96-22593. Schedule for Rating Disabilities; Respiratory System  

  • [Federal Register Volume 61, Number 173 (Thursday, September 5, 1996)]
    [Rules and Regulations]
    [Pages 46720-46731]
    From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
    [FR Doc No: 96-22593]
    
    
    =======================================================================
    -----------------------------------------------------------------------
    
    DEPARTMENT OF VETERANS AFFAIRS
    
    38 CFR Part 4
    
    RIN 2900-AE94
    
    
    Schedule for Rating Disabilities; Respiratory System
    
    AGENCY: Department of Veterans Affairs.
    
    ACTION: Final rule.
    
    -----------------------------------------------------------------------
    
    SUMMARY: This document amends that portion of the Department of 
    Veterans Affairs (VA) Schedule for Rating Disabilities that addresses 
    the Respiratory System. The intended effect of this action is to update 
    the respiratory portion of the rating schedule to ensure that it uses 
    current medical terminology and unambiguous criteria, and that it 
    reflects medical advances which have occurred since the last review.
    
    DATES: This amendment is effective October 7, 1996.
    
    FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
    Regulations Staff (213A), Compensation and Pension Service, Veterans 
    Benefits Administration, Department of Veterans Affairs, 810 Vermont 
    Avenue, NW, Washington DC 20420, (202) 273-7210.
    
    SUPPLEMENTARY INFORMATION: As part of its first comprehensive review of 
    the rating schedule since 1945, VA published a proposal to amend 38 CFR 
    4.96 and 4.97, which address the respiratory system. The proposal was 
    published in the Federal Register of January 19, 1993 (58 FR 4962-69). 
    Interested persons were invited to submit written comments on or before 
    March 22, 1993. We received comments from Paralyzed Veterans of 
    America, Disabled American Veterans, Veterans of Foreign Wars, the 
    American Legion, several VA employees, and one member of the general 
    public.
        One commenter suggested a need for a zero percent level for all 
    conditions.
        On October 6, 1993, VA revised its regulation addressing the issue 
    of zero percent evaluations (38 CFR 4.31) to authorize assignment of a 
    zero percent evaluation for any disability in the rating schedule when 
    minimum requirements for a compensable evaluation are not met. In 
    general, that regulatory provision precludes the need for zero percent 
    criteria for every condition. VA believes that it is useful to include 
    a zero percent evaluation only if it is necessary to give the rating 
    board clear and unambiguous instructions on rating where it might 
    otherwise be unclear whether commonly occurring minor findings warrant 
    a zero percent or higher evaluation.
        One commenter suggested that the proposed revision would 
    discriminate against veterans whose initial evaluations would be 
    assigned under a new and deliberalized schedule.
        Significant medical advances have occurred since the last 
    comprehensive review of the rating schedule, and it is appropriate to 
    take these advances into account in revising the rating schedule. Doing 
    so is, in fact, one of the primary reasons for conducting this review. 
    In our judgment, veterans will not be discriminated against by having 
    their disabilities evaluated under criteria which reflect the effects 
    of those medical advances. For veterans evaluated under the former 
    criteria, Congress amended 38 U.S.C. 1155 to prohibit a reduction in a 
    veteran's disability rating because of a readjustment of the rating 
    schedule
    
    [[Page 46721]]
    
    unless an improvement in the disability has been shown.
        One commenter stated that rating schedule revisions appear to be 
    based on optimum success in overcoming the effects of disease rather 
    than average impairment.
        VA disagrees. 38 U.S.C. 1155 directs that ``ratings shall be based, 
    as far as practicable, upon the average impairments of earning capacity 
    resulting from such injuries in civil occupations.'' The word 
    ``average,'' as used in the statute, refers to the ``usual or normal 
    kind, amount, quantity, rate, etc.'' (``Webster's New World 
    Dictionary,'' Third College Edition). To the extent possible, we have 
    based our changes on average or usual or normal courses of disease and 
    recovery.
        The previous schedule provided a two-year period of total 
    evaluation following the cessation of treatment for malignant neoplasms 
    of the respiratory tract (DC 6819). As with malignant neoplasms in 
    other revised sections of the rating schedule, we proposed that a 100-
    percent rating continue following the cessation of surgical, X-ray, 
    antineoplastic chemotherapy or other therapeutic procedure, with a 
    mandatory examination six months following cessation of treatment. 
    Before any change in evaluation based upon the examination can be made, 
    the provisions of Sec. 3.105(e) must be implemented, and evaluation is 
    made on residuals if there has been no metastasis or recurrence. We 
    received a number of comments about that proposed change. One commenter 
    said that six months is not a long enough convalescence.
        We believe that an examination six months following the cessation 
    of treatment affords sufficient time for convalescence and 
    stabilization of residuals, particularly since the rule requires only 
    an examination, not a reduction, at that time. 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 reduces an evaluation and an 
    additional 60-day notice before the reduced evaluation takes effect. 
    The revised procedure, by requiring an examination, will not only 
    assure that all residuals are documented, but also that the veteran 
    receives timely notice of any proposed action and an expanded 
    opportunity to present evidence showing that the proposed action should 
    not be taken or should be mitigated. In our judgment, this method will 
    better ensure that actual residual disabilities and recuperation times 
    are taken into account because they will be documented on the required 
    examination, and the veteran will have better opportunities to present 
    evidence demonstrating the current level of disabilities.
        We have revised the note under DC 6819 for the sake of clarity and 
    consistency. We have 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 the revised provisions 
    for malignancies of the genitourinary system. This is not a substantive 
    change.
        One commenter felt that applying Sec. 3.105(e) will cause 
    administrative problems and will significantly lengthen the period of a 
    total evaluation when claims are received months or years after 
    surgery. He felt that a retroactive increase to 100 percent 
    simultaneously with the initiation of due process under Sec. 3.105(e) 
    to determine the extent of residual disability would be inconsistent.
        Since Sec. 3.105(e) applies only to reductions in ``compensation 
    payments currently being made,'' it does not apply where a total 
    evaluation is assigned and reduced retroactively.
        When the proposed rule was published, we cited improvements in the 
    administration of chemotherapy and radiation therapy as one reason for 
    eliminating a fixed convalescent period. One commenter requested that 
    we justify our statement that chemotherapy has improved.
        While the first effective drugs for treating cancer were introduced 
    in the mid and late 1940's, the results were disappointing because 
    responses were incomplete and of short duration, and doses were limited 
    by toxicity (``Cecil Textbook of Medicine'' 1118 (James B. Wyngaarden, 
    M.D. et al. eds., 19th ed. 1992)). In 1945 there was only one drug 
    known to be effective--nitrogen mustard. Today there are nearly 50 
    chemotherapeutic agents in use. The dose and frequency of 
    administration of the newer agents often differ from those of earlier 
    agents, and the actions of some of the newer agents are more targeted 
    in their actions, so that side effects may be fewer and treatment 
    shorter than before. In use since the 1960's, combination chemotherapy 
    has also marked a turning point in the effective treatment of 
    neoplastic disease (``Harrison's Principles of Internal Medicine'' 1587 
    (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)).
        Another commenter stated that the proposed changes in convalescence 
    should be justified by medical experts or text citations and that our 
    medical consultants should be named.
        As part of the process of reviewing the rating schedule, we 
    contracted with an outside consultant, Abt Associates Incorporated, to 
    submit recommendations for revisions to those portions of the rating 
    schedule dealing with the respiratory system. We also received advice 
    and suggestions from physicians in the Veterans Health Administration, 
    and we consulted standard medical and surgical textbooks, including 
    ``Harrison's Principles of Internal Medicine'' (Jean D. Wilson, M.D. et 
    al. eds., 12th ed. 1991), ``Cecil Textbook of Medicine'' (James B. 
    Wyngaarden, M.D. et al. eds., 19th ed. 1992), and ``The Merck Manual,'' 
    (16th ed. 1992). The convalescent periods adopted in this change 
    represent, in our judgment, based on sound medical advice, neither the 
    longest nor the shortest periods that any individual patient might 
    require for recovery, but the usual or normal periods during which a 
    normal patient, under normal circumstances, would be expected to 
    recover from a specific condition or surgical procedure. For the 
    unusual case where a longer convalescence is needed, the provisions of 
    Secs. 4.29 and 4.30 allow an extension of convalescence.
        One commenter said that the reductions in the revision appear to be 
    on a purely economic basis.
        This review was carried out from a medical perspective. Its purpose 
    is to ensure that the rating schedule uses current medical terminology 
    and unambiguous criteria, and that it reflects medical advances which 
    have occurred since the last review. Cost cutting was not an issue.
        One commenter suggested that we revise the title of DC 6522, 
    allergic rhinitis, to ``allergic or vasomotor rhinitis'' because both 
    conditions exhibit the same manifestations and are at times 
    indistinguishable.
        We agree and have revised the title of DC 6522 accordingly.
        Another commenter, without giving his reasons, suggested that we 
    combine DC's 6510 through 6514 (the codes for chronic pansinusitis, 
    ethmoid sinusitis, frontal sinusitis, maxillary sinusitis, and sphenoid 
    sinusitis) into a single code for sinusitis.
        Retaining a separate code for each of the sinuses will allow 
    statistical tracking of disease of individual sinuses. Since the 
    commenter gave no reason for suggesting the change, and no substantial 
    advantage to either the veteran or the rating board is evident, we have 
    kept separate codes.
    
