Schedule for Rating Disabilities; Genitourinary System Disabilities

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AE11

Schedule for Rating Disabilities; Genitourinary System

Disabilities

AGENCY: Veterans Affairs.

ACTION: Final regulation.

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SUMMARY: The Department of Veterans Affairs (VA) has amended its

Schedule for Rating Disabilities of the Genitourinary System. This

amendment is based on a General Accounting Office (GAO) study noting

that there has been no comprehensive review of the rating schedule

since 1945, and recommending that such a review be conducted. The

effect of this action is to update the genitourinary portion of the

rating schedule to ensure that it uses current medical terminology,

unambiguous criteria, and that it reflects medical advances which have

occurred since the last review.

DATES: This amendment is effective February 17, 1994.

FOR FURTHER INFORMATION CONTACT: Bob Seavey, Consultant, Regulations

Staff, Compensation and Pension Service, Veterans Benefits

Administration, Department of Veterans Affairs, 810 Vermont Avenue NW.,

Washington, DC 20420, (202) 233-3005.

SUPPLEMENTARY INFORMATION: In December 1988, the General Accounting

Office (GAO) recommended that VA prepare a plan for a comprehensive

review of the rating schedule and, based on the results, revise the

medical criteria accordingly. As part of the process to implement these

recommendations, VA published a proposal to amend 38 CFR 4.115 and

4.115a in the Federal Register of December 2, 1991 (56 FR 61216-20).

Interested persons were invited to submit written comments, suggestions

or objections on or before January 2, 1992. We received comments from

the Veterans of Foreign Wars, the Disabled American Veterans, the

Paralyzed Veterans of America, and VA employees.

We have made a number of editorial changes, primarily of syntax and

punctuation, throughout the final rule. These changes are intended to

clarify the rating criteria and represent no substantive amendment.

Generic terms such as ``severe,'' ``moderate,'' and ``mild,'' which

preceded various evaluation criteria in the proposed regulations, have

been removed. Rather than helping to explain or clarify the specific

evaluation criteria which they precede, these terms inject an element

of ambiguity not otherwise present. Under diagnostic code 7524, we have

deleted the phrase ``other than undescended or congenitally

undeveloped'' for the noncompensable evaluation criteria since the NOTE

following adequately explains that an undescended or congenitally

undeveloped testis is not ratable.

We proposed that Sec. 4.115 be amended to allow separate evaluation

of coexisting ``heart disease'' in the event of an absent kidney, or

when chronic renal disease has progressed to the point where regular

dialysis is required. One commenter pointed out that in addition to

heart disease, hypertension is often manifested in cases of renal

disease, but that the proposed regulatory language would preclude a

separate evaluation for hypertension. He suggested that we substitute

the term ``cardiovascular disease'' for ``heart disease.'' Although we

agree that this provision should apply to hypertension as well as heart

disease, we believe that the term ``cardiovascular'' is too broad since

it might be interpreted to include cardiovascular conditions unrelated

to renal dysfunction. We have therefore amended Sec. 4.115 to specify

that coexisting heart disease or hypertension may be separately

evaluated in the absence of one kidney or when the claimant requires

dialysis.

Our proposed rating formula for renal dysfunction under Sec. 4.115a

included a requirement at the 100 percent level for blood urea nitrogen

(BUN) and creatinine thresholds of more than 100mg% and 10mg%,

respectively. One commenter felt that the proposed requirements are too

high and suggested that 80mg% and 8mg% would be more appropriate. Upon

further review, we have concluded that measurements over 80/8mg%

suggest a need for dialysis and would therefore be a more appropriate

threshold. We have accordingly amended the criteria for a 100 percent

evaluation in Sec. 4.115a. In keeping with that change, we have also

amended the ranges of BUN and creatinine readings required for an 80

percent evaluation to 40-80mg% and 4-8mg%, respectively.

