2018-07081. Schedule for Rating Disabilities; Gynecological Conditions and Disorders of the Breast

AGENCY:

Department of Veterans Affairs.

ACTION:

Final rule.

SUMMARY:

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (VASRD) by revising the portion of the rating schedule that addresses gynecological conditions and disorders of the breast. The effect of this action is to ensure that this portion of the rating schedule uses current medical terminology and to provide detailed and updated criteria for evaluation of gynecological conditions and disorders of the breast.

DATES:

Effective Date: This rule is effective on May 13, 2018.

FOR FURTHER INFORMATION CONTACT:

Ioulia Vvedenskaya, M.D., M.B.A., Medical Officer, Part 4 VASRD Regulations Staff (211C), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, [phone]. (This is not a toll-free telephone number.)

SUPPLEMENTARY INFORMATION:

VA published a proposed rule in the Federal Register at 80 FR 10637 on February 27, 2015, to amend 38 CFR 4.116, the portion of the VASRD dealing with gynecological conditions and disorders of the breast. VA provided a 60-day public comment period and interested persons were invited to submit written comments on or before April 28, 2015. VA received 13 comments.

Several commenters expressed their support for the proposed rule and thanked VA for promoting gender equality in the rating schedule.

One commenter demanded compensation for his multiple debilitating health issues, which he attributed to exposure to toxic substances at Fort McClellan. He also urged VA to pass the Fort McClellan Health Registry Act, H.R. 411, 113th Cong. (2013). Several commenters stated their belief that their multiple medical conditions are due to exposure to toxic substances at Fort McClellan and asked to be considered for service connection. Another commenter provided information about his medical conditions, which he stated he developed after his reservist's training at Fort McClellan that involved chemical agent training. These comments focus on issues of service connection, rather than the appropriate rating for already service-connected disabilities, and individual claims for VA benefits, which are beyond the scope of this rulemaking. Regarding the commenter's request that VA “pass” the Fort McClellan Health Registry Act, VA notes that this act is a Congressional act and not before VA. This comment is also beyond the scope of this rulemaking. Therefore, VA makes no changes to the proposed rule based on these comments.

One commenter had a question about the proposed note to diagnostic code 7615 “Ovary, disease, injury, or adhesions of” asking if the note would create a narrow category for disability evaluation by identifying dysmenorrhea and secondary amenorrhea. The commenter's concern is not entirely clear. To the extent the commenter is asking whether VA considers dysmenorrhea and secondary amenorrhea disabilities for rating purposes, the note to diagnostic code 7615 provides that dysmenorrhea and secondary amenorrhea shall be rated under that diagnostic code. To the extent the commenter is asking whether identification of dysmenorrhea and secondary amenorrhea in the note limits the application of diagnostic code 7615 to those diseases, it does not. Dysmenorrhea and secondary amenorrhea are only examples of diseases that would be rated under diagnostic code 7615. Other impairments associated with disease, injury, or adhesions of the ovaries will continue to be rated under diagnostic code 7615. Therefore, VA makes no changes based on this comment.

One commenter wanted to include premature hysterectomy secondary to menorrhagia as an additional gynecological disability in the rating schedule. VA evaluates service-connected hysterectomy under diagnostic codes 7617 and 7618. The cause of the hysterectomy may be a factor in determining service connection, but is not important in evaluating the condition. Therefore, VA makes no changes based on this comment.

One commenter suggested adding a new diagnostic code or adjusting an existing code for infertility due to the loss or loss of use of other organs besides the uterus and ovaries, specifically fallopian tubes. The commenter asserted that, with respect to the uterus and ovaries, the minimum rating for a condition that causes infertility is 20 percent and that this rating does not take into account symptoms, only whether the organs are able to function reproductively. Therefore, the commenter asserts that any damage to any part of the female reproductive system that causes infertility should result in at least a 20 percent evaluation.

While tubal damage may be associated with infertility, infertility is not in itself a disability for VA rating purposes. It does not result in the loss of average earning capacity. See 38 CFR 4.1 (stating that the purpose of the rating schedule is to represent the average impairment in earning capacity resulting from diseases and injuries in civil occupations). Diagnostic code 7614, Fallopian tube, disease, injury, or adhesions of, provides disability ratings for functional impairment due to symptoms associated with fallopian tube damage. If loss or loss of use of a creative organ due to service-connected fallopian tube damage is present, VA will consider special monthly compensation under the provisions of 38 CFR 3.350(a). VA makes no changes based on this comment.