    [[Page 46722]]
    
        One commenter felt that subjective descriptors like ``marked'' 
    under DC's 6522 (allergic rhinitis), 6523 (chronic rhinitis), and 6516 
    (laryngitis), and ``abundant'' in DC 6601 (bronchiectasis) in the 
    proposed revision should be eliminated for the sake of objectivity.
        VA agrees, and we have revised the criteria accordingly. In some 
    cases we have simply removed subjective terms such as ``marked'' and 
    ``mild'' when they did not substantively explain or clarify the 
    evaluation criteria. In other cases, we have supplied objective 
    definitions of terms. In still others, establishing more objective and 
    unambiguous criteria required greater modification of the proposed 
    criteria, and these changes will be discussed under the affected 
    diagnostic codes.
        In the case of chronic laryngitis (DC 6516), removing ``marked'' 
    and ``moderate'' required additional changes in the criteria to 
    distinguish the 10- and 30-percent levels. We proposed a ten-percent 
    evaluation for moderate hoarseness with inflammation of cords or mucous 
    membrane and a thirty-percent evaluation for marked hoarseness with 
    pathological changes such as inflammation of cords or mucous membrane, 
    thickening or nodules of cords, or submucous infiltration. We have 
    revised the requirements for a ten-percent evaluation to hoarseness 
    with inflammation of cords or mucous membrane and for a thirty-percent 
    evaluation to hoarseness with thickening or nodules of cords, polyps, 
    submucous infiltration, or pre-malignant changes on biopsy. This 
    clarifies the criteria for the given percentages.
        For several conditions with nasal obstruction: septum, nasal, 
    deviation of (DC 6502), allergic or vasomotor rhinitis (DC 6522), and 
    bacterial rhinitis (DC 6523), we proposed a ten-percent evaluation if 
    there is ``marked'' interference with breathing space. We replaced that 
    subjective criterion with ``more than 50-percent obstruction of nasal 
    passage on both sides or complete obstruction on one side'' for a ten-
    percent evaluation in all three conditions. This clarifies the criteria 
    for the given percentages.
        In the general rating formula for sinusitis, the criteria included 
    such subjective terms as ``severe symptoms,'' ``frequently 
    incapacitating recurrences,'' and ``frequent severe headaches.'' We 
    proposed a 100-percent evaluation for ``following radical surgery with 
    chronic osteomyelitis, or; severe symptoms after repeated surgeries.'' 
    We proposed a 30-percent evaluation for ``frequently incapacitating 
    recurrences, and frequent severe headaches, and purulent discharge or 
    crusting reflecting purulence.'' We proposed a ten-percent level for 
    ``infrequent headaches with discharge or crusting or scabbing.'' We 
    have revised these criteria by specifying the frequency of 
    incapacitating or non-incapacitating episodes of sinusitis per year and 
    the specific symptoms for the various levels. For example, we changed 
    the criteria for a 30-percent evaluation to a requirement for three or 
    more incapacitating episodes per year of sinusitis requiring prolonged 
    (lasting four to six weeks) antibiotic treatment, or; more than six 
    non-incapacitating episodes per year of sinusitis characterized by 
    headaches, pain, and purulent discharge or crusting. The change is to 
    clarify the criteria.
        One commenter, while agreeing with the removal of ambiguous words 
    such as ``severe,'' urged that the rules not be made too concrete.
        We believe that providing clear and objective criteria is the best 
    way to assure that disabilities will be evaluated fairly and 
    consistently. At the same time we are aware that there must be some 
    flexibility in application of the criteria because patients do not 
    commonly present as textbook models of disease. Rating boards are 
    required to assess all the evidence of record before determining a 
    disability evaluation and must use their judgment in determining, for 
    example, which level of evaluation is more appropriate when there is 
    conflicting information. Therefore, no matter how objective the 
    criteria, an element of judgment in their application remains.
        We proposed criteria for bronchiectasis (DC 6601) that included 
    ``severe'' hemoptysis, ``chronic'' antibiotic usage, and ``chronic 
    recurrent'' pneumonia. One commenter said that the words ``severe,'' 
    ``chronic,'' and ``chronic recurrent'' are not objective and that in 
    fact they are unnecessary.
        VA agrees. However, simply eliminating those adjectives would not 
    have left appropriate criteria, so we have revised the criteria to make 
    them more objective. We have specified the required duration of 
    incapacitating episodes of infection or frequency of antibiotic usage 
    for each level of severity of bronchiectasis. At the 60- and 30-percent 
    levels, we also provided alternative objective criteria based on such 
    symptoms as cough, purulent sputum, and weight loss. Our change is to 
    clarify the criteria for the evaluation of bronchiectasis.
        The previous schedule used a variety of symptoms, signs, and X-ray 
    findings to evaluate pulmonary diseases. We proposed that many be 
    evaluated, at least in part, on criteria based on the results of 
    pulmonary function tests (PFT's). One commenter, concerned that a 
    single set of PFT's on a given day might not accurately represent the 
    veteran's usual condition, recommended that VA place greater emphasis 
    on interpreting examination reports in light of all evidence of record 
    and require that test results be reviewed by a pulmonary disease 
    specialist or by the medical specialist on the rating board.
        Rating boards are required by Sec. 4.2 to evaluate all evidence of 
    record before assigning an evaluation. It is highly unlikely that the 
    results of a single set of PFT's would be the only available evidence 
    on which to evaluate the level of severity of a pulmonary condition. 
    Current clinical information, treatment records, previous examination 
    reports, and other laboratory results are generally available for 
    consideration. Rating boards seek medical consultation when they feel 
    it is necessary. The medical consultant to the rating board is readily 
    available for information and advice, and the rating board may request 
    an examination by a pulmonary disease specialist when it feels it is 
    needed. It would be both impractical and unnecessary to consult with a 
    pulmonary disease specialist on every case in which PFT's have been 
    conducted.
        One commenter suggested that the criteria in the previous rating 
    schedule for evaluating respiratory diseases be retained as a backup 
    for cases where pulmonary function testing is not available.
        The equipment for carrying out PFT's is widely available, but if an 
    examining facility is not equipped for the tests, the examination will 
    need to be conducted at another facility, as is the case with other 
    specialized testing, such as for vision or hearing. VA therefore does 
    not believe retention of the previous criteria as backup is necessary.
        Another commenter stated that pulmonary function testing is 
    contraindicated in certain instances for medical reasons, such as a 
    history of spontaneous pneumothorax, a hole in the tympanic membrane, 
    or a recent history of active tuberculosis, and that provisions are 
    therefore needed for evaluating these conditions when PFT's cannot be 
    done.
        The Veterans Health Administration has advised us that the medical 
    conditions listed by the commenter do not contraindicate pulmonary 
    function testing. The major limiting factor in carrying out such 
    testing is the inability of some patients to follow directions, as
    
    [[Page 46723]]
    
