth of, benign.
8004.........................  Parkinson's disease (paralysis agitans).
8005.........................  Bulbar palsy.
8007.........................  Stroke (ischemic, hemorrhagic, or
                                thrombotic), including cerebral
                                infarction or cerebrovascular accident.
8010.........................  Myelitis.
8011.........................  Poliomyelitis, anterior.
8012.........................  Hematomyelia.
8013.........................  Syphilis, cerebrospinal.
8014.........................  Syphilis, meningovascular
8015.........................  Tabes dorsalis.
8017.........................  Amyotrophic lateral sclerosis.
8018.........................  Multiple sclerosis and neuromyelitis
                                optica spectrum disorder (NMOSD).
8019.........................  Meningitis, cerebrospinal, epidemic.
8020.........................  Brain, abscess.
8021.........................  Spinal cord, new growths of, malignant.
8022.........................  Spinal cord, new growths of, benign.
8023.........................  Progressive muscular atrophy.
8024.........................  Syringomyelia.
8025.........................  Myasthenia gravis.
8026.........................  Parkinson's plus, or secondary
                                parkinsonism syndromes.
8027.........................  Essential tremor.
8028.........................  Dystonia.
8036.........................  Primary lateral sclerosis.
8045.........................  Residuals of traumatic brain injury
                                (TBI).
8046.........................  Cerebral arteriosclerosis.
------------------------------------------------------------------------
                         Miscellaneous Diseases
------------------------------------------------------------------------
8100.........................  Migraine.
8103.........................  Hemifacial spasm (tic, convulsive).
8104.........................  Paramyoclonus multiplex (convulsive
                                state, myoclonic type).
8105.........................  Chorea, Sydenham's.
8106.........................  Chorea, Huntington's.
8107.........................  Athetosis, acquired.
8108.........................  Narcolepsy.
------------------------------------------------------------------------
                           The Cranial Nerves
------------------------------------------------------------------------
8205.........................  Fifth (trigeminal), motor neuropathy.
8207.........................  Seventh (facial), motor neuropathy.
8209.........................  Ninth (glossopharyngeal), motor
                                neuropathy.
8210.........................  Tenth (pneumogastric, vagus), motor
                                neuropathy.
8211.........................  Eleventh (spinal accessory, external
                                branch), motor neuropathy.
8212.........................  Twelfth (hypoglossal), motor neuropathy.
------------------------------------------------------------------------
                            Peripheral Nerves
------------------------------------------------------------------------
8510.........................  Upper radicular group, motor neuropathy.
8511.........................  Middle radicular group, motor neuropathy.
8512.........................  Lower radicular group, motor neuropathy.
8513.........................  All radicular groups, motor neuropathy.
8514.........................  Radial nerve (musculospiral), motor
                                neuropathy.
8515.........................  Median nerve, motor neuropathy.
8516.........................  Ulnar nerve, motor neuropathy.
8517.........................  Musculocutaneous nerve, motor neuropathy.
8518.........................  Axillary nerve (circumflex), motor
                                neuropathy.
8519.........................  Long thoracic nerve, motor neuropathy.
8520.........................  Sciatic nerve, motor neuropathy.
8521.........................  Common peroneal nerve (external
                                popliteal), motor neuropathy.
8522.........................  Superficial peroneal nerve
                                (musculocutaneous), motor neuropathy.
8523.........................  Deep peroneal nerve (anterior tibial),
                                motor neuropathy.
8524.........................  Tibial nerve (internal popliteal), motor
                                neuropathy.
8525.........................  Posterior tibial nerve, motor neuropathy.
8526.........................  Femoral nerve (anterior crural), motor
                                neuropathy.
8527.........................  Saphenous nerve (internal saphenous),
                                sensory neuropathy.

[[Page 88939]]

 
8528.........................  Obturator nerve, motor neuropathy.
8529.........................  Lateral cutaneous nerve of the thigh
                                (external cutaneous), sensory
                                neuropathy.
8530.........................  Ilio-inguinal nerve, motor neuropathy.
------------------------------------------------------------------------
               Other Neoplasms of the Neurological System
------------------------------------------------------------------------
8540.........................  Soft tissue sarcoma (Neurogenic origin).
------------------------------------------------------------------------
                             The Epilepsies
------------------------------------------------------------------------
8910.........................  Epilepsy, grand mal (includes tonic-
                                clonic seizures).
8911.........................  Epilepsy, petit mal (includes absence
                                seizures).
8912.........................  Jacksonian and focal motor or sensory.
8913.........................  Diencephalic.
8914.........................  Psychomotor.
 