The same commenter proposes to add the diagnosis of repeated miscarriages to the list of presumptive conditions for female veterans who have been exposed to radiation, herbicides, or other environmental factors that could negatively impact the ability of a fetus to properly develop and carry to full term. The commenter also suggested VA provide for an award of special monthly compensation under the provisions of § 3.350(a) for repeated miscarriages of an unknown etiology while on active duty. Miscarriages themselves are not disabilities for VA rating purposes, as they do not result in impairment of earning capacity. See 38 CFR 4.1. The proposed rating criteria provide for adequate ratings based on impairment in earning capacity due to service-connected damage to reproductive organs, which may include chronic residuals of medical or surgical complications of pregnancy incurred during service. Additionally, special monthly compensation may be warranted for loss or loss of use of a creative organ due to service-connected disability. See 38 CFR 3.350(a)(1). Updating the list of presumptive conditions for veterans who have been exposed to radiation, herbicides, or other environmental factors is beyond the scope of this rulemaking, which is about the rating of conditions which have been service connected, not about which diseases should be subject to presumptive service connection. Therefore, VA makes no changes based on these comments.

The same commenter asked how powerful a diagnosis of female sexual arousal disorder would be as supporting evidence for military sexual trauma (MST). This rulemaking concerns the rating schedule in part 4, specifically 38 CFR 4.116, and the evaluations that VA assigns for physiological impairment due to disorders of the gynecological system and disorders of the breasts. The evidentiary criteria for posttraumatic stress disorder are listed in 38 CFR 3.304(f). Further, mental disabilities due to MST are evaluated under the rating schedule for mental disorders in § 4.130. This comment is beyond the scope of this rulemaking. Therefore, VA makes no changes based on this comment.

One commenter was supportive of the overall changes and additions to this section of the rating schedule. However, the commenter expressed concern that the proposed rating criteria for diagnostic code 7621 do not adequately measure disability affecting multiple body systems. Specifically, the commenter stated that the proposed rule was unclear as to whether a veteran would obtain evaluations under other body systems for the complications of pelvic organ prolapse, or whether the mild, moderate, or severe rating under proposed amended diagnostic code 7621 is meant to encompass all symptoms due to one or multiple pelvic organ prolapses. The commenter stated that, if these manifestations in different body systems are meant to be compensated under diagnostic code 7621, there is great potential for undercompensating the veteran, as separate ratings under the genitourinary and digestive system may afford a higher combined evaluation. The commenter further questioned whether rating the manifestations separately would constitute “pyramiding” under 38 CFR 4.14.

The same commenter also indicated that the Pelvic Organ Prolapse Quantification (POP-Q) scoring system upon which proposed diagnostic code 7621 was based does not correlate with the severity of symptoms affecting multiple body systems. In addition, the same commenter suggested that VA add a note to diagnostic code 7621 to clarify that functional impairment of other body systems, including the urinary and the digestive systems, as a result of pelvic organ prolapse, shall be evaluated under the appropriate diagnostic codes.

Evaluations under proposed diagnostic code 7621 were intended to represent the average severity of symptoms, including gynecological, urinary, and digestive symptoms, and level of impairment as contemplated by the POP-Q system. Therefore, assigning separate ratings under proposed diagnostic code 7621 and the genitourinary or digestive systems would have violated pyramiding principles under 38 CFR 4.14 by allowing evaluations for urinary and/or digestive symptoms twice. See Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). VA acknowledges, however, that the average may not apply to all women and that two women with the same degree of prolapse (as measured by POP-Q) may experience different disabling effects based on their anatomical size. Therefore, in order to more accurately evaluate functional impairment and to ensure that the severity of the symptoms affecting multiple body systems are fully captured, VA amends the proposed rating criteria and the note under diagnostic code 7621 to include guidance on how to rate the residuals and complications of pelvic organ prolapse.