    might occur, for example, in individuals who are severely ill following 
    a stroke. Even in such individuals, the new criteria allow assignment 
    of a total evaluation for respiratory disease because there are a 
    number of criteria warranting a 100-percent evaluation, including cor 
    pulmonale, right ventricular hypertrophy, and respiratory failure, that 
    can be assessed without the need for patient cooperation. As under the 
    previous criteria, for a small number of patients with a less severe 
    respiratory disease, an evaluation may have to be deferred until 
    pulmonary function testing is feasible.
        Machines that are used for disability testing purposes must meet 
    the calibration standards of The American Thoracic Society, which are 
    internationally accepted. This assures that the basis of evaluations 
    will be the most accurate and consistent measurements possible.
        We proposed a 100-percent level of evaluation for larynx, stenosis 
    of, (DC 6520) if there is either a Forced Expiratory Volume in one 
    second (FEV-1) of less than 40-percent predicted, or a permanent 
    tracheostomy, and a 60-percent evaluation if there is an FEV-1 of 40- 
    to 55-percent predicted. We proposed a 100-percent evaluation for 
    chronic bronchitis (DC 6600), pulmonary emphysema (DC 6603), chronic 
    obstructive pulmonary disease (DC 6604) and restrictive lung diseases 
    if there is an FEV-1 of less than 40-percent predicted, a ratio of FEV-
    1 to Forced Vital Capacity (FVC) less than 40-percent, a DLCO less than 
    40-percent predicted, maximum exercise capacity less than 15 ml/kg/min 
    oxygen consumption, cor pulmonale (right heart failure), right 
    ventricular hypertrophy, pulmonary hypertension, episode(s) of acute 
    respiratory failure, or a requirement for outpatient oxygen therapy. We 
    proposed a 60-percent evaluation for the same group of conditions if 
    there is an FEV-1 of 40- to 55-percent predicted, an FEV-1/FVC of 40- 
    to 55-percent, a DLCO of 40- to 55-percent predicted, or maximum oxygen 
    consumption of 15 to 20 ml/kg/min. We proposed a 100-percent evaluation 
    for bronchial asthma (DC 6602) if there is an FEV-1 less than 40-
    percent predicted, an FEV-1/FVC less than 40-percent, more than one 
    attack per week with episodes of respiratory failure, or daily use of 
    systemic high dose corticosteroids or immuno-suppressive medication, 
    and a 60-percent evaluation if there is an FEV-1 of 40- to 55-percent 
    predicted, an FEV-1 of 40- to 55-percent, at least monthly visits to a 
    physician for exacerbations, or intermittent courses of systemic 
    corticosteroids.
        One commenter said that the levels of reduction of pulmonary 
    function for the 60- and 100-percent evaluation levels of DC's 6520, 
    6600, 6602, 6603, 6604, and 6844 (one of the restrictive lung 
    conditions) that we proposed are extreme and do not represent average 
    impairments.
        VA disagrees. The criteria we have provided for a 100-percent 
    evaluation for these conditions are consistent with the criteria used 
    by the American Thoracic Society for its ``severely impaired (unable to 
    meet the physical demands of most jobs)'' category. This is not more 
    stringent than the requirement for ``dyspnea at rest'' or ``dyspnea on 
    slight exertion,'' which were among the criteria for a 100-percent 
    level of evaluation for many pulmonary conditions in the previous 
    schedule. We also provided alternative requirements for a 100-percent 
    evaluation, such as heart failure, that are consistent with criteria 
    for this level in other sections of the rating schedule. The criteria 
    we have provided for 60 percent are proportionately lower than those 
    for the 100-percent level.
        One commenter questioned what values will be assigned as normals in 
    PFT's.
        Normal values of PFT's, for VA purposes, are those that exceed the 
    requirements for a 10-percent evaluation, and those levels are also 
    consistent with the American Thoracic Society standards for normal 
    values except in the case of the FEV-1/FVC ratio, where we include the 
    75- to 80-percent level in the criteria that warrant a ten-percent 
    evaluation. Although the American Thoracic Society uses an evaluation 
    of 75 percent as the normal level of the FEV-1/FVC ratio, two widely 
    used medical textbooks use other normals: Cecil (374) uses ``80 
    percent,'' and Harrison (1035) uses ``approximately 75 to 80 percent.'' 
    Therefore, our designation of over 80 percent as normal is consistent 
    with current medical teaching.
        The same commenter recommended that we specify that pulmonary 
    function be tested before bronchodilatation in order to reflect 
    ordinary conditions of life.
        VA disagrees. The American Lung Association/American Thoracic 
    Society Component Committee on Disability Criteria recommends testing 
    for pulmonary function after optimum therapy. The results of such tests 
    reflect the best possible functioning of an individual and are the 
    figures used as the standard basis of comparison of pulmonary function. 
    Using this standard testing method assures consistent evaluations.
        One commenter stated that, while pulmonary function testing 
    provides a very accurate picture of functional impairment of the 
    respiratory system, compensation should be based on the limitation of 
    earning capacity.
        The determination of compensation based on limitation of earning 
    capacity is not inconsistent with the use of objective PFT's. A major 
    objective of the rating schedule revision is to provide criteria that 
    are accurate, consistent, and unambiguous. The widespread use and 
    acceptance of PFT's (American Thoracic Society, American Medical 
    Association, etc.) indicates their value in assessing the severity of 
    pulmonary diseases. Their usefulness lies in part in the fact that they 
    correlate with the functional impairment that an individual 
    experiences. The more severe the pulmonary disease, the more abnormal 
    one or more PFT's are likely to be, and the more interference there is 
    likely to be with occupational functioning. Using PFT's as a means of 
    evaluation fulfills to as great an extent as is possible, the desire 
    for evaluation criteria that allow accuracy and consistency and that 
    are not ambiguous. The commenter offered no alternative suggestions for 
    criteria to evaluate pulmonary disease.
        One commenter felt that PFT's should be the exclusive basis for 
    evaluating lung disorders because they are strictly objective.
        VA disagrees. While we have used the results of pulmonary function 
    tests as evaluation criteria when they are appropriate, they are not 
    suitable for the evaluation of all lung conditions. Asthma, for 
    example, is an episodic condition that may exhibit normal PFT's at most 
    times despite significantly disabling disease, and it therefore 
    requires other criteria for its evaluation, such as the need for a 
    certain type or frequency of treatment.
        One commenter, noting that we had proposed to assign most lung 
    disorders (restrictive lung diseases, chronic bronchitis, asthma, 
    emphysema, chronic obstructive pulmonary disease, and bronchiectasis) 
    evaluation levels of 10, 30, 60, and 100 percent, but interstitial lung 
    diseases levels of 0, 10, 40, 70, and 100 percent, said that it would 
    be more logical and consistent to assign all lung conditions the same 
    evaluation levels. Another commenter stated that lung conditions with 
    similar impairments of lung functions should receive similar ratings. 
    He suggested listing FEV-1, FVC, FEV-1/FVC, and DLCO under all lung 
    diseases requiring PFT's, as recommended by the American
    
    [[Page 46724]]
    
    Thoracic Society and found in the AMA Guides.
        Individual categories of pulmonary disorders often affect the 
    results of one PFT more than another. Our non-VA panel of specialist 
    consultants felt that FEV-1 and the ratio of FEV-1 to FVC are good 
    indicators of the level of severity of many pulmonary diseases, but 
    that the FVC and DLCO are more appropriate PFT's to evaluate 
    interstitial diseases. The American Medical Association's ``Guides to 
    the Evaluation of Permanent Impairment,'' Third Edition, Revised 
    (1990), says that ``for interstitial lung disease, the FVC has proved 
    to be a reliable and valid index of significant impairment,'' and it 
    goes on to say that the DLCO is especially useful in detecting 
    abnormalities that limit gas transference, such as emphysema or 
    interstitial fibrosis of the lung parenchyma. A standard medical 
    textbook (Cecil, 401), says that the ratio of FEV-1 to FVC may be 
    normal or increased in interstitial disease. It is therefore not useful 
    as a criterion to evaluate the severity of this type of disease. Our 
    use of the proposed criteria is thus consistent with the effects of the 
    various conditions on PFT's.
        Regarding the comment about using the same evaluation levels for 
    all lung disorders, VA agrees that there is no compelling reason to use 
    evaluation levels for interstitial lung disease that differ from those 
    used for the majority of other lung diseases. We have, therefore, for 
    the sake of greater consistency, revised the criteria for interstitial 
    lung disease by substituting 30- and 60-percent levels for the 40- and 
    70-percent levels. This required adjustments in the FVC and DLCO levels 
    used as criteria, both because of the changed evaluation levels and to 
    make them correspond with the PFT criteria for other pulmonary 
    conditions. We also removed the zero-percent evaluation for 
    consistency.
        One commenter said that while an FEV-1 above 80 percent is 
    considered normal in the proposed revision of the respiratory disease 
    section of the rating schedule, the Veterans Health Administration's 
    ``Physician's Guide for Disability Evaluation Examinations'' (a manual 
    that gives guidance to examining physicians who do compensation and 
    pension examinations) states that 83 percent is normal, and these 
    figures are inconsistent.
        The ``Physician's Guide'' is meant to insure that all necessary 
    tests are performed and that all findings are provided for diagnosis 
    and/or evaluation to meet the specific requirements of the Schedule for 
    Rating Disabilities and related programs. It is available to VA and fee 
    basis examiners conducting examinations for VA disability benefits. The 
    current version of the Guide (revised 1994), which is computerized and 
    no longer available in printed form, does not provide lists of normal 
    PFT results. The examining physician is required to obtain PFT's where 
    the criteria call for them but need not interpret the results since the 
    criteria themselves contain the actual figures that warrant various 
    evaluations. As with any examination, it is incumbent upon the rating 
    board to return to the examiner reports that lack information necessary 
    to apply the provisions of the rating schedule (see 38 CFR 4.2).
        We proposed notes under DC's 6600 (chronic bronchitis), 6603 
    (pulmonary emphysema), 6604 (chronic obstructive pulmonary disease) and 
    under the general rating formula for restrictive lung diseases 
    outlining the requirements for home oxygen. One commenter said that the 
    requirements for home oxygen are too specific and should be flexible 
    enough to allow for a physician's assessment that the patient needs 
    oxygen. Another commenter said that the term ``home oxygen'' is 
    confusing because many use oxygen away from home and the requirement 
    for oxygen may be temporary, pending stabilization or during an acute 
    illness.
        VA agrees that the decision to use home oxygen should be a medical, 
    not a rating, decision, and we have therefore deleted the note 
    explaining the technical requirements for home oxygen. We proposed that 
    ``meets requirements for home oxygen'' be one of the criteria for the 
    100-percent level of the conditions listed above, but the preferred 
    current term for such treatment is ``outpatient oxygen therapy,'' and 
    we have revised the language accordingly.
        A commenter asked how VA will deal with results of PFT's from non-
    VA facilities that are at variance with VA test results.
        This potential problem is not unique to the area of PFT's. Any 
    laboratory test may show different results when performed on the same 
    individual in the same facility at different times or when the same 
    test is performed on the same individual at more than one facility. 
    Rating boards are required to consider and reconcile all evidence of 
    record, and at times they may seek additional testing or a medical 
    opinion to help reconcile differences.
        One commenter suggested we assign a minimum evaluation of 10 
    percent for any lung disorder if the patient must take daily 
    medication.
        VA disagrees. Because of the broad range of pulmonary conditions 
    and medications used to treat them, a 10-percent evaluation would not 
    necessarily be warranted in all cases on the basis of daily medication 
    alone. For example, daily use of an expectorant or cough medicine would 
    not necessarily be indicative of a condition warranting a ten-percent 
    level of evaluation.
        We proposed to add sarcoidosis (DC 6846) to the rating schedule 
    with evaluation levels of 0, 30, and 60 percent. We received two 
    comments about this change. One stated that while the criteria of 
    pulmonary involvement with fever, weight loss, and night sweats 
    requiring high dose systemic corticosteroids for control establish a 
    60-percent level of evaluation in the case of sarcoidosis, similar 
    criteria (active infection with systemic symptoms such as fever, night 
    sweats, weight loss, or hemoptysis) establish a 100-percent evaluation 
    for bacterial infections of the lung (DC's 6822, 6823, and 6824). He 
    felt that the criteria described should be considered totally disabling 
    for both conditions.
        VA agrees that some of the criteria we had proposed for the 60-
    percent level of sarcoidosis are more consistent with total disability. 
    We have therefore revised the criteria for the 60-percent evaluation 
    level and added a 100-percent evaluation level. We have made fever, 
    night sweats, and weight loss part of the criteria for the 100-percent 
    level and pulmonary disease requiring systemic high dose (therapeutic) 
    steroids for control of the criterion for the 60-percent level. We also 
    slightly revised the 30 percent criteria by adding ``maintenance'' in 
    parentheses as a description of the steroid therapy and removed 
    ``mild'' modifying symptoms because it is a subjective term, and 
    whether maintenance or therapeutic doses of steroid are used makes a 
    clearer differentiation of the level of severity.
        The other commenter stated that it will be difficult to establish 
    service connection for sarcoidosis on a presumptive basis if there is 
    no ten-percent level, because presumptive service connection requires 
    that a condition be manifest to a degree of ten percent or more within 
    one year of discharge.
        The evaluation levels we provide for various conditions are meant 
    to reflect the ordinary levels of severity that may be seen in those 
    conditions, and we do not provide ten-percent evaluation levels in 
    order to aid presumptive service connection. The proposed evaluation 
    criteria for sarcoidosis included 30- and 60-percent evaluation levels, 
    and either of those levels would
    
