[Federal Register Volume 60, Number 77 (Friday, April 21, 1995)]
[Rules and Regulations]
[Pages 19851-19856]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-9714]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AE72
Schedule for Rating Disabilities; Gynecological Conditions and
Disorders of the Breast
AGENCY: Department of Veterans Affairs.
ACTION: Final regulation.
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SUMMARY: This document amends the section of the Department of Veterans
Affairs (VA) Schedule for Rating Disabilities on Gynecological
Conditions and Disorders of the Breast. This amendment is based on a
General Accounting Office (GAO) study noting that there has been no
comprehensive review of the rating schedule since 1945, and
recommending that such a review be conducted. The intended effect of
this action is to update the gynecological and breast disorders section
of the rating schedule to ensure that it uses current medical
terminology, unambiguous criteria, and that it reflects medical
advances which have occurred since the last review.
EFFECTIVE DATE: This amendment is effective May 22, 1995.
FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,
Regulations Staff, Compensation and Pension Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW.,
Washington, DC 20420, (202) 273-7210.
SUPPLEMENTARY INFORMATION: In December 1988, the General Accounting
Office (GAO) recommended that VA prepare a plan for a comprehensive
review of the rating schedule and, based on the results, revise the
medical criteria accordingly. As part of the process to implement these
recommendations, VA published in the Federal Register of March 26, 1992
(57 FR 10450-53) a proposal to amend 38 CFR 4.116 and 4.116a.
Interested persons were invited to submit written comments,
suggestions, or objections on or before April 27, 1992. We received
comments from Disabled American Veterans, Veterans of Foreign Wars,
Paralyzed Veterans of America, and from several VA employees.
Two commenters suggested that we revise the proposed criteria for
rating endometriosis under diagnostic code (DC) 7629, placing the
emphasis on pain and abnormal bleeding rather than on headaches.
Upon further review, VA concurs that symptoms such as headaches and
muscle cramps are not the most appropriate criteria for evaluating
endometriosis, and we have therefore modified the proposed criteria. At
the 50 percent level, the proposed criteria specified endometriomas
larger than 2 x 2 cm., ovary or tubes bound down or obstructed by
adhesions, or obliteration of the cul-de-sac. These criteria have been
modified to call for lesions involving the bladder or bowel confirmed
by laparoscopy, pelvic pain or heavy or irregular bleeding not
controlled by treatment, and bowel or bladder symptoms. The proposed 30
percent level called for several lesions or minimal adhesions with side
effects such as headaches, muscle cramps, or edema despite treatment;
but the schedule has been revised to require pelvic pain or heavy or
irregular bleeding not controlled by treatment.
One commenter suggested that we include 10 percent and 100 percent
levels for evaluation of endometriosis.
Upon further consideration we have added a 10 percent level for
those cases in which pain or bleeding requires continuous treatment.
However, endometriosis does not in our judgment reach the level of
total disability. Some women have incapacitating symptoms, but on a
cyclic basis related to their menstrual periods. Others have milder
symptoms on a constant basis. Providing a 50 percent level recognizes
the substantial level of disability that women may experience because
of endometriosis, but we believe that, in general, the highest level of
disability assigned for a condition should not exceed the evaluation
for absence of the organ involved. In this case, 50 percent for removal
of the uterus and both ovaries is the highest post-surgical evaluation.
One individual suggested that a convalescent period of six months
at 100 percent should be provided for endometriosis following surgery
or other corrective procedure. [[Page 19852]]
VA does not concur. The most extensive surgery that is likely to be
needed for endometriosis is a hysterectomy and bilateral salpingo-
oophorectomy. Healing, convalescence, and residuals are likely to be
similar to those after such surgery for other conditions. We have
established a convalescent period for this type of surgery of three
months, which is discussed in more detail below. More conservative
surgery is often indicated, including some done on an outpatient basis.
Recovery would be even more rapid in such cases and, in our judgment,
six months of convalescence cannot be justified.
One commenter noted that 30-40 percent of patients with
endometriosis become infertile and that 10-15 percent of infertile
women have endometriosis.