Two commenters felt that the word ``invalidism'' in the proposed

criteria for the 100 and 80 percent levels for renal dysfunction is

inappropriate because it is archaic, too subjective, and in fact

suggests a level of severity more consistent with entitlement to

special monthly compensation. VA agrees, and has substituted the phrase

``precluding more than sedentary activity'' for the 100 percent

evaluation, and the phrase ``generalized poor health characterized by *

* *'' for the 80 percent evaluation.

Under the 60 percent evaluation level for renal dysfunction, we had

proposed that qualifying manifestations of hypertension be referred to

as ``moderate hypertension'' whereas under the 30 percent level we had

proposed that hypertension be ``minimally compensable under diagnostic

code 7101.'' One commenter recommended that hypertension be described

consistently in terms of diagnostic code 7101 throughout the criteria

for renal dysfunction. We agree. Such a change would promote not only a

clearer understanding of the rule, but internal consistency within the

rating schedule as well. We have therefore modified the criteria for a

60 percent evaluation to require hypertension at least 40 percent

disabling under diagnostic code 7101, for a 30 percent evaluation to

require hypertension at least 10 percent disabling under diagnostic

code 7101, and the zero percent evaluation to include hypertension non-

compensable under diagnostic code 7101.

One commenter felt that either albumin and casts with a history of

acute nephritis or renal dysfunction with mild hypertension warrants a

10 percent evaluation rather than the zero percent we had proposed

under the criteria for renal dysfunction. We do not concur. Albuminuria

and granular casts are clinical findings which may or may not indicate

active kidney disease, but which themselves are not inherently

disabling. Since the level of compensation is determined primarily by

the extent to which a condition is disabling, and since an asymptomatic

condition, or combination of asymptomatic conditions, imposing no

discernible industrial impairment does not warrant a compensable

evaluation, we find no reason to assign these conditions a compensable

evaluation in the absence of chronic kidney disease or hypertension

which is compensable under diagnostic code 7101.

Two commenters questioned the reduction of the evaluation for loss

of a single kidney from 30 percent to zero percent disabling. Although

long-term renal function returns to near normal due to hypertrophy of

the remaining kidney, the significant anatomical alteration caused by

removal of a kidney, the resulting surgical scar, and the precautions

which must be taken to protect the remaining kidney, could reasonably

be expected to prevent a veteran from engaging in certain, but by no

means all, occupations. Upon further reconsideration, we have therefore

elected to retain the minimum 30 percent evaluation for loss of a

single kidney under diagnostic code 7500.

One commenter felt that the proposed criteria for rating voiding

dysfunction under Sec. 4.115a would be inadequate for evaluating

veterans with neurogenic bladders who use either indwelling or

intermittent catheterization to void, and suggested a separate

diagnostic code for neurogenic bladder. Although a need for separate

rating criteria was implied, the commenter offered no alternative

criteria for our consideration.

VA agrees that it would be useful to have a separate diagnostic

code for this disability, which is common in cases of severe spinal

cord injury. We have therefore added diagnostic code 7542 for

neurogenic bladder with instructions to rate the condition under the

criteria for voiding dysfunction, which we believe are adequate to

evaluate neurogenic bladder. Neurogenic bladder is manifested as urine

leakage or frequent urination, both of which correspond to categories

of voiding dysfunction as proposed. In addition, the word ``appliance''

as used in the criteria for incontinence clearly includes all types of

catheters as well as any other assistive device for urination.

Under the general rating criteria for urinary frequency in

Sec. 4.115a, we had proposed separate sets of evaluation criteria for

daytime and nighttime frequency. The criteria for daytime frequency

were assigned evaluations of 40, 20, and 10 percent. For nighttime

frequency, awakening to void five or more times per night was proposed

as 20 percent, awakening to void three to four times was assigned 10

percent, and one to two times was non-compensable. One commenter felt

that the evaluations for nighttime frequency should be higher than

proposed, while another believed that the distinction between daytime

and nighttime frequency is artificial and should be eliminated.