    [[Page 46725]]
    
    establish presumptive service connection if present within one year of 
    discharge. Sarcoidosis may also be evaluated under other criteria, 
    however, as indicated in a note following the evaluation criteria. 
    Therefore, a 10-percent level, as well as other levels of evaluation, 
    may be assigned under DC 6600 (chronic bronchitis) based on the results 
    of pulmonary function tests, or under skin disease, eye disease, etc., 
    when there is extra-pulmonary involvement.
        One commenter suggested that we add a diagnostic code and 
    evaluation criteria for asbestosis. He suggested that we evaluate the 
    condition based on its restrictive aspects, X-ray changes, and pleural 
    changes.
        VA agrees that asbestosis is a common enough disease in the veteran 
    population to warrant its own diagnostic code. We have therefore 
    removed asbestosis from the list of pneumoconioses in DC 6832 and have 
    added asbestosis as DC 6833. It will be evaluated under the general 
    rating formula for interstitial diseases, as recommended by our panel 
    of consultants. The X-ray changes unique to asbestosis are not 
    necessarily related to the degree of disability but are helpful in 
    establishing the fact of asbestos exposure. They therefore relate more 
    to the issue of service connection rather than to evaluation, and we 
    have not made them part of the evaluation criteria. We have adjusted 
    the numbering of the proposed diagnostic codes following asbestosis to 
    accommodate the added condition. We have changed the proposed DC's for 
    histoplasmosis of lung from 6833 to 6834, coccidioidomycosis from 6834 
    to 6835, blastomycosis from 6835 to 6836, cryptococcosis from 6836 to 
    6837, aspergillosis from 6837 to 6838, mucormycosis from 6838 to 6839, 
    diaphragm paralysis or paresis from 6839 to 6840, spinal cord injury 
    with respiratory insufficiency from 6840 to 6841, kyphoscoliosis, 
    pectus excavatum, pectus carinatum from 6841 to 6842, traumatic chest 
    wall defect, pneumothorax, hernia, etc., from 6842 to 6843, post-
    surgical residual from 6843 to 6844, chronic pleural effusion or 
    fibrosis from 6844 to 6845, sarcoidosis from 6845 to 6846, and sleep 
    apnea from 6846 to 6847.
        One commenter asked why we have not proposed to rate the 
    disfigurement and disability from radical neck surgery under 
    respiratory disorders.
        Radical neck surgery is not appropriate for inclusion in the 
    respiratory system section of the rating schedule because it primarily 
    results in loss of muscle tissue (of the neck), subcutaneous tissue, 
    and lymph nodes. There is ordinarily no effect on the respiratory 
    system from such surgery. Disability from this loss of tissue can be 
    most appropriately evaluated under diagnostic codes in other sections, 
    such as DC 5322 (Muscle Group XXII, muscles of the front of the neck) 
    or DC 7800 (disfiguring scars of the head, face, or neck).
        We proposed that injuries to the pharynx (DC 6521) have a single 
    evaluation level of 50 percent based on the presence of stricture or 
    obstruction of the pharynx or nasopharynx or on paralysis or absence of 
    the soft palate. A commenter said that the resulting symptoms are 
    severe enough to be considered 60-percent disabling, equivalent to 
    complete organic aphonia (DC 6519) or stenosis of larynx (DC 6520), 
    which have both 60- and 100-percent evaluation levels.
        VA disagrees. The impairments from these three conditions differ 
    because they are in different locations. The major effect of pharyngeal 
    and palatal injuries is swallowing difficulty rather than respiratory 
    difficulty, and any resulting speech impairment is not likely to 
    approach the level of aphonia. (A 50-percent evaluation for these 
    injuries is comparable to the 50-percent evaluation criteria in the 
    digestive system for severe esophageal stricture, permitting passage of 
    liquids only.) Laryngeal stenosis, on the other hand, causes both 
    respiratory and speech impairment. However, if there is a case where 
    the impairment from pharyngeal injury more closely resembles aphonia or 
    the effects of laryngeal stenosis, an evaluation analogous to one of 
    those conditions may be used instead (Sec. 4.20). In our judgment, the 
    criteria and level of evaluation we have provided are appropriate for 
    most pharyngeal injuries, and there are adequate provisions for 
    evaluating those few that may be more severe.
        Note (1) under the proposed general rating formula for inactive 
    pulmonary tuberculosis stated that when a veteran is placed on the 100-
    percent rating for inactive tuberculosis, the medical authorities will 
    be appropriately notified of the fact, and of the necessity under 38 
    U.S.C. 356 to notify the Adjudication Division in the event of failure 
    to submit to examination or to follow prescribed treatment. A commenter 
    said that the citation of 38 U.S.C. 356, repealed by Public Law 90-493, 
    should be followed by a notation that it is to be found as footnote 1 
    to section 1156 of title 38, United States Code.
        We agree and have revised the note accordingly.
        One commenter felt that there is inequity in the evaluation 
    criteria for laryngectomy and partial aphonia because if partial 
    aphonia allows a person to whisper, the rating is 60 percent while if 
    laryngectomy allows a person to whisper, the rating is 100 percent.
        VA disagrees. Disability resulting from a laryngectomy is not 
    comparable to partial aphonia with an intact larynx. In the case of 
    laryngectomy, a significant organ has been removed which has functions 
    beyond that of speech. The larynx acts as the sphincter guarding the 
    gateway to the trachea, and a laryngectomy produces a serious 
    compromise of the respiratory tract, requiring a permanent 
    tracheostomy. Partial aphonia may result from any of several causes, 
    including inflammatory and benign neoplastic conditions, but since they 
    affect speech without affecting respiration, we have retained the 
    evaluation criteria as proposed.
        Another comment regarding total laryngectomy (DC 6518) and complete 
    organic aphonia (DC 6519) was that there should be a footnote at these 
    codes as a reminder to consider special monthly compensation (SMC), 
    which may be awarded for complete organic aphonia under the provisions 
    of 38 CFR 3.350.
        In our judgment, the rating agency should refer directly to the 
    complex and extensive regulations regarding special monthly 
    compensation in Sec. 3.350 whenever the question of special monthly 
    compensation arises. However, in response to the comment, we have taken 
    two steps to remind the rating board to consider the possibility of 
    SMC. We added paragraph (c), ``Special monthly compensation,'' to 
    Sec. 4.96 requiring the rating board to refer to Sec. 3.350 any time it 
    evaluates a claim involving complete organic aphonia; and we placed 
    footnotes at DC's 6518 and 6519, conditions which may be associated 
    with complete organic aphonia, instructing rating boards to review for 
    entitlement to SMC. While those conditions clearly call for review for 
    entitlement to SMC, there are other conditions in this portion of the 
    rating schedule where there might also be entitlement to SMC. The lack 
    of a footnote does not relieve the rating board of the responsibility 
    of recognizing additional circumstances where SMC might be warranted. 
    We believe that the combination of the regulatory requirement contained 
    in the note and the footnotes is the best method of making sure that 
    potential entitlement to SMC is considered.
        In view of the addition of paragraph (c) to Sec. 4.96, we have 
    changed the title
    