While endometriosis may be associated with infertility, infertility
is not itself a disability for VA rating purposes. It does not result
in impairment of average earning capacity. If loss or loss of use of a
creative organ is established as due to endometriosis, special monthly
compensation under the provisions of 38 CFR 3.350(a) may be considered.
One commenter suggested a language change under the criteria for
evaluation of prolapse of the uterus, DC 7621, from ``complete--through
vulva'' to ``complete--through vagina and introitus.''
The language suggested by the commenter is more technically
accurate and we have revised the language as suggested.
Four commenters expressed concern about a lack of clarity in the
criteria for evaluating residuals of breast surgery under DC 7626. One
said that the phrase ``following mastectomy or lumpectomy without
significant alteration of size or form'' at the 0 percent level is
confusing because literally ``mastectomy'' will result in significant
alteration of size or form and that therefore ``biopsy'' should be
substituted for ``mastectomy.'' Another said that it is impossible to
remove the breast (i.e., perform a mastectomy) without significant
alteration of size or form, and that therefore ``mastectomy'' should be
replaced by ``lumpectomy.'' One felt that the phrase ``significant
alteration of size or form'' is too subjective to be useful, and also
that a mastectomy or lumpectomy which requires removal of some breast
tissue together with supporting tissues will change the size and form
of the breast and should be compensated at a 10 percent level.
In response to these comments, VA has simplified the criteria for
evaluating breast surgery residuals and has clarified them by adding a
note defining the terms used for the various types of breast surgery
specified at each level of evaluation. At the 0 percent level, we have
replaced the words ``mastectomy or lumpectomy'' with ``wide local
excision,'' a term that we also define for VA purposes in the note.
Since the commenters did not offer alternative language for us to
consider, however, we have retained the phrase ``significant alteration
of size or form.'' We believe the term is objective enough to be useful
since it requires a substantial, as opposed to a subtle or minimal,
alteration in the normal size or form of the breast. Furthermore, a
mastectomy or lumpectomy or any other wide local excision that
significantly alters the size or form of the breast will be
compensated, not at 10 percent, but at 30 percent. For degrees of
alteration that are not significant, a 10 percent evaluation is not
warranted because there is no industrial impairment and little or no
cosmetic deformity.
Two commenters suggested that there be major and minor evaluations
for breast surgery under DC 7626, comparable to muscle loss under DC
5302, extrinsic muscles of shoulder girdle.
VA does not concur. Muscle loss is not the only disability that
results from a radical mastectomy. There are two additional disabling
aspects: removal of the breast and removal of lymphatic tissue. The
residuals of removal of a breast include pain and deformity, each of
variable extent, and a 30 percent level of disability has been
established for removal of one breast without involvement of muscle or
lymphatic tissue. Disability of the pectoral muscle under DC 5302 is
assessed solely on loss of function, and complete removal warrants an
evaluation of 30 percent or 40 percent, depending on whether it is on
the major or minor side. Residuals from the removal of lymphatic tissue
during a radical mastectomy may be as mild in degree as minimal
deformity or pain or as severe as massive lymphedema of an arm. Thus
the residual disability from each of the three elements has a range of
severity, and it is the combination of the three that we have taken
into account in assigning a level of disability following breast
surgery. Considering all of these facets of disability, we do not
believe that the difference between muscle loss on the major and on the
minor side significantly influences the overall disability from a
radical mastectomy. Fifty percent was the assigned level of impairment
for a unilateral radical mastectomy in the 1945 rating schedule. In our
judgment this is a reasonable assessment, and we have retained it in
this revision. In other than radical breast surgery there is no muscle
impairment at all, so the comment on major and minor evaluations is not
applicable.
One commenter, stating that there is no industrial impairment
following mastectomy with significant alteration of size or form but
without removal of axillary lymph nodes unless there are painful scars,
suggested that the proposed evaluation of 50 percent for both and 30
percent for one should be lower.
VA does not agree with the commenter. Residuals of mastectomy may
include pain, deformity, and sense of loss with psychological distress.
Any of these may have an effect on an individual's functioning and can
occur regardless of whether or not the external appearance of the
clothed individual is altered. We are retaining the current evaluations
because the residuals remain essentially the same as they have been for
many years, and, in our judgment, result in residual disability
consistent with the levels currently assigned.