Separate criteria for nighttime frequency were proposed since a

patient may be more likely to report this symptom to an examining

physician, especially in the early stages of renal disease. Upon

further review, however, VA agrees that nighttime frequency is just as

indicative of significant disease as daytime frequency, and that

different evaluation levels are not warranted. We have therefore

incorporated the three levels originally proposed for nighttime

frequency with the 40, 20, and 10 percent levels under daytime

frequency. Instances in which a person is awakened to void only once a

night, however, have not been made compensable, since this degree of

frequency does not, in our judgment, impose a disability significant

enough to warrant the payment of compensation.

One commenter felt that the frequency of the need to change

absorbent materials under the criteria for rating voiding dysfunction

is not a useful measure of incontinence because: (1) The changing of

absorbent materials does not accurately quantify the degree of

disability, (2) the wearing of absorbent materials may be inappropriate

for paraplegics, and (3) there is no objective method to determine the

frequency of the need to change absorbent materials.

We do not concur. A person who needs to change absorbent materials

often has a greater loss of voluntary control than one who needs

changes less frequently. The frequency of changes can be objectively

reported either by the veteran or the person providing care, with the

frequency of the need for such changes determined by an examining

physician. These criteria represent, in our judgment, a satisfactory

means to measure urinary incontinence and, since no reasonable

alternative has been suggested, we have elected to retain them. For

some persons, wearing absorbent materials may be inappropriate; such

people require the use of a catheter or some other means to compensate

for the loss of control. As previously discussed, the criteria at the

60 percent level addressing the use of such an appliance are adequate

to evaluate the disabilities of those for whom the use of absorbent

materials is inappropriate.

One commenter remarked that the words ``increased to the next

higher'' were unclear in the instruction for arteriolar nephrosclerosis

following diagnostic code 7507. We agree that this language, which was

retained from the prior rating schedule, is ambiguous. The intended

effect is to recognize that heart disease or hypertension is more

serious when the claimant also has renal disabilities. We have amended

the instruction following diagnostic code 7507 to clarify this

principle.

Under the diagnostic codes for nephrolithiasis (7508),

ureterolithiasis (7510), and stricture of the ureter (7511), a 30

percent evaluation was proposed for recurrent stone formation requiring

diet therapy, drug therapy, or frequent surgical therapy. One commenter

believed a higher evaluation should be assigned for ``frequent surgical

therapy,'' since frequent surgery implies a condition more severe than

one controlled through diet or drug therapy. By ``surgical therapy'' we

meant to include extraction through a catheter or fragmentation through

such means as extracorporeal shock wave lithotripsy. To remove any

ambiguity and thus avoid confusion, we have amended the criteria under

diagnostic codes 7508, 7510, and 7511 to refer to ``invasive or non-

invasive procedures'' rather than ``surgical therapy,'' and we have

replaced the term ``frequent'' with the more objective measurement of

more than twice per year.

One commenter stated that the words ``multiple urethroperineal'' in

the evaluation criteria for fistula of the urethra (7519) were unclear.

Once again, we agree that a term retained from the prior rating

schedule is vague and potentially confusing. We have added the word

``fistulae'' to indicate that when there are two or more fistulous

tracts draining from the perineum a 100 percent evaluation will be

assigned.

Under diagnostic code 7531 (kidney transplants), we originally

proposed that a follow-up examination be conducted six months after

surgery in the same manner as for malignancies (diagnostic code 7528).

Diagnostic code 7531 previously required assignment of a 100 percent

evaluation with a prospective reduction two years after surgery. Three

commenters stated that a period longer than six months is warranted

because of the fragile condition of these patients, the complications

of surgery, the side-effects of immunosuppressive therapy, and the risk

of transplant rejection. One commenter suggested that a one year period

would be reasonable.

Considering the possibility of late immunologic, medical, and

surgical complications, we believe it is more reasonable to assess

residual disability one year after surgery instead of six months. We

have therefore amended the NOTE following diagnostic code 7531 to state

that a mandatory VA examination will be conducted one year after

hospital discharge instead of the six months originally proposed.