    [[Page 46726]]
    
    of this section to ``Special provisions regarding evaluation of 
    respiratory conditions,'' which is more descriptive of its current 
    contents.
        The previous rating schedule had separate diagnostic codes and 
    evaluations for pneumonectomy (60 percent under DC 6815) and lobectomy 
    (50 percent if bilateral, and 30 percent if unilateral, under DC 6816). 
    We proposed that all pulmonary post-surgical residuals, including 
    lobectomy and pneumonectomy, be evaluated under DC 6843, post-surgical 
    residual, as restrictive lung disease, based on the objective findings 
    of PFT's. One commenter said this change is an arbitrary decrease 
    because no advancement in medical science can change the degree of 
    disability resulting from such surgery.
        VA does not concur. Since there is an objective method to measure 
    residual breathing impairment, it is more equitable to use that method 
    so that evaluation of the residuals of any type of lung resection is 
    made on the actual residuals found. The previous schedule did not 
    provide evaluations for residuals more severe than the levels specified 
    under those codes. It required, for example, that lobectomy be 
    bilateral to qualify for a 50-percent level of impairment. Under the 
    revised criteria, a veteran will be assigned an evaluation according to 
    the level of disability reflected by the PFT's, whatever the extent of 
    the surgery. This will assure that veterans with comparable residual 
    pulmonary disabilities are consistently evaluated.
        We proposed that chronic lung abscess (DC 6824) be evaluated under 
    a general rating formula for bacterial infections of the lung and 
    directed that post-surgical residuals and post-treatment fibrosis and 
    scars be rated as chronic bronchitis (DC 6600). One commenter pointed 
    out that there may be other types of residuals besides fibrosis and 
    scars, such as thoracoplasty, lobectomy, or purulent pleurisy, and 
    suggested that the residuals be rated as appropriate.
        We agree, and have revised the statement under DC 6824 to read: 
    ``Depending on the specific findings, rate residuals as interstitial 
    lung disease, restrictive lung disease, or, when obstructive lung 
    disease is the major residual, as chronic bronchitis (DC 6600).''
        The previous schedule called for a 100-percent rating for one year 
    following the date of inactivity of active pulmonary tuberculosis (DC 
    6731). We proposed that once pulmonary tuberculosis becomes inactive, 
    it be evaluated on the residual scar or fibrosis as chronic bronchitis 
    (DC 6600). Three commenters objected to the change. One said that 
    eliminating a period of convalescence when there is a new worldwide 
    outbreak of tuberculosis is questionable, one said that the change is 
    not justifiable, and one said that we should provide a period of 
    readjustment because individuals have difficulty finding employment 
    after release from treatment for tuberculosis.
        On further consideration, VA agrees that some provision for 
    readjustment is appropriate, and we have revised DC 6731 to require 
    that a mandatory examination be requested immediately after 
    notification that active tuberculosis has become inactive. Any change 
    in evaluation will be carried out under the provisions of 
    Sec. 3.105(e). This will assure that a total evaluation will continue 
    for at least several months, which will provide a period of 
    readjustment, and will also assure that the extent of any residual 
    impairment has been documented by examination.
        The third commenter stated that the proposal to rate residual scar 
    or fibrosis of inactive tuberculosis (DC 6731) as chronic bronchitis 
    (DC 6600) is too restrictive because there may be other residuals.
        We agree, and have revised the statement under DC 6731 to read: 
    ``Depending on the specific findings, rate residuals as interstitial 
    lung disease, restrictive lung disease, or, when obstructive lung 
    disease is the major residual, as chronic bronchitis (DC 6600). Rate 
    thoracoplasty as removal of ribs under DC 5297.''
        We proposed separate diagnostic codes for chronic bronchitis (DC 
    6600), pulmonary emphysema (DC 6603), and chronic obstructive pulmonary 
    disease (DC 6604), with evaluation under identical criteria. One 
    commenter suggested a single diagnostic code, ``chronic obstructive 
    pulmonary disease (bronchitis or emphysema),'' for all of these 
    conditions, since the proposed criteria are essentially identical.
        VA disagrees. While pulmonary emphysema, chronic obstructive 
    pulmonary disease (COPD), and chronic bronchitis often coexist and are 
    sometimes hard to differentiate, they are not synonymous. COPD 
    ordinarily refers to a combination of chronic obstructive bronchitis 
    and emphysema (Cecil, 389), but the term is not always used precisely. 
    Emphysema may be localized or generalized, and is not always 
    categorized as COPD. Since an individual may receive a diagnosis of any 
    of the three conditions, it is useful to have a separate diagnostic 
    code for each entity for statistical purposes and to aid the rating 
    board in selecting appropriate evaluation criteria.
        We proposed to add spinal cord injury with respiratory 
    insufficiency (DC 6840) as one of six restrictive lung diseases to be 
    evaluated under a general rating formula. One commenter, without 
    explaining how the conditions differ or offering an alternative for us 
    to consider, suggested that spinal cord injury with respiratory 
    insufficiency not be evaluated as a restrictive lung disease because 
    ventilator dependency secondary to spinal cord injury is distinct from 
    other lung diseases.
        VA disagrees. The panel of non-VA specialists convened by a 
    contract consultant included spinal cord injury with respiratory 
    insufficiency among the restrictive pulmonary diseases. Cecil (377), in 
    discussing restrictive pulmonary disease, includes those conditions 
    that affect the chest wall or respiratory muscles. We have provided 
    alternative criteria for restrictive lung disease at each evaluation 
    level, and if any one of the criteria for a particular level is 
    present, that level of evaluation can be assigned. A wide range of 
    respiratory conditions with a predominantly restrictive effect can 
    therefore be evaluated under our criteria, even though one condition 
    might be reflected in an abnormality of one PFT more than another. As a 
    result, our criteria are broad enough to encompass any likely 
    functional impairment spinal cord injury with respiratory insufficiency 
    may produce.
        The previous rating schedule provided a one hundred-percent 
    evaluation for six months following spontaneous pneumothorax (now DC 
    6843). We proposed to provide a convalescent period of three months 
    following total pneumothorax. We received two comments objecting to 
    this proposal. One commenter said that our statement in the preamble to 
    the proposed revision that pneumothorax resolves sooner than six months 
    is not supported by medical evidence, and the other said that 
    decreasing the convalescent period may impede full recovery.
        VA disagrees. ``The Merck Manual,'' (731, 16th ed. 1992), states 
    that a small pneumothorax requires no special treatment and that the 
    air is reabsorbed in a few days. It also says that full absorption of a 
    larger airspace may take two to four weeks, a period which can be 
    shortened by the use of a tube for drainage. Cecil (450), states that a 
    small pneumothorax is reabsorbed in 7 to 14 days and that larger ones 
    may be treated with a tube for 2 to 4 days if very large, under 
    tension, or very symptomatic. A persistent or complicated pneumothorax
    
    [[Page 46727]]
    
    may require surgery, and in that case, the provisions of 
    Sec. 4.30(b)(2) allow the rating board to assign convalescence for up 
    to a total of six months. Therefore, it is our judgment that three 
    months of convalescence is adequate in the average case.
        We received one comment on avoiding pyramiding, the prohibited 
    practice of evaluating the same disability under various diagnoses (see 
    38 CFR 4.14). The commenter suggested that we direct that DC 6520, 
    stenosis of larynx, not be combined with other codes in this section 
    because the criterion for airflow obstruction due to stenosis of the 
    larynx is similar to those for disease of bronchi or lungs.
        Stenosis of the larynx may be evaluated on the basis of the results 
    of pulmonary function tests, if there is respiratory impairment, or as 
    aphonia, when interference with speech is the main impairment. Only in 
    cases of laryngeal stenosis where respiratory impairment is the basis 
    of evaluation would it be pyramiding to combine such an evaluation with 
    the evaluation of another pulmonary condition. Therefore, a strict 
    prohibition against combining evaluations for stenosis of the larynx 
    with evaluations for pulmonary conditions is not warranted. The 
    statement in Sec. 4.96, paragraph (a), stipulating that when there is 
    lung or pleural involvement, DC's 6819 and 6920 will not be combined 
    with each other or with DC's 6600 through 6817 or 6822 through 6847 is 
    sufficient to alert the rating board to possible problems of pyramiding 
    when evaluating pulmonary conditions.
        The same commenter additionally said that, to prevent pyramiding, 
    VA should state that evaluations under DC's 6520 (stenosis of larynx), 
    6511, 6512, 6513, and 6514 (sinusitis in various locations) should not 
    be combined with one another and likewise that evaluations under DC's 
    6522, 6523, and 6524 (rhinitis of various types) should not be combined 
    with one another.
        In VA's judgment, there is no need to specifically prohibit 
    pyramiding of the various codes for sinusitis or rhinitis as the 
    commenter suggests. The rating board is required in general by 
    Sec. 4.14 not to pyramid disabilities. The board must use its judgment 
    as to whether a single evaluation encompasses all disability present or 
    not. A specific prohibition might be useful if all conditions involved 
    always had the same manifestations, but this is not true of either 
    sinusitis or rhinitis.
        The commenter went on to say that, alternatively, Sec. 4.96 could 
    be amended to state that it does not remove the prohibition against 
    pyramiding that may apply to other diagnostic codes.
        VA disagrees. Such an amendment is not necessary because Sec. 4.14, 
    which prohibits the practice of ``pyramiding,'' applies to the entire 
    rating schedule, and all rating boards are required to follow it.
        For further clarity, we have revised the criteria for pulmonary 
    vascular disease, DC 6817. We proposed that the criterion for 30 
    percent be ``acute pulmonary embolism with residual symptoms,'' and we 
    changed that language to ``symptomatic following resolution of acute 
    pulmonary embolism.'' We proposed that the criterion at the zero-
    percent level be ``resolved pulmonary thromboembolism with no residual 
    symptoms,'' and we changed that language to ``asymptomatic, following 
    resolution of pulmonary thromboembolism.'' These do not represent 
    substantive changes. Because pulmonary vascular disease may result in 
    residuals other than those included in the proposed criteria, such as 
    chronic pleural thickening, for the sake of completeness, we added a 
    note under DC 6817 directing to evaluate other residuals under the most 
    appropriate diagnostic code.
        In the proposed regulation for chronic bronchitis (DC 6600), 
    pulmonary emphysema (DC 6603), chronic obstructive pulmonary disease 
    (DC 6604), and restrictive lung diseases, we inadvertently omitted an 
    upper level of DLCO that would warrant a ten percent evaluation. We 
    have corrected this oversight in the final regulation by making the 
    DLCO requirement for the 10-percent evaluation ``66- to 80-percent 
    predicted.''
        An additional change we made for the sake of completeness was the 
    addition of a note following DC 6504, nose, loss of part of, or scars, 
    stating that this disability may alternatively be evaluated as DC 7800, 
    disfiguring scars of the head, face, or neck.
        We made minor editorial changes in language in several cases, such 
    as changing ``rate'' to ``evaluate'' and ``applicable'' to 
    ``appropriate'', but these are not substantive changes.
        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
    
        Disability benefits, Individuals with disabilities, Pensions, 
    Veterans.
    