We proposed to retain Sec. 4.116 of the 1945 rating schedule intact
with only minor changes, but one commenter criticized that section as
ambiguous and confusing, particularly the part which indicates that
removal of uterus, ovaries, etc., is considered disabling, but only
prior to the natural menopause.
VA agrees that the implied distinction of surgery before or after
the natural menopause is not warranted. The rating schedule spells out,
without qualification or restriction, the evaluations to be assigned
following the removal of female reproductive organs once the
convalescent period has ended. The surgical residuals from the anatomic
removal of an organ or organs do not differ depending on whether or not
natural, surgical, or any other type of menopause has occurred. The
last sentence of Sec. 4.116 has therefore been deleted.
We have also removed the sentences addressing congenital
malformations and new growths. They are redundant since they state
principles stated elsewhere, specifically in Sec. 4.9, covering
congenital or developmental defects as applied to the entire rating
schedule, in Sec. 4.10, covering functional impairment in general, and
in the criteria under DC's 7627 and 7628, covering evaluation of
neoplasms.
Finally, the first two sentences of Sec. 4.116, ``[i]n rating
disability from gynecological conditions the following will not be
considered as ratable conditions: (a) The natural menopause, (b)
amenorrhea, when this is based upon [[Page 19853]] developmental defect
or abnormality, and (c) pregnancy and childbirth and their incidents,
except surgical complications under certain circumstances'' and ``The
surgical complications of pregnancy will not be held the result of
service except when additional disability resulted from treatment
therein or they are otherwise attributable to unusual circumstances of
service,'' have been changed. The second sentence contains unclear
remarks about the surgical complications of pregnancy, seemingly
restricting service connection for many of them. Chronic disabilities
resulting from pregnancy, whether medical or surgical, are subject to
service connection if incurred during service, as with other chronic
disabilities. Since this sentence is not only ambiguous but offers no
specific information that would aid in evaluation of disabilities, it
has been deleted.
The first sentence has been shortened and the type of amenorrhea
that is not considered a ratable condition clarified as ``primary''
amenorrhea. This remaining sentence would serve better as a note, and
we have deleted Sec. 4.116 in its entirety and retained this sentence
as part of Note (1) at the beginning of this portion of the rating
schedule. We have also added a sentence to the note stating that
chronic residuals of medical or surgical complications of pregnancy may
be disabilities for rating purposes. Since Sec. 4.116 has been deleted,
Sec. 4.116a has been redesignated as Sec. 4.116.
One commenter felt that the rating schedule should include rating
criteria for cervical dysplasia.
VA does not concur. Cervical dysplasia is neither disease nor
injury, but a cellular abnormality of the cervix revealed by a Pap
smear. It may resolve without residuals or it may represent a
premalignant condition which is a forerunner of carcinoma or carcinoma
in situ of the cervix. If carcinoma develops in service, whether or not
preceded by cervical dysplasia, it will be service-connected. If
carcinoma develops after service, the diagnosis of cervical dysplasia
in service may or may not be a factor in establishing service
connection, which will be determined under either presumptive
provisions of 38 CFR 3.309(a) or the general principles relating to
service connection in 38 CFR 3.303 et seq. Since cervical dysplasia is
not itself a disability, it does not in our judgment warrant inclusion
in the rating schedule.
One commenter objected to the retention of separate sections for
genitourinary conditions and gynecological conditions, calling this a
remnant of antiquated prejudices.
VA does not concur. In fact, the separation of these disciplines is
standard throughout modern medicine, with separate specialists,
textbooks, medical school and hospital departments, etc. Urology has
developed as a specialty that includes both the urinary tract and the
male genital tract because these two systems share some common anatomy.
This is not the case in females, however, where the genital tract is
independent of the urinary tract and is the focus of the separate
specialty of gynecology. Combining these systems would be contrary to a
major focus of the current revision, which is to bring the rating
schedule in line with current medical practice, and would be of no
discernible advantage to veterans or to those using the rating
schedule.
The same commenter asserted that conditions of the gynecological
system, especially the loss of procreative organs, do not cause
impairment of earning capacity and should therefore not be compensated.