A minimum rating of 30 percent was proposed under the diagnostic

code for kidney transplant for as long as a patient is on

immunosuppressive medication. One commenter stated that almost all

persons who have undergone transplant surgery permanently require

immunosuppressive medication. Upon further review, VA agrees that it is

so seldom that immunosuppressive therapy can be stopped after

transplantation, that the proposed exception to the minimum evaluation

under diagnostic code 7531 is not necessary. We have deleted that

exception from the final rule.

One commenter believed that there should be an evaluation level of

30 percent in addition to the 20 percent level proposed under

diagnostic code 7532, Renal tubular dysfunctions, since various renal

tubular nephropathies may have severe disabling effects. Another

commenter suggested that the category of renal tubular dysfunctions was

too vague and seemed to embrace a variety of conditions which should be

singly listed, and that they often render veterans unemployable due to

the combination of treatment and symptoms.

Renal tubular disorders include disorders of the proximal nephron

function, disorders of function of the ascending limb of the loop of

Henle, and disorders of distal nephron function. We have amended the

parenthetical portion of the heading of diagnostic code 7532 to include

additional examples of these diseases, which have common

characteristics and should therefore be rated under the same criteria

to ensure consistency. These conditions generally cause metabolic

imbalances which can be adequately treated by replacement therapy; as

such, in our judgment, they do not warrant an evaluation greater than

20 percent. They may on occasion, however, result in more severe kidney

dysfunction. For that reason we have added an instruction to

alternatively rate this disability as renal dysfunction, which will

allow evaluations greater than 20 percent.

One commenter stated that in keeping with ``current BVA [Board of

Veterans Appeals] policy,'' the diagnostic code for penile deformity

with loss of erectile power (7522) should provide a 20 percent

evaluation even when erectile power has been restored by means of a

penile implant.

VA does not concur. Under diagnostic code 7522, two distinct

elements are required for a 20 percent evaluation: (1) Penile deformity

and (2) loss of erectile power. If either element is absent following

insertion of a penile implant or for any other reason the criteria for

a 20 percent evaluation under this code are not met, and the

instruction which the commenter requests is therefore not warranted. VA

regulations are binding upon all agencies within the Department of

Veterans Affairs, and neither BVA nor any other VA agency is free to

adopt an official policy which is contrary to established regulations.

The same commenter also requested that we add a NOTE to diagnostic

code 7522 indicating entitlement to special monthly compensation under

38 U.S.C. 1114(k).

Although loss of erectile power establishes entitlement to special

monthly compensation under 38 U.S.C. 1114(k), we do not believe that a

NOTE to such effect in the rating schedule is warranted. The criteria

regarding entitlement to special monthly compensation are extensive,

very complicated, and seldom correspond exactly to evaluation criteria

in the rating schedule. For that reason, it is important that raters

refer to the regulations governing special monthly compensation rather

than relying on cross-references in the rating schedule.

One commenter objected to the proposed elimination of a compensable

evaluation for loss of a single testicle under diagnostic code 7524,

alleging that such loss disrupts normal endocrine function and

interferes with the maintenance of secondary sex characteristics. VA

does not concur. In fact, any retrogressive changes in secondary sex

characteristics even following removal of both testes after sexual

maturity would occur slowly, if at all (Oswald S. Lowsley and T.J.

Kirwin, ``Clinical Urology'' 230 (Williams and Wilkins 1956)). A

solitary testis is in most cases adequate to sustain normal endocrine

function without hormone replacement therapy. No significant employment

handicap would likely result from this condition and a compensable

evaluation, in our judgment, is not warranted.

The same commenter objected to the proposed elimination of the

minimum rating of 20 percent for removal of the prostate gland

(diagnostic code 7526). VA does not concur. Because of the development

of improved surgical techniques for extraction of the prostate through

the perineum, bladder, surrounding capsule, or urethra, a minimum

disability evaluation of 20 percent is not warranted. Often the only

residual of this surgery is sterility, which is compensated not under

the rating schedule but by means of special monthly compensation under

38 U.S.C. 1114(k). Should any other disability result, it would be

rated under the diagnostic code for injuries, infections, hypertrophy,

and postoperative residuals of the prostate gland (7527), with

evaluations based on the criteria for voiding dysfunction or urinary

tract infections. In our judgment, this provision allows for a broad

enough range of evaluations to rate residual disability as established

by medical examination.