        Approved: May 13, 1996.
    Jesse Brown,
    Secretary of Veterans Affairs.
        For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
    is amended as set forth below:
    
    PART 4--SCHEDULE FOR RATING DISABILITIES
    
        1. The authority citation for part 4 continues to read as follows:
    
        Authority: 38 U.S.C. 1155.
    
    Subpart B--Disability Ratings
    
        2. In Sec. 4.96, the section heading and paragraph (a) are revised, 
    and paragraph (c) is added to read as follows:
    
    
    Sec. 4.96  Special provisions regarding evaluation of respiratory 
    conditions.
    
        (a) Rating coexisting respiratory conditions. Ratings under 
    diagnostic codes 6600 through 6817 and 6822 through 6847 will not be 
    combined with each other. Where there is lung or pleural involvement, 
    ratings under diagnostic codes 6819 and 6820 will not be combined with 
    each other or with diagnostic codes 6600 through 6817 or 6822 through 
    6847. A single rating will be assigned under the diagnostic code which 
    reflects the predominant disability with elevation to the next higher 
    evaluation where the severity of the overall disability warrants such 
    elevation. However, in cases protected by the provisions of Pub. L. 90-
    493, the graduated ratings of 50 and 30 percent for inactive 
    tuberculosis will not be elevated.
    * * * * *
        (c) Special monthly compensation. When evaluating any claim 
    involving complete organic aphonia, 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
    
    [[Page 46728]]
    
    conditions which potentially establish entitlement to special monthly 
    compensation; however, there are other conditions in this section which 
    under certain circumstances also establish entitlement to special 
    monthly compensation.
    
    (Authority: 38 U.S.C. 1155)
    
        3. Section 4.97 is revised to read as follows:
    
    
    Sec. 4.97  Schedule of ratingsrespiratory system.
    
    ------------------------------------------------------------------------
                                                                      Rating
    ------------------------------------------------------------------------
                         DISEASES OF THE NOSE AND THROAT                    
    ------------------------------------------------------------------------
    6502  Septum, nasal, deviation of:                                      
        Traumatic only,                                                     
            With 50-percent obstruction of the nasal passage on             
             both sides or complete obstruction on one side........       10
    6504  Nose, loss of part of, or scars:                                  
        Exposing both nasal passages...............................       30
        Loss of part of one ala, or other obvious disfigurement....       10
                                                                            
    Note: Or evaluate as DC 7800, scars, disfiguring, head, face,           
     or neck.                                                               
                                                                            
    6510  Sinusitis, pansinusitis, chronic.                                 
    6511  Sinusitis, ethmoid, chronic.                                      
    6512  Sinusitis, frontal, chronic.                                      
    6513  Sinusitis, maxillary, chronic.                                    
    6514  Sinusitis, sphenoid, chronic.                                     
        General Rating Formula for Sinusitis (DC's 6510 through             
         6514):                                                             
            Following radical surgery with chronic osteomyelitis,           
             or; near constant sinusitis characterized by                   
             headaches, pain and tenderness of affected sinus, and          
             purulent discharge or crusting after repeated                  
             surgeries.............................................       50
            Three or more incapacitating episodes per year of               
             sinusitis requiring prolonged (lasting four to six             
             weeks) antibiotic treatment, or; more than six non-            
             incapacitating episodes per year of sinusitis                  
             characterized by headaches, pain, and purulent                 
             discharge or crusting.................................       30
            One or two incapacitating episodes per year of                  
             sinusitis requiring prolonged (lasting four to six             
             weeks) antibiotic treatment, or; three to six non-             
             incapacitating episodes per year of sinusitis                  
             characterized by headaches, pain, and purulent                 
             discharge or crusting.................................       10
            Detected by X-ray only.................................        0
                                                                            
        Note: An incapacitating episode of sinusitis means one that         
         requires bed rest and treatment by a physician.                    
                                                                            
    6515  Laryngitis, tuberculous, active or inactive.                      
        Rate under Secs.  4.88c or 4.89, whichever is appropriate.          
    6516  Laryngitis, chronic:                                              
        Hoarseness, with thickening or nodules of cords, polyps,            
         submucous infiltration, or pre-malignant changes on biopsy       30
        Hoarseness, with inflammation of cords or mucous membrane..       10
    6518  Laryngectomy, total......................................  \1\ 100
        Rate the residuals of partial laryngectomy as laryngitis            
         (DC 6516), aphonia (DC 6519), or stenosis of larynx (DC            
         6520).                                                             
    6519  Aphonia, complete organic:                                        
        Constant inability to communicate by speech................  \1\ 100
        Constant inability to speak above a whisper................       60
                                                                            
        Note: Evaluate incomplete aphonia as laryngitis, chronic            
         (DC 6516).                                                         
                                                                            
    6520  Larynx, stenosis of, including residuals of laryngeal             
     trauma (unilateral or bilateral):                                      
        Forced expiratory volume in one second (FEV-1) less than 40         
         percent of predicted value, with Flow-Volume Loop                  
         compatible with upper airway obstruction, or; permanent            
         tracheostomy..............................................      100
        FEV-1 of 40- to 55-percent predicted, with Flow-Volume Loop         
         compatible with upper airway obstruction..................       60
        FEV-1 of 56- to 70-percent predicted, with Flow-Volume Loop         
         compatible with upper airway obstruction..................       30
        FEV-1 of 71- to 80-percent predicted, with Flow-Volume Loop         
         compatible with upper airway obstruction..................       10
                                                                            
        Note: Or evaluate as aphonia (DC 6519).                             
                                                                            
    6521  Pharynx, injuries to:                                             
        Stricture or obstruction of pharynx or nasopharynx, or;             
         absence of soft palate secondary to trauma, chemical burn,         
         or granulomatous disease, or; paralysis of soft palate             
         with swallowing difficulty (nasal regurgitation) and               
         speech impairment.........................................       50
    6522  Allergic or vasomotor rhinitis:                                   
        With polyps................................................       30
        Without polyps, but with greater than 50-percent                    
         obstruction of nasal passage on both sides or complete             
         obstruction on one side...................................       10
    6523  Bacterial rhinitis:                                               
        Rhinoscleroma..............................................       50
        With permanent hypertrophy of turbinates and with greater           
         than 50-percent obstruction of nasal passage on both sides         
         or complete obstruction on one side.......................       10
    6524  Granulomatous rhinitis:                                           
        Wegener's granulomatosis, lethal midline granuloma.........      100
        Other types of granulomatous infection.....................       20
    ------------------------------------------------------------------------
                       DISEASES OF THE TRACHEA AND BRONCHI                  
    ------------------------------------------------------------------------
    6600  Bronchitis, chronic:                                              
        FEV-1 less than 40 percent of predicted value, or; the              
         ratio of Forced Expiratory Volume in one second to Forced          
         Vital Capacity (FEV-1/FVC) less than 40 percent, or;               
         Diffusion Capacity of the Lung for Carbon Monoxide by the          
         Single Breath Method (DLCO (SB)) less than 40-percent              
         predicted, or; maximum exercise capacity less than 15 ml/          
         kg/min oxygen consumption (with cardiac or respiratory             
         limitation), or; cor pulmonale (right heart failure), or;          
         right ventricular hypertrophy, or; pulmonary hypertension          
         (shown by Echo or cardiac catheterization), or; episode(s)         
         of acute respiratory failure, or; requires outpatient              
         oxygen therapy............................................      100
    
    [[Page 46729]]
    
                                                                            
        FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40           
         to 55 percent, or; DLCO (SB) of 40- to 55-percent                  
         predicted, or; maximum oxygen consumption of 15 to 20 ml/          
         kg/min (with cardiorespiratory limit).....................       60
        FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56           
         to 70 percent, or; DLCO (SB) 56- to 65-percent predicted..       30
        FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71           
         to 80 percent, or; DLCO (SB) 66- to 80-percent predicted..       10
    6601  Bronchiectasis:                                                   
        With incapacitating episodes of infection of at least six           
         weeks total duration per year.............................      100
        With incapacitating episodes of infection of four to six            
         weeks total duration per year, or; near constant findings          
         of cough with purulent sputum associated with anorexia,            
         weight loss, and frank hemoptysis and requiring antibiotic         
         usage almost continuously.................................       60
        With incapacitating episodes of infection of two to four            
         weeks total duration per year, or; daily productive cough          
         with sputum that is at times purulent or blood-tinged and          
         that requires prolonged (lasting four to six weeks)                
         antibiotic usage more than twice a year...................       30
        Intermittent productive cough with acute infection                  
         requiring a course of antibiotics at least twice a year...       10
        Or rate according to pulmonary impairment as for chronic            
         bronchitis (DC 6600).                                              
                                                                            