First, VA amends diagnostic code 7621 to provide a 10 percent disability rating in all cases of complete or incomplete pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy. This minimum level of compensation recognizes the disabling effects of the alteration to a woman's normal anatomy, such as a feeling of vaginal fullness or heaviness or pressure in the pelvis, that are not generally included in the compensable levels of disability in other body systems. The higher disability ratings in originally proposed diagnostic code 7621 took into consideration genitourinary, digestive, and skin symptoms, which will now be evaluated separately as described in the revised note to diagnostic code 7621.

Second, VA agrees with the commenter that information should be added to the proposed note under diagnostic code 7621 to clarify how rating personnel should evaluate urinary and digestive symptoms associated with pelvic organ prolapse. Specifically, VA is adding information to the note under diagnostic code 7621 to clarify that rating personnel should separately evaluate any genitourinary, digestive, or skin symptoms under the appropriate diagnostic code(s) and combine all evaluations with the 10 percent evaluation under diagnostic code 7621. With this clarification, VA ensures that women with pelvic organ prolapse will receive adequate levels of compensation based on the functional impairment associated with their prolapse, regardless of any anatomical differences. The discussion by the commenter identified another potential approach of considering the greater evaluation under either proposed diagnostic code 7621 or the appropriate system. Under that approach, however, a veteran whose evaluation was based on a diagnostic code under a different body system would not be compensated for the disabling effects of prolapse specific to the gynecological system. The revised rule ensures that the disabling effects associated with multiple body systems are fully captured.

The same commenter also suggested VA amend VA Form 21-0960K-2, Gynecological Conditions Disability Benefits Questionnaire (DBQ) to add questions regarding the effects of any diagnosed gynecological condition on the digestive system and consideration of whether the veteran has loss of use of a creative organ. The commenter noted that the DBQ already asks the examiner to comment on whether the gynecological conditions impact the genitourinary system. Currently, VA Form 21-0960K-2 asks an examiner to report any complications resulting from obstetrical or gynecological conditions or procedures. Additionally, VA Form 21-0960K-2 asks the examiner if the veteran has any other pertinent findings, complications, conditions, signs and/or symptoms related to any conditions listed in the diagnosis section of the form. Therefore, VA has an adequate mechanism to capture each and every condition related to the effects of any diagnosed gynecological condition, including the digestive system and loss of use of a creative organ. VA also notes that all affected DBQs will be updated upon issuance of this final rule and will adhere to the same principles of recording pertinent findings. Therefore, VA makes no changes based on these comments.

Lastly, the same commenter suggested VA add a separate diagnostic code in § 4.116 for loss of coital function due to removal of the vagina by colpectomy and a note to consider special monthly compensation under 38 CFR 3.350(a) to increase rating consistency. VA appreciates this comment, but notes that the VASRD, in accordance with 38 CFR 4.1, is “a guide in the evaluation of disability” in terms of occupational impairment and is not an exhaustive list of all potential diseases or conditions. This is further reinforced by 38 CFR 4.20, which specifically provides for analogous evaluations for unlisted conditions according to closely related diseases or injuries based on function affected, anatomical location, and symptomatology.

Colpectomy, also known as vaginectomy, is a surgical procedure that obliterates the vaginal canal in order to alleviate the symptoms of advanced pelvic organ prolapse or to treat gynecological malignancies. Such obliterative procedure is reserved for women who are not candidates for more extensive surgery or do not plan future vaginal intercourse. Colpectomy is generally deemed appropriate for elderly patients with medical comorbidities or for patients with previous failed prolapse surgery or pessary trials who are not sexually active. Evans, J., Karram, M., “Step by step: Obliterating the vaginal canal to correct pelvic organ prolapse,” OBG Manag. 2012 February;24(2):30-41 https://www.mdedge.com/​sites/​default/​files/​Document/​September-2017/​0212_​OBGM_​Karram.pdf. Colpectomy in younger patients is performed to treat advanced vaginal and/or uterine cancer. In cases of uterine cancer, colpectomy is used exclusively in conjunction with total abdominal hysterectomy. In cases of vaginal cancer, vaginectomy may be partial, subtotal, or total, depending on the extent of the disease. Vaginal reconstruction is offered in order to preserve coital function. Bardavil, T. et al., “Vaginal Cancer” (updated Jan. 11, 2015), Medscape, https://emedicine.medscape.com/​article/​269188-overview#a23 (last accessed March 8, 2018). Partial vaginectomy is not associated with the loss of coital function.