A second commenter suggested that our proposed method of evaluating
disabilities of the gynecological system based on the need for or
response to treatment is inappropriate because it is not based on
impairment of earning capacity as required by 38 U.S.C. 1155. A third
related comment was an objection that the proposed evaluations covering
disease, injury, or adhesions of the female reproductive organs (DC
7610-7615) were based on optimum success in overcoming the effects of
disease and the results of surgery rather than the resultant average
impairment.
VA disagrees with the three commenters. The conditions in this
system may cause pain, abnormal bleeding, incontinence, etc., and such
symptoms undoubtedly cause women to lose time from work, which affects
the ability to obtain and retain employment, and thus affects income.
In addition, loss of procreative organs may affect endocrine function,
renal function, psychological function, etc., any of which may affect
the ability to work. How well a patient feels, which often relates to
how well or how poorly a disease or injury has responded to treatment,
is a significant factor in employment. A person who requires continuous
treatment is more disabled than one who does not, and one who has
symptoms despite continuous treatment is even more impaired. Since
evaluation criteria for conditions in other body systems (e.g., malaria
(DC 9304), leukemia (DC 7703), and hypo- and hyper-thyroidism (DC 7900
and DC 7903)) take into account the need for treatment, the evaluation
criteria which we proposed under DC's 7610 through 7615 are also
consistent with other portions of the rating schedule. Our method of
evaluating many of these conditions based on response to treatment is
therefore appropriate because it assigns those who have symptoms
despite treatment the highest level of evaluation because they are the
ones who will suffer the most adverse effects on employment.
One commenter suggested that we not compensate pelvic inflammatory
disease, which he states is most often a sexually transmitted disease,
because, short of tertiary complications of syphilis, male veterans are
not compensated for sexually transmitted diseases. He stated that the
proposed rule retains disparate ratings for the same type of disability
affecting male and female veterans.
VA again disagrees. The provisions of 38 CFR 3.301(c)(1)
specifically permit consideration of service connection for residuals
of venereal disease if the initial infection occurred during active
service. The commenter's statement that males are not compensated for
residuals of venereal disease is inaccurate. Urethral strictures, for
example, which in some cases represent residuals of venereal disease,
may be compensable disabilities. We would also point out that venereal
disease presents differently, both acutely and chronically, in males
and females, and that rating criteria and entitlement to compensation
are based on disability, not on etiology. For these reasons, we find
that the inclusion of pelvic inflammatory disease in the rating
schedule does not represent disparate evaluations of similar
disabilities for males and females, and the commenter's statements do
not, in our judgment, establish a rational basis for deleting this
condition from the rating schedule.
We proposed changing the convalescent periods for Ovary, removal of
(DC 7619) and Uterus and both ovaries, removal of (DC 7617) from six
months to three months, and two commenters objected. One stated that by
reducing certain evaluations and periods of convalescence, VA was
exceeding the GAO mandate to review the rating schedule to update
medical terminology and evaluation criteria, and that a statistical
study of impairment in earning capacity should be done. The other said
that removal of both uterus and ovaries is a far more significant
surgical procedure than the removal of the uterus alone or ovary alone
and there is a basis for continuation of the six-month convalescent
period.
VA disagrees. A convalescent period of three months after removal
of the [[Page 19854]] uterus and/or ovaries is regarded as adequate for
most patients because of improvements in surgical techniques and in
postoperative care, including the practice of early ambulation. The
average convalescent period is actually shorter than three months, with
most patients requiring no more than six to eight weeks to convalesce.
VA's mandate to readjust the schedule does not derive from GAO but from
38 U.S.C. 1155, which instructs the Secretary to revise the schedule
``in accord with experience.'' A need for shorter periods of
convalescence represents a significant medical advance since the last
revision, and changes in the rating schedule to reflect this are
appropriate.
Three commenters objected to the proposal concerning the period of
total evaluation following the completion of therapy for malignancy,
citing the wide variety of possible side effects, the varying
individual time requirements for convalescence, and the complexity of
certain medical procedures.
VA does not concur with the objections. The commenters appear to
have misinterpreted the proposed rule to mean that a convalescent
evaluation will be terminated six months after treatment has ceased.