Three commenters urged that the previous convalescent period of one

year following cancer treatment (diagnostic code 7528) be retained,

stating that the complexity of certain medical procedures, the wide

variety of possible side-effects, and the time required to recover from

treatment precludes any realistic reduction of these recuperative

periods.

The commenters appear to have misinterpreted the proposed rule to

mean that a convalescent evaluation will terminate after six months.

The rule actually requires an examination, not a reduction, six months

after the assignment of total benefits. If the claimant remains totally

disabled, the 100 percent evaluation will continue without

interruption. If a reduction in evaluation is warranted, it will be

implemented under the provisions of 38 CFR 3.105(e).

This application of total convalescence evaluations will take into

account the wide array of possible side-effects and complications of

treatment by ensuring that any changes in evaluation are supported by

the specific findings of a current medical examination. A total

evaluation will extend indefinitely after treatment is discontinued,

with a required VA examination six months thereafter. If the results of

this or any subsequent examination warrant a reduction in evaluation,

the reduction will be implemented under the provisions of 38 CFR

3.105(e). There can be no reduction at the end of six months since any

proposed reduction would be based on the examination and the

notification process can begin only after the examination is reviewed.

This method also has the advantage of offering the veteran more

contemporary notice of any proposed action and, under the provisions of

38 CFR 3.105(e), expanding the opportunity to present evidence showing

that the proposed action should not be taken. We have revised the

wording of the NOTE based upon the concerns of the commenters, however,

to ensure that it cannot be misinterpreted as requiring a reduction six

months after treatment is terminated.

Several commenters objected to the elimination of a minimum 10

percent evaluation following treatment of cancer under diagnostic code

7528. One commenter stated that malignancies of this kind result in a

``permanent mental fixation.'' Another commenter stated that there may

be residual damage to the genitourinary system from radiation

treatment.

VA acknowledges that disability often follows cancer treatment, and

residual impairment of the genitourinary system will accordingly be

rated as either voiding or renal dysfunction. Although any residual

warranting compensation would be ascertainable on VA examination, the

existence of such residuals cannot be presumed in every case.

Psychiatric or any other complications are subject to service

connection under 38 CFR 3.310(a) of this chapter. The recurrence of

cancer at any time would warrant restoration of the 100 percent

evaluation. Rating the actual residuals will in our judgment allow

assignment of an evaluation reflecting the true severity of the

individual disability.

One commenter stated that because the proposed amendments included

reductions in certain percentage evaluations, VA was exceeding the GAO

mandate to review the rating schedule for the purpose of updating

medical terminology and evaluation criteria.

VA does not concur. VA's mandate to review the rating schedule

derives from the statutory authority which Congress has granted the

Secretary of Veterans Affairs to adopt a schedule of ratings, including

the authority to establish percentage evaluations (38 U.S.C. 1155).

Although GAO may recommend that the Secretary review the schedule from

a particular perspective, it has no authority to limit the scope of any

review which the Secretary subsequently conducts under that statutory

authority. The GAO recommendations resulted from a study finding that

the rating schedule uses outdated medical terminology, contains

ambiguous rating criteria, and does not reflect recent medical

advances. If it is to conduct a good faith review, particularly when

considering medical advances, VA cannot preclude the possibility that

some evaluations may be changed. Congress, in fact, specifically

foresaw such a possibility when it enacted legislation to amend 38

U.S.C. 1155 in order to protect the level of evaluations assigned under

superseded rating criteria. (See 137 Cong. Rec. H5928 (daily ed. July

29, 1991) (statement of Rep. Montgomery).)

One commenter implied that the proposed changes could not be made

without statistical studies showing the economic impact of

genitourinary impairments on disabled individuals. He cited a

statistical study conducted in the 1960s which he contends does not

support the proposed reductions.