                              * * * * * * *
------------------------------------------------------------------------

0
12. Amend Appendix C to part 4 by:
0
a. Adding, in alphabetical order, an entry for ``Dystonia'';
0
b. Removing the entry for ``Embolism, brain'';
0
c. Revising the entry for ``Encephalitis, epidemic'';
0
d. Under the entry for ``Epilepsies'', revising the entries for ``Grand 
mal'' and ``Petit mal'';
0
e. Adding, in alphabetical order, entries for ``Essential tremor'' and 
``Hemifacial spasm (tic, convulsive)'';
0
f. Removing the entry for ``Hemorrhage'';
0
g. Adding, in alphabetical order, an entry for ``Intraocular 
hemorrhage'';
0
h. Adding, in alphabetical order, an entry for ``Motor/sensory 
neuropathy'';
0
i. Revising the entry for ``Multiple sclerosis'';
0
j. Removing the entry for ``Neuralgia'';
0
k. Removing the entry for ``Neuritis'';
0
l. Adding an entry for ``Optic neuropathy'';
0
m. Under the entry for ``Paralysis'', removing the entry for 
``Agitans'';
0
n. Removing the entry for ``Paralysis, nerve'';
0
o. Revising the entry for ``Paramyoclonus multiplex'';
0
p. Adding, in alphabetical order, entries for ``Parkinson's disease 
(paralysis agitans)'', ``Parkinson's plus, or secondary parkinsonism 
syndromes'', ``Primary lateral sclerosis'', and ``Stroke (ischemic, 
hemorrhagic, or thrombotic), including cerebral infarction or 
cerebrovascular accident''; and
0
q. Removing the entries for ``Thrombosis, brain'' and ``Tic, 
convulsive''.
    The revisions and additions read as follows:

        Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
                                                     Diagnostic code No.
------------------------------------------------------------------------
 
                              * * * * * * *
Dystonia..........................................                  8028
 
                              * * * * * * *
Encephalitis, infectious..........................                  8000
 
                              * * * * * * *
Epilepsies:
 
                              * * * * * * *
    Grand mal (includes tonic-clonic seizures)....                  8910
 
                              * * * * * * *
    Petit mal (includes absence seizures).........                  8911
 
                              * * * * * * *
Essential tremor..................................                  8027
 
                              * * * * * * *
Hemifacial spasm (tic, convulsive)................                  8103
 
                              * * * * * * *
Intraocular hemorrhage............................                  6007
 
                              * * * * * * *
Motor/sensory neuropathy:
    Cranial nerves:
        Eleventh (spinal accessory, external                        8211
         branch)..................................
        Fifth (trigeminal)........................                  8205
        Ninth (glossopharyngeal)..................                  8209

[[Page 88940]]

 
        Seventh (facial)..........................                  8207
        Tenth (pneumogastric, vagus)..............                  8210
        Twelfth (hypoglossal).....................                  8212
    Peripheral nerves:
        All radicular groups......................                  8513
        Axillary (circumflex).....................                  8518
        Common peroneal (external popliteal)......                  8521
        Deep peroneal (anterior tibial)...........                  8523
        Femoral (anterior crural).................                  8526
        Ilio-inguinal.............................                  8530
        Lateral cutaneous nerve of the thigh                        8529
         (external cutaneous).....................
        Long thoracic.............................                  8519
        Lower radicular group.....................                  8512
        Median....................................                  8515
        Middle radicular group....................                  8511
        Musculocutaneous..........................                  8517
        Obturator.................................                  8528
        Posterior tibial..........................                  8525
        Radial (musculospiral)....................                  8514
        Saphenous (internal saphenous)............                  8527
        Sciatic...................................                  8520
        Superficial peroneal (musculocutaneous)...                  8522
        Tibial (internal popliteal)...............                  8524
        Ulnar.....................................                  8516
        Upper radicular group.....................                  8510
 
                              * * * * * * *
Multiple sclerosis and other demyelinating                          8018
 diseases of the central nervous system...........
 
                              * * * * * * *
Optic neuropathy..................................                  6026
 
                              * * * * * * *
Paramyoclonus multiplex (convulsive state,                          8104
 myoclonic type)..................................
 
                              * * * * * * *
Parkinson's disease (paralysis agitans)...........                  8004
Parkinson's plus, or secondary parkinsonism                         8026
 syndromes........................................
 
                              * * * * * * *
Primary lateral sclerosis.........................                  8036
 
                              * * * * * * *
Stroke (ischemic, hemorrhagic, or thrombotic),                      8007
 including cerebral infarction or cerebrovascular
 accident.........................................
 
                              * * * * * * *
------------------------------------------------------------------------

[FR Doc. 2024-25665 Filed 11-8-24; 8:45 am]
BILLING CODE 8320-01-P

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