However, under the proposed change, there cannot be a reduction at the
end of six months because the process of reevaluation does not begin
until that time. First, there must be a VA examination six months after
completion of treatment. Then, if the results of that or any subsequent
examination warrant a reduction in evaluation, the reduction will be
implemented under the provisions of 38 CFR 3.105(e), which require a
60-day notice before VA can reduce an evaluation and an additional 60-
day notice before the reduced evaluation takes effect. The revision not
only requires a current examination to assure that all residuals are
documented, but also offers the veteran more contemporaneous notice of
any proposed action and expands the veteran's opportunity to present
evidence showing that the proposed action should not be taken. In our
judgment this method will better ensure that actual side effects and
recuperation times are taken into account because they will be noted on
the required VA exam. Based on commenters' concerns, however, we have
revised the note under this code so that it cannot be misinterpreted as
requiring a reduction six months after treatment is terminated. We have
also added to the note a direction to rate on residuals, if there has
been no local recurrence or metastasis, in order to make these
provisions consistent with those we provided for malignancies of the
revised genitourinary system. This is not a substantive change, but has
been made to provide further clarity, as well as internal consistency
within the rating schedule.
Two commenters urged us to retain a minimum evaluation of 10
percent following surgery or the completion of therapy for malignancy.
VA does not agree. Residuals following the medical or surgical
treatment of malignancy are common, but vary widely in type and
severity, and a specified arbitrary level of residual disability cannot
be assumed to be present in every case. As previously discussed, we
will be requiring a VA examination for each individual before adjusting
the convalescent evaluation, and that examination will also ensure that
actual residual disabilities will be documented and assigned an
accurate evaluation, which may be more or less than 10 percent.
Two commenters suggested that we retain the evaluation for removal
of one ovary with or without partial removal of the other at 10 percent
rather than changing it to 0 percent. Another stated that removal of
one ovary is analogous to atrophy of both ovaries and should therefore
be rated at 20 percent.
VA does not concur. One ovary or even part of an ovary produces
sufficient hormone to maintain normal reproductive and endocrine
functions without hormonal replacement therapy. The ultimate test of
ovarian hormonal function is the ability to support a pregnancy, and it
is a well-established medical fact that one ovary is sufficient to
support a pregnancy. This is significantly different from complete
atrophy of both ovaries (DC 7620), where there would be no hormonal
output, and replacement therapy would be necessary.
Two commenters requested that we annotate certain diagnostic codes
in this section to indicate entitlement to special monthly compensation
(SMC) under 38 U.S.C. 1114(k) for loss of a creative organ. One
suggested annotating DC's 7617, 7618, 7619, and 7626, and the other
suggested annotations ``where appropriate.''
Because the statutory requirements for SMC are very complicated and
in some cases involve more than one body system, it is impractical to
provide detailed information at every location in the rating schedule
where the potential for entitlement to SMC might arise. Rating
specialists must be aware of the need to refer to 38 CFR 3.350, the
governing regulation, in every instance where the veteran has a
condition which potentially establishes eligibility for SMC. To that
end, we have added a note at the beginning of Sec. 4.116 requiring
rating specialists to refer to Sec. 3.350 any time they evaluate a
claim involving loss or loss of use of one or more creative organs. In
view of the comments received, we have also placed footnotes after
diagnostic codes 7617 (removal of uterus and both ovaries), 7618
(removal of uterus), 7619 (removal of ovary), and 7620 (complete
atrophy of both ovaries) instructing raters to review for entitlement
to SMC. While the conditions we have annotated clearly call for review
for entitlement to SMC, almost any condition in this section might,
under certain circumstances, establish entitlement to SMC. The note at
the beginning of Sec. 4.116 makes it clear that it is the
responsibility of the rating specialist to recognize those
circumstances and assign SMC when warranted. The lack of a footnote
does not relieve rating specialists of that responsibility.
Viewing the rating schedule as a whole, we are concerned that if
there are footnotes only for obvious grants of SMC, individual veterans
entitled to SMC in less obvious situations will be disadvantaged if
rating specialists fail to recognize potential entitlement because they
have not been prompted to do so by a footnote. We believe that the
combination of the regulatory requirement in the note and the footnotes
is the best method of making sure that potential entitlement to SMC is
considered.