Accordingly, the vast majority of colpectomy procedures involve associated partial or complete hysterectomy, currently addressed in diagnostic code 7618 and a new, separate diagnostic code for colpectomy is unnecessary; functional impairment due to the colpectomy/total vaginectomy is adequately addressed under diagnostic code 7618 for partial and/or total hysterectomy. In rare cases, colpectomy is performed without any form of hysterectomy; VA will evaluate these circumstances analogously to diagnostic code 7618, and, in the absence of functional impairment or other findings, apply the provisions of 38 CFR 4.31 to establish service connection at a noncompensable rate. This approach provides VA with adequate criteria to evaluate functional impairment associated with colpectomy, with or without hysterectomy, and to establish service connection for a disability for purposes of an award of special monthly compensation under 38 CFR 3.350(a). We note that while vaginal damage due to colpectomy may be associated with loss of coital function, coital function is not in itself a disability for VA rating purposes. It does not result in the loss of earning capacity. See 38 CFR 4.1.

Entitlement to special monthly compensation for anatomical loss or loss of use of a creative organ may not be awarded more than once per creative organ. In the case of colpectomy with loss of coital function, the presence or absence of partial/total hysterectomy does not entitle a female veteran to additional awards of special monthly compensation based on further anatomical loss of a creative organ; in either scenario the veteran has met the statutory criteria for anatomical loss or loss of use of the female creative organ with varying degrees of functional disability associated with the loss/loss of use. Accordingly, establishing a separate diagnostic code for colpectomy would not create entitlement to additional special monthly compensation under 38 CFR 3.350. For these reasons, VA makes no changes based on these comments at this time.

One commenter was supportive of the proposed addition of the new diagnostic code 7632, Female sexual arousal disorder (FSAD). The commenter noted that the title used, “Female sexual arousal disorder,” is not the current medical term used in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In DSM-5, gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: Female Sexual Interest/Arousal Disorder.

VA's proposed diagnostic code 7632 differs from the DSM-5 diagnosis because it only addresses the physiologic form of FSAD, which is caused in part by decreased blood flow to the genital area and peripheral nerve damage due to micro trauma or disease process. This form of FSAD does not include the psychological features of Female Sexual Interest/Arousal Disorder outlined in DSM-5 such as lack of, or significantly reduced, sexual interest or desire. If an individual is diagnosed with Female Sexual Interest/Arousal Disorder as outlined in DSM-5 that is service connected, she will be rated under the appropriate diagnostic code under 38 CFR 4.130, which pertains to mental disorders. Furthermore, if her disability picture includes FSAD, defined as the continual or recurrent inability to accomplish or maintain an ample lubrication-swelling reaction during sexual intercourse, then separate compensation under diagnostic code 7632 would be appropriate. Therefore, VA makes no changes based on this comment.

VA appreciates the comments submitted in response to the proposed rule. Based on the rationale stated in the proposed rule and in this document, the proposed rule is adopted as a final rule with the changes noted above. Additionally, VA notes that it is making a technical correction to its proposed changes to Appendix B to Part 4—Numerical Index of Disabilities. Specifically, VA inadvertently left out instructions to delete references to diagnostic codes 7622 and 7623 which, as discussed in the proposed rule, are being removed.

Effective Date of Final Rule

Veterans Benefits Administration (VBA) personnel utilize the Veterans Benefit Management System for Rating (VBMS-R) to process disability compensation claims that involve disability evaluations made under the VASRD. In order to ensure that there is no delay in processing veterans' claims, VA must coordinate the effective date of this final rule with corresponding VBMS-R system updates. As such, this final rule will apply effective May 13, 2018, the date VBMS-R system updates related to this final rule will be complete.

Executive Orders 12866, 13563, and 13771

Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a “significant regulatory action,” which requires review by the Office of Management and Budget (OMB), as “any regulatory action that is likely to result in a rule that may: (1) Have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) Create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) Materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) Raise novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in this Executive Order.”

The economic, interagency, budgetary, legal, and policy implications of this regulatory action have been examined and it has been determined not to be a significant regulatory action under Executive Order 12866. VA's impact analysis can be found as a supporting document at http://www.regulations.gov,, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA's website at http://www.va.gov/​orpm by following the link for VA Regulations Published from FY 2004 through FYTD. This rule is not an E.O. 13771 regulatory action because this rule is not significant under E.O. 12866.