        Note: An incapacitating episode is one that requires                
         bedrest and treatment by a physician.                              
                                                                            
    6602  Asthma, bronchial:                                                
        FEV-1 less than 40-percent predicted, or; FEV-1/FVC less            
         than 40 percent, or; more than one attack per week with            
         episodes of respiratory failure, or; requires daily use of         
         systemic (oral or parenteral) high dose corticosteroids or         
         immuno-suppressive medications............................      100
        FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40           
         to 55 percent, or; at least monthly visits to a physician          
         for required care of exacerbations, or; intermittent (at           
         least three per year) courses of systemic (oral or                 
         parenteral) corticosteroids...............................       60
        FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56           
         to 70 percent, or; daily inhalational or oral                      
         bronchodilator therapy, or; inhalational anti-inflammatory         
         medication................................................       30
        FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71           
         to 80 percent, or; intermittent inhalational or oral               
         bronchodilator therapy....................................       10
                                                                            
        Note: In the absence of clinical findings of asthma at time         
         of examination, a verified history of asthmatic attacks            
         must be of record.                                                 
                                                                            
    6603  Emphysema, pulmonary:                                             
        FEV-1 less than 40 percent of predicted value, or; the              
         ratio of Forced Expiratory Volume in one second to Forced          
         Vital Capacity (FEV-1/FVC) less than 40 percent, or;               
         Diffusion Capacity of the Lung for Carbon Monoxide by the          
         Single Breath Method (DLCO (SB)) less than 40-percent              
         predicted, or; maximum exercise capacity less than 15 ml/          
         kg/min oxygen consumption (with cardiac or respiratory             
         limitation), or; cor pulmonale (right heart failure), or;          
         right ventricular hypertrophy, or; pulmonary hypertension          
         (shown by Echo or cardiac catheterization), or; episode(s)         
         of acute respiratory failure, or; requires outpatient              
         oxygen therapy............................................      100
        FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40           
         to 55 percent, or; DLCO (SB) of 40- to 55-percent                  
         predicted, or; maximum oxygen consumption of 15 to 20 ml/          
         kg/min (with cardiorespiratory limit).....................       60
        FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56           
         to 70 percent, or; DLCO (SB) 56- to 65-percent predicted..       30
        FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71           
         to 80 percent, or; DLCO (SB) 66- to 80-percent predicted..       10
    6604  Chronic obstructive pulmonary disease:                            
        FEV-1 less than 40 percent of predicted value, or; the              
         ratio of Forced Expiratory Volume in one second to Forced          
         Vital Capacity (FEV-1/FVC) less than 40 percent, or;               
         Diffusion Capacity of the Lung for Carbon Monoxide by the          
         Single Breath Method (DLCO (SB)) less than 40-percent              
         predicted, or; maximum exercise capacity less than 15 ml/          
         kg/min oxygen consumption (with cardiac or respiratory             
         limitation), or; cor pulmonale (right heart failure), or;          
         right ventricular hypertrophy, or; pulmonary hypertension          
         (shown by Echo or cardiac catheterization), or; episode(s)         
         of acute respiratory failure, or; requires outpatient              
         oxygen therapy............................................      100
        FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40           
         to 55 percent, or; DLCO (SB) of 40- to 55-percent                  
         predicted, or; maximum oxygen consumption of 15 to 20 ml/          
         kg/min (with cardiorespiratory limit).....................       60
        FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56           
         to 70 percent, or; DLCO (SB) 56- to 65-percent predicted..       30
        FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71           
         to 80 percent, or; DLCO (SB) 66- to 80-percent predicted..       10
    ------------------------------------------------------------------------
                 DISEASES OF THE LUNGS AND PLEURA--TUBERCULOSIS             
         Ratings for Pulmonary Tuberculosis Entitled on August 19, 1968     
    ------------------------------------------------------------------------
    6701  Tuberculosis, pulmonary, chronic, far advanced, active...      100
    6702  Tuberculosis, pulmonary, chronic, moderately advanced,            
     active........................................................      100
    6703  Tuberculosis, pulmonary, chronic, minimal, active........      100
    6704  Tuberculosis, pulmonary, chronic, active, advancement             
     unspecified...................................................      100
    6721  Tuberculosis, pulmonary, chronic, far advanced, inactive.         
    6722  Tuberculosis, pulmonary, chronic, moderately advanced,            
     inactive......................................................         
    6723  Tuberculosis, pulmonary, chronic, minimal, inactive......         
    6724  Tuberculosis, pulmonary, chronic, inactive, advancement           
     unspecified...................................................         
        General Rating Formula for Inactive Pulmonary Tuberculosis:         
         For two years after date of inactivity, following active           
         tuberculosis, which was clinically identified during               
         service or subsequently...................................      100
        Thereafter for four years, or in any event, to six years            
         after date of inactivity..................................       50
        Thereafter, for five years, or to eleven years after date           
         of inactivity.............................................       30
        Following far advanced lesions diagnosed at any time while          
         the disease process was active, minimum...................       30
        Following moderately advanced lesions, provided there is            
         continued disability, emphysema, dyspnea on exertion,              
         impairment of health, etc.................................       20
        Otherwise..................................................        0
                                                                            
    Note (1): The 100-percent rating under codes 6701 through 6724          
     is not subject to a requirement of precedent hospital                  
     treatment. It will be reduced to 50 percent for failure to             
     submit to examination or to follow prescribed treatment upon           
     report to that effect from the medical authorities. When a             
     veteran is placed on the 100-percent rating for inactive               
     tuberculosis, the medical authorities will be appropriately            
     notified of the fact, and of the necessity, as given in                
     footnote 1 to 38 U.S.C. 1156 (and formerly in 38 U.S.C. 356,           
     which has been repealed by Public Law 90-493), to notify the           
     Adjudication Division in the event of failure to submit to             
     examination or to follow treatment.                                    
    
    [[Page 46730]]
    
                                                                            
    Note (2): The graduated 50-percent and 30-percent ratings and           
     the permanent 30 percent and 20 percent ratings for inactive           
     pulmonary tuberculosis are not to be combined with ratings for         
     other respiratory disabilities. Following thoracoplasty the            
     rating will be for removal of ribs combined with the rating            
     for collapsed lung. Resection of the ribs incident to                  
     thoracoplasty will be rated as removal.                                
    ------------------------------------------------------------------------
     Ratings for Pulmonary Tuberculosis Initially Evaluated After August 19,
                                      1968                                  
    ------------------------------------------------------------------------
    6730   Tuberculosis, pulmonary, chronic, active................      100
                                                                            
        Note: Active pulmonary tuberculosis will be considered              
         permanently and totally disabling for non-service-                 
         connected pension purposes in the following circumstances:         
            (a) Associated with active tuberculosis involving other         
             than the respiratory system.                                   
            (b) With severe associated symptoms or with extensive           
             cavity formation.                                              
            (c) Reactivated cases, generally.                               
            (d) With advancement of lesions on successive                   
             examinations or while under treatment.                         
            (e) Without retrogression of lesions or other evidence          
             of material improvement at the end of six months               
             hospitalization or without change of diagnosis from            
             ``active'' at the end of 12 months hospitalization.            
             Material improvement means lessening or absence of             
             clinical symptoms, and X-ray findings of a stationary          
             or retrogressive lesion.                                       
                                                                            
    6731  Tuberculosis, pulmonary, chronic, inactive:                       
        Depending on the specific findings, rate residuals as               
         interstitial lung disease, restrictive lung disease, or,           
         when obstructive lung disease is the major residual, as            
         chronic bronchitis (DC 6600). Rate thoracoplasty as                
         removal of ribs under DC 5297.                                     
                                                                            
        Note: A mandatory examination will be requested immediately         
         following notification that active tuberculosis evaluated          
         under DC 6730 has become inactive. Any change in                   
         evaluation will be carried out under the provisions of             
         Sec.  3.105(e).                                                    
                                                                            
    6732  Pleurisy, tuberculous, active or inactive:                        
        Rate under Secs.  4.88c or 4.89, whichever is appropriate.          
    ------------------------------------------------------------------------
                             NONTUBERCULOUS DISEASES                        
    ------------------------------------------------------------------------
    6817  Pulmonary Vascular Disease:                                       
        Primary pulmonary hypertension, or; chronic pulmonary               
         thromboembolism with evidence of pulmonary hypertension,           
         right ventricular hypertrophy, or cor pulmonale, or;               
         pulmonary hypertension secondary to other obstructive              
         disease of pulmonary arteries or veins with evidence of            
         right ventricular hypertrophy or cor pulmonale............      100
        Chronic pulmonary thromboembolism requiring anticoagulant           
         therapy, or; following inferior vena cava surgery without          
         evidence of pulmonary hypertension or right ventricular            
         dysfunction...............................................       60
        Symptomatic, following resolution of acute pulmonary                
         embolism..................................................       30
        Asymptomatic, following resolution of pulmonary                     
         thromboembolism...........................................        0
                                                                            