On further review, we have made some additional changes to the
proposed revisions for the sake of clarity and objectivity. The title
of DC 7627 has been changed from ``Breast, removal of'' to ``Breast,
surgery of,'' since surgery often stops short of removal of a breast.
In order to eliminate the need to search in other sections of the
rating schedule for criteria to evaluate DC 7625, Fistula,
urethrovaginal, (which in the proposed rule was to be rated as voiding
dysfunction under the genitourinary schedule), we have provided the
criteria for voiding dysfunction (continual urine leakage, post
surgical urinary diversion, urinary incontinence, or stress
incontinence subset of criteria) under DC 7625. The only difference is
that we changed the word urethroperineal to urethrovaginal, as being
more specific to this system.
Similarly, we proposed that Fistula, rectovaginal (DC 7624) be
evaluated as DC 7332, rectum and anus, impairment of sphincter control
(in the digestive system section of the rating schedule). In response
to a general comment on the proposed rating schedule revisions of a
number of body systems, which strongly [[Page 19855]] favored the
elimination of subjectivity and urged its extension, we removed terms
such as ``extensive leakage'' and ``fairly frequent'', which are part
of the criteria for DC 7332, in favor of criteria that are more
precise, but still based on the extent of fecal leakage and the
necessity for wearing a pad.
We made one additional minor technical change under DC 7628, Benign
neoplasms of the gynecological system or breast. The word
``genitourinary'' has been replaced by the word ``urinary'' as being
more specific to this system.
VA appreciates the comments submitted in response to the proposed
rule, which is now adopted with the amendments noted above.
The Secretary hereby certifies that this regulatory amendment will
not have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act (RFA), 5
U.S.C. 601-612. The reason for this certification is that this
amendment would not directly affect any small entities. Only VA
beneficiaries could be directly affected. Therefore, pursuant to 5
U.S.C. 605(b), this amendment is exempt from the initial and final
regulatory flexibility analysis requirements of sections 603 and 604.
This regulatory amendment has been reviewed by the Office of
Management and Budget under the provisions of Executive Order 12866,
Regulatory Planning and Review, dated September 30, 1993.
(The Catalog of Federal Domestic Assistance program numbers are
64.104 and 64.109.)
List of Subjects in 38 CFR Part 4
Individuals with disability, Pensions, Veterans.
Approved: December 22, 1994.
Jesse Brown,
Secretary of Veterans Affairs.
For the reasons set forth in the preamble, 38 CFR part 4, subpart
B, is amended as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
Subpart B--Disability Ratings
1. The authority citation for part 4 is revised to read as follows:
Authority: 38 U.S.C. 1155.
2. The undesignated center heading appearing before Sec. 4.116 is
revised to read as follows:
Gynecological Conditions and Disorders of the Breast
3. Section 4.116 is removed.
4. Section 4.116a is redesignated as Sec. 4.116 and its heading and
text are revised to read as follows:
Sec. 4.116. Schedule of ratingsgynecological conditions and disorders
of the breast.
------------------------------------------------------------------------
Rating
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Note 1: Natural menopause, primary amenorrhea, and
pregnancy and childbirth are not disabilities for rating
purposes. Chronic residuals of medical or surgical
complications of pregnancy may be disabilities for rating
purposes.
Note 2: When evaluating any claim involving loss or loss of
use of one or more creative organs, refer to Sec. 3.350 of
this chapter to determine whether the veteran may be
entitled to special monthly compensation. Footnotes in the
schedule indicate conditions which potentially establish
entitlement to special monthly compensation; however,
almost any condition in this section might, under certain
circumstances, establish entitlement to special monthly
compensation.
7610 Vulva, disease or injury of (including vulvovaginitis).
7611 Vagina, disease or injury of.
7612 Cervix, disease or injury of.
7613 Uterus, disease, injury, or adhesions of.
7614 Fallopian tube, disease, injury, or adhesions of
(including pelvic inflammatory disease (PID)).