Regulatory Flexibility Act

The Secretary hereby certifies that this final rule will not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. This final rule will not affect any small entities. Only certain VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.

Unfunded Mandates

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

Paperwork Reduction Act

This final rule contains provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521). Specifically, this final rule is associated with information collections related to the filing of disability benefits claims (VA Form 21-526EZ) as well as Disability Benefits Questionnaires (DBQs) which enable a claimant to gather the necessary information from his or her treating physician as to the current symptoms and severity of a disability (VA Forms 21-0960K-1, Breast Conditions and Disorders DBQ, and 21-0960K-2, Gynecological Conditions DBQ). Both information collections are currently approved by the Office of Management and Budget (OMB) and have been assigned OMB control numbers 2900-0747 and 2900-0778, respectively. VA has reviewed the impact of this final rule on these information collections and determined that the information collection burden is de minimis.

Catalog of Federal Domestic Assistance

The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.009, Veterans Medical Care Benefits; 64.104, Pension for Non-Service-Connected Disability for Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death.

List of Subjects in 38 CFR Part 4

• Disability benefits
• Pensions
• Veterans

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Jacquelyn Hayes-Byrd, Deputy Chief of Staff, Department of Veterans Affairs, approved this document on April 3, 2018, for publication.

Dated: April 3, 2018.

Jeffrey M. Martin,

Impact Analyst, Office of Regulation Policy & Management, Office of the Secretary, Department of Veterans Affairs.

For the reasons set out in the preamble, VA amends 38 CFR part 4 as follows:

PART 4—SCHEDULE FOR RATING DISABILITIES

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

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

Subpart B—Disability Ratings

2. Amend § 4.116 as follows:

a. Revise the entry for diagnostic code 7610;

b. Add a note at the end of the entries for diagnostic codes 7615 and 7619;

c. Revise the entry for diagnostic code 7621;

d. Remove the entries for diagnostic codes 7622 and 7623;

e. Revise the entries for diagnostic codes 7627 and 7628;

f. Add entries for diagnostic codes 7630 through 7632 in numerical order; and

g. Add an authority citation at the end of the section.

The revisions and additions read as follows:

§ 4.116

Schedule of ratings—gynecological conditions and disorders of the breast.

	Rating
	*         *         *         *         *         *         *
7610 Vulva or clitoris, disease or injury of (including vulvovaginitis)
	*         *         *         *         *         *         *
7615 * * *
Note: For the purpose of VA disability evaluation, a disease, injury, or adhesions of the ovaries resulting in ovarian dysfunction affecting the menstrual cycle, such as dysmenorrhea and secondary amenorrhea, shall be rated under diagnostic code 7615
	*         *         *         *         *         *         *
7619 * * *
Note: In cases of the removal of one ovary as the result of a service-connected injury or disease, with the absence or nonfunctioning of a second ovary unrelated to service, an evaluation of 30 percent will be assigned for the service-connected ovarian loss
	*         *         *         *         *         *         *
7621 Complete or incomplete pelvic organ prolapse due to injury, disease, or surgical complications of pregnancy	10
Note: Pelvic organ prolapse occurs when a pelvic organ such as bladder, urethra, uterus, vagina, small bowel, or rectum drops (prolapse) from its normal place in the abdomen. Conditions associated with pelvic organ prolapse include: uterine or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or any combination thereof. Evaluate pelvic organ prolapse under DC 7621. Evaluate separately any genitourinary, digestive, or skin symptoms under the appropriate diagnostic code(s) and combine all evaluations with the 10 percent evaluation under DC 7621
	*         *         *         *         *         *         *
7627 Malignant neoplasms of gynecological system	100
Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. 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 § 3.105(e) of this chapter. Rate chronic residuals to include scars, lymphedema, disfigurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body system
7628 Benign neoplasms of gynecological system. Rate chronic residuals to include scars, lymphedema, disfigurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body system
	*         *         *         *         *         *         *
7630 Malignant neoplasms of the breast	100
Note: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, 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 § 3.105(e) of this chapter. Rate chronic residuals according to impairment of function due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code 7626
7631 Benign neoplasms of the breast and other injuries of the breast. Rate chronic residuals according to impairment of function due to scars, lymphedema, or disfigurement (e.g., limitation of arm, shoulder, and wrist motion, or loss of grip strength, or loss of sensation, or residuals from harvesting of muscles for reconstructive purposes), and/or under diagnostic code 7626
7632 Female sexual arousal disorder (FSAD)	1 0
1 Review for entitlement to special monthly compensation under § 3.350 of this chapter.