        Note: Evaluate other residuals following pulmonary embolism         
         under the most appropriate diagnostic code, such as                
         chronic bronchitis (DC 6600) or chronic pleural effusion           
         or fibrosis (DC 6844), but do not combine that evaluation          
         with any of the above evaluations.                                 
                                                                            
        6819  Neoplasms, malignant, any specified part of                   
         respiratory system exclusive of skin growths..............      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.         
                                                                            
    6820  Neoplasms, benign, any specified part of respiratory              
     system. Evaluate using an appropriate respiratory analogy.             
    ------------------------------------------------------------------------
                         Bacterial Infections of the Lung                   
    ------------------------------------------------------------------------
    6822  Actinomycosis.                                                    
    6823  Nocardiosis.                                                      
    6824  Chronic lung abscess.                                             
        General Rating Formula for Bacterial Infections of the Lung         
         (diagnostic codes 6822 through 6824):                              
            Active infection with systemic symptoms such as fever,          
             night sweats, weight loss, or hemoptysis..............      100
        Depending on the specific findings, rate residuals as               
         interstitial lung disease, restrictive lung disease, or,           
         when obstructive lung disease is the major residual, as            
         chronic bronchitis (DC 6600).                                      
    ------------------------------------------------------------------------
                            Interstitial Lung Disease                       
    ------------------------------------------------------------------------
    6825  Diffuse interstitial fibrosis (interstitial pneumonitis,          
     fibrosing alveolitis).                                                 
    6826  Desquamative interstitial pneumonitis.                            
    6827  Pulmonary alveolar proteinosis.                                   
    6828  Eosinophilic granuloma of lung.                                   
    6829  Drug-induced pulmonary pneumonitis and fibrosis.                  
    6830  Radiation-induced pulmonary pneumonitis and fibrosis.             
    6831  Hypersensitivity pneumonitis (extrinsic allergic                  
     alveolitis).                                                           
    6832  Pneumoconiosis (silicosis, anthracosis, etc.).                    
    6833  Asbestosis.                                                       
        General Rating Formula for Interstitial Lung Disease                
         (diagnostic codes 6825 through 6833):                              
            Forced Vital Capacity (FVC) less than 50-percent                
             predicted, or; Diffusion Capacity of the Lung for              
             Carbon Monoxide by the Single Breath Method (DLCO              
             (SB)) less than 40-percent predicted, or; maximum              
             exercise capacity less than 15 ml/kg/min oxygen                
             consumption with cardiorespiratory limitation, or; cor         
             pulmonale or pulmonary hypertension, or; requires              
             outpatient oxygen therapy.............................      100
            FVC of 50- to 64-percent predicted, or; DLCO (SB) of 40-        
              to 55-percent predicted, or; maximum exercise                 
             capacity of 15 to 20 ml/kg/min oxygen consumption with         
             cardiorespiratory limitation..........................       60
            FVC of 65- to 74-percent predicted, or; DLCO (SB) of 56-        
              to 65-percent predicted..............................       30
    
    [[Page 46731]]
    
                                                                            
            FVC of 75- to 80-percent predicted, or; DLCO (SB) of 66-        
              to 80-percent predicted..............................       10
    ------------------------------------------------------------------------
                              Mycotic Lung Disease                          
    ------------------------------------------------------------------------
    6834  Histoplasmosis of lung.                                           
    6835  Coccidioidomycosis.                                               
    6836  Blastomycosis.                                                    
    6837  Cryptococcosis.                                                   
    6838  Aspergillosis.                                                    
    6839  Mucormycosis.                                                     
        General Rating Formula for Mycotic Lung Disease (diagnostic         
         codes 6834 through 6839):                                          
            Chronic pulmonary mycosis with persistent fever, weight         
             loss, night sweats, or massive hemoptysis.............      100
            Chronic pulmonary mycosis requiring suppressive therapy         
             with no more than minimal symptoms such as occasional          
             minor hemoptysis or productive cough..................       50
            Chronic pulmonary mycosis with minimal symptoms such as         
             occasional minor hemoptysis or productive cough.......       30
            Healed and inactive mycotic lesions, asymptomatic......        0
                                                                            
        Note: Coccidioidomycosis has an incubation period up to 21          
         days, and the disseminated phase is ordinarily manifest            
         within six months of the primary phase. However, there are         
         instances of dissemination delayed up to many years after          
         the initial infection which may have been unrecognized.            
         Accordingly, when service connection is under                      
         consideration in the absence of record or other evidence           
         of the disease in service, service in southwestern United          
         States where the disease is endemic and absence of                 
         prolonged residence in this locality before or after               
         service will be the deciding factor.                               
    ------------------------------------------------------------------------
                            Restrictive Lung Disease                        
    ------------------------------------------------------------------------
    6840  Diaphragm paralysis or paresis.                                   
    6841  Spinal cord injury with respiratory insufficiency.                
    6842  Kyphoscoliosis, pectus excavatum, pectus carinatum.               
    6843  Traumatic chest wall defect, pneumothorax, hernia, etc.           
    6844  Post-surgical residual (lobectomy, pneumonectomy, etc.).          
    6845  Chronic pleural effusion or fibrosis.                             
        General Rating Formula for Restrictive Lung Disease                 
         (diagnostic codes 6840 through 6845):                              
            FEV-1 less than 40 percent of predicted value, or; the          
             ratio of Forced Expiratory Volume in one second to             
             Forced Vital Capacity (FEV-1/FVC) less than 40                 
             percent, or; Diffusion Capacity of the Lung for Carbon         
             Monoxide by the Single Breath Method (DLCO (SB)) less          
             than 40-percent predicted, or; maximum exercise                
             capacity less than 15 ml/kg/min oxygen consumption             
             (with cardiac or respiratory limitation), or; cor              
             pulmonale (right heart failure), or; right ventricular         
             hypertrophy, or; pulmonary hypertension (shown by Echo         
             or cardiac catheterization), or; episode(s) of acute           
             respiratory failure, or; requires outpatient oxygen            
             therapy...............................................      100
            FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of          
             40 to 55 percent, or; DLCO (SB) of 40- to 55-percent           
             predicted, or; maximum oxygen consumption of 15 to 20          
             ml/kg/min (with cardiorespiratory limit)..............       60
            FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of          
             56 to 70 percent, or; DLCO (SB) 56- to 65-percent              
             predicted.............................................       30
            FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of          
             71 to 80 percent, or; DLCO (SB) 66- to 80-percent              
             predicted.............................................       10
        Or rate primary disorder.                                           
                                                                            
        Note (1): A 100-percent rating shall be assigned for                
         pleurisy with empyema, with or without pleurocutaneous             
         fistula, until resolved.                                           
                                                                            
        Note (2): Following episodes of total spontaneous                   
         pneumothorax, a rating of 100 percent shall be assigned as         
         of the date of hospital admission and shall continue for           
         three months from the first day of the month after                 
         hospital discharge.                                                
                                                                            
        Note (3): Gunshot wounds of the pleural cavity with bullet          
         or missile retained in lung, pain or discomfort on                 
         exertion, or with scattered rales or some limitation of            
         excursion of diaphragm or of lower chest expansion shall           
         be rated at least 20-percent disabling. Disabling injuries         
         of shoulder girdle muscles (Groups I to IV) shall be               
         separately rated and combined with ratings for respiratory         
         involvement. Involvement of Muscle Group XXI (DC 5321),            
         however, will not be separately rated.                             
                                                                            
    6846  Sarcoidosis:                                                      
        Cor pulmonale, or; cardiac involvement with congestive              
         heart failure, or; progressive pulmonary disease with              
         fever, night sweats, and weight loss despite treatment....      100
        Pulmonary involvement requiring systemic high dose                  
         (therapeutic) corticosteroids for control.................       60
        Pulmonary involvement with persistent symptoms requiring            
         chronic low dose (maintenance) or intermittent                     
         corticosteroids...........................................       30
        Chronic hilar adenopathy or stable lung infiltrates without         
         symptoms or physiologic impairment........................        0
        Or rate active disease or residuals as chronic bronchitis           
         (DC 6600) and extra-pulmonary involvement under specific           
         body system involved......................................         
    6847  Sleep Apnea Syndromes (Obstructive, Central, Mixed):              
        Chronic respiratory failure with carbon dioxide retention           
         or cor pulmonale, or; requires tracheostomy...............      100
        Requires use of breathing assistance device such as                 
         continuous airway pressure (CPAP) machine.................       50
        Persistent day-time hypersomnolence........................       30
        Asymptomatic but with documented sleep disorder breathing..       0 
    ------------------------------------------------------------------------
    \1\ Review for entitlement to special monthly compensation under Sec.   
      3.350 of this chapter.                                                
    
    [FR Doc. 96-22593 Filed 9-4-96; 8:45 am]
    BILLING CODE 8320-01-P
    
    
    

Document Information

Effective Date:
10/7/1996
Published:
09/05/1996
Department:
Veterans Affairs Department
Entry Type:
Rule
Action:
Final rule.
Document Number:
96-22593
Dates:
This amendment is effective October 7, 1996.
Pages:
46720-46731 (12 pages)
RINs:
2900-AE94: Schedule for Rating Disabilities--The Respiratory System
RIN Links:
https://www.federalregister.gov/regulations/2900-AE94/schedule-for-rating-disabilities-the-respiratory-system
PDF File:
96-22593.pdf
CFR: (4)
38 CFR 4.30(b)(2)
38 CFR 3.105(e)
38 CFR 4.96
38 CFR 4.97