7615 Ovary, disease, injury, or adhesions of.
General Rating Formula for Disease, Injury, or Adhesions of
Female Reproductive Organs (diagnostic codes 7610 through
7615):
Symptoms not controlled by continuous treatment............ 30
Symptoms that require continuous treatment................. 10
Symptoms that do not require continuous treatment.......... 0
7617 Uterus and both ovaries, removal of, complete:
For three months after removal............................. \1\100
Thereafter................................................. \1\50
7618 Uterus, removal of, including corpus:
For three months after removal............................. \1\100
Thereafter................................................. \1\30
7619 Ovary, removal of:
For three months after removal............................. \1\100
Thereafter:
Complete removal of both ovaries....................... \1\30
Removal of one with or without partial removal of the
other................................................. \1\0
7620 Ovaries, atrophy of both, complete....................... \1\20
7621 Uterus, prolapse:
Complete, through vagina and introitus..................... 50
Incomplete................................................. 30
7622 Uterus, displacement of:
With marked displacement and frequent or continuous
menstrual disturbances.................................... 30
With adhesions and irregular menstruation.................. 10
7623 Pregnancy, surgical complications of:
With rectocele or cystocele................................ 50
With relaxation of perineum................................ 10
7624 Fistula, rectovaginal:
Vaginal fecal leakage at least once a day requiring wearing
of pad.................................................... 100
Vaginal fecal leakage four or more times per week, but less
than daily, requiring wearing of pad...................... 60
Vaginal fecal leakage one to three times per week requiring
wearing of pad............................................ 30
Vaginal fecal leakage less than once a week................ 10
Without leakage............................................ 0
7625 Fistula, urethrovaginal:
Multiple urethrovaginal fistulae........................... 100
Requiring the use of an appliance or the wearing of
absorbent materials which must be changed more than four
times per day............................................. 60
Requiring the wearing of absorbent materials which must be
changed two to four times per day......................... 40
Requiring the wearing of absorbent materials which must be
changed less than two times per day....................... 20
7626 Breast, surgery of:
Following radical mastectomy:
Both................................................... 80
One.................................................... 50
Following modified radical mastectomy:
Both................................................... 60
One.................................................... 40
Following simple mastectomy or wide local excision with
significant alteration of size or form:
Both................................................... 50
One.................................................... 30
Following wide local excision without significant
alteration of size or form:
Both or one............................................ 0
Note: For VA purposes:
(1) Radical mastectomy means removal of the entire
breast, underlying pectoral muscles, and regional
lymph nodes up to the coracoclavicular ligament ......
[[Page 19856]]
(2) Modified radical mastectomy means removal of the
entire breast and axillary lymph nodes (in continuity
with the breast). Pectoral muscles are left intact....
(3) Simple (or total) mastectomy means removal of all
of the breast tissue, nipple, and a small portion of
the overlying skin, but lymph nodes and muscles are
left intact...........................................
(4) Wide local excision (including partial mastectomy,
lumpectomy, tylectomy, segmentectomy, and
quadrantectomy) means removal of a portion of the
breast tissue.........................................
7627 Malignant neoplasms of gynecological system or breast.... 100
Note: A rating of 100 percent shall continue beyond the
cessation of any surgical, X-ray, antineoplastic
chemotherapy or other therapeutic procedure. Six months
after discontinuance of such treatment, the appropriate
disability rating shall be determined by mandatory VA
examination. Any change in evaluation based upon that or
any subsequent examination shall be subject to the
provisions of Sec. 3.105(e) of this chapter. If there has
been no local recurrence or metastasis, rate on residuals.
7628 Benign neoplasms of the gynecological system or breast.
Rate according to impairment in function of the urinary or
gynecological systems, or skin.
7629 Endometriosis:
Lesions involving bowel or bladder confirmed by
laparoscopy, pelvic pain or heavy or irregular bleeding
not controlled by treatment, and bowel or bladder symptoms 50
Pelvic pain or heavy or irregular bleeding not controlled
by treatment.............................................. 30
Pelvic pain or heavy or irregular bleeding requiring
continuous treatment for control.......................... 10
Note: Diagnosis of endometriosis must be substantiated by
laparoscopy.
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\1\Review for entitlement to special monthly compensation under Sec.
3.350 of this chapter.
[FR Doc. 95-9714 Filed 4-20-95; 8:45 am]
BILLING CODE 8320-01-P