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

3. Amend appendix A to part 4 by:

a. Revising the entries for diagnostic codes 7610, 7615, 7619, 7621, 7622, 7623, 7627, and 7628; and

b. Adding, in numerical order, entries for diagnostic codes 7630 through 7632.

The revisions and additions read as follows:

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

Sec.	Diagnostic code No.
	*         *         *         *         *         *         *
	7610	Criterion May 22, 1995; title May 13, 2018.
	*         *         *         *         *         *         *
	7615	Criterion May 22, 1995; note May 13, 2018.
	*         *         *         *         *         *         *
	7619	Criterion May 22, 1995; note May 13, 2018.
	*         *         *         *         *         *         *
	7621	Criterion May 22, 1995; evaluation May 13, 2018.
	7622	Removed May 13, 2018.
	7623	Removed May 13, 2018.
	*         *         *         *         *         *         *
	7627	Criterion March 10, 1976; criterion May 22, 1995; title, note May 13, 2018.
	7628	Added May 22, 1995; title, criterion May 13, 2018.
	*         *         *         *         *         *         *
	7630	Added May 13, 2018.
	7631	Added May 13, 2018.
	7632	Added May 13, 2018.
	*         *         *         *         *         *         *

4. Amend appendix B to part 4 by:

a. Revising the entries for diagnostic codes 7610 and 7621;

b. Removing the entries for diagnostic codes 7622 and 7623;

c. Revising the entries for diagnostic codes 7627 and 7628; and

d. Adding, in numerical order, entries for diagnostic codes 7630 through 7632.

The revisions and additions read as follows:

Appendix B to Part 4—Numerical Index of Disabilities

Diagnostic code No.
	*         *         *         *         *         *         *
Gynecological Conditions and Disorders of the Breast
7610	Vulva or clitoris, disease or injury of (including vulvovaginitis).
	*         *         *         *         *         *         *
7621	Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy.
	*         *         *         *         *         *         *
7627	Malignant neoplasms of gynecological system.
7628	Benign neoplasms of gynecological system.
	*         *         *         *         *         *         *
7630	Malignant neoplasms of the breast.
7631	Benign neoplasms of the breast and other injuries of the breast.
7632	Female sexual arousal disorder (FSAD).
	*         *         *         *         *         *         *

5. Amend appendix C to part 4 as follows:

a. Add in alphabetical order an entry for “Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy, including uterine or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or combination”.

b. Add in alphabetical order an entry for “Female sexual arousal disorder (FSAD)”.

c. Under the heading “Injury,” add in alphabetical order an entry for “Breast”.

d. Under the heading “Neoplasms: Benign:”:

i. Add in alphabetical order an entry for “Breast”.

ii. Remove “Gynecological or breast” and in its place add “Gynecological”.

e. Under the heading “Neoplasms: Malignant:”:

i. Add in alphabetical order an entry for “Breast”.

ii. Remove “Gynecological or breast” and in its place add “Gynecological”.

f. Remove the entry “Pregnancy, surgical complications”.

g. Under the heading “Uterus,” remove the entry “Displacement”.

h. Remove “Vulva disease or injury of” and add in its place “Vulva or clitoris, disease or injury of”.

The additions and revisions read as follows:

Appendix C to Part 4—Alphabetical Index of Disabilities

	Diagnostic code No.
	*         *         *         *         *         *         *
Complete or incomplete pelvic organ prolapse due to injury or disease or surgical complications of pregnancy, including uterine or vaginal vault prolapse, cystocele, urethrocele, rectocele, enterocele, or combination	7621
	*         *         *         *         *         *         *
Female sexual arousal disorder (FSAD)	7632
	*         *         *         *         *         *         *
Injury:
	*         *         *         *         *         *         *
Breast	7631
	*         *         *         *         *         *         *
Neoplasms:
Benign:
Breast	7631
	*         *         *         *         *         *         *
Malignant:
Breast	7630
	*         *         *         *         *         *         *