The statute authorizing establishment of the schedule directs that

``[t]he Secretary shall from time to time readjust the schedule of

ratings in accordance with experience'' (emphasis supplied). Rather

than requiring statistical studies or any other specific type of data,

the statute clearly leaves the nature of the experience which warrants

an adjustment, and by extension the manner in which any review is

conducted, to the discretion of the Secretary. Although during the

1970s VA considered adjusting the rating schedule based on the same

statistical studies cited by the commenter, that approach proved to be

unsatisfactory and the proposed changes were not adopted.

To allow as much public participation in the process as possible,

we published an Advance Notice of Proposed Rulemaking (ANPRM) in the

Federal Register on August 21, 1989 (54 FR 34531-2). We received

responses from VA employees, the Naval Physical Evaluation Board, the

Veterans of Foreign Wars, the Disabled American Veterans, the Director

of Urology Programs at the National Institutes of Health, and the

general public. We also contracted with an outside consultant to

suggest revisions. In formulating recommendations, the consultant

convened a five-member panel of physicians, each specializing in a

different aspect of urology. We developed our proposed changes only

after reviewing all of the material received in response to the ANPRM,

from the consultant, and from specialists from the Veterans Health

Administration in renal diseases.

One commenter believed that the proposed changes did not reflect

the average person's ability to cope with genitourinary disorders as 38

U.S.C. 1155 requires, but were instead based upon optimum success in

overcoming the effects of disease and the results of surgery.

Presumably the commenter was referring to the convalescent periods

specified under various diagnostic codes in this portion of the

schedule.

VA does not concur. 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, quality, rate, etc.'' (``Webster's New World

Dictionary,'' Third College Edition). We have outlined above the range

of medical advice available to us when we conducted this review. The

convalescent periods adopted in this change represent in our judgment,

based on sound medical advice, neither the longest nor 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. We also note that these convalescent periods

represent the point at which the individual patient's condition is to

be evaluated by examination, and do not preclude an extension of a

total evaluation if appropriate based on the individual patient's

condition. (See comments regarding diagnostic code 7528.)

Another commenter believed that certain changes were proposed

``with an eye towards cost cutting.'' As discussed above, the revisions

were proposed based on medical considerations; no cost studies or

projections were conducted in conjunction with this review. Cost

cutting therefore was not an issue, and we believe that these revisions

will prove to have negligible budget impact.

One commenter stated that VA should consider the effects of

genitourinary conditions on life expectancy when revising this portion

of the rating schedule.

VA does not concur. To consider a factor so far removed from ``the

average impairments of earning capacity'' as the effects of various

conditions on life expectancy would clearly exceed the parameters

established by Congress in 38 U.S.C. 1155.

One commenter contended that it would be unfair for VA to reduce

any of the evaluations in the current rating schedule because doing so

could prevent some veterans from maintaining their current levels of

evaluation and thereby deprive them of the protection which would

otherwise attach to those evaluation levels after 20 years under the

provisions of 38 U.S.C. 110.

VA does not concur. In section 103(a) of the Veterans' Benefits

Programs Improvement Act of 1991 (Pub. L. 102-86), Congress modified 38

U.S.C. 1155 to provide that a readjustment to the rating schedule will

not result in a reduction of any disability evaluation in effect on the

date of the readjustment unless that disability has actually improved.

The statute effectively protects against the situation which the

commenter anticipates. Since no evaluation may be reduced solely due to

a readjustment to the rating schedule, a readjustment cannot compromise

the potential for any veteran to have an evaluation preserved under the

provisions of 38 U.S.C. 110.

One commenter suggested that VA allow special monthly compensation

at the level for aid and attendance whenever a veteran requires

hemodialysis three or more times a week. Another commenter suggested

that we allow special monthly compensation under 38 U.S.C. 1114 (k) for

loss of a single kidney.

VA does not concur. The entitlement criteria for special monthly

compensation are established by Congress and codified at 38 U.S.C. 1114

(k) through (s). Regulations implementing these statutory grants of

special monthly compensation are found in VA's Adjudication regulations

(38 CFR part 3) rather than in the Schedule for Rating Disabilities (38

CFR part 4). This issue is therefore beyond the scope of the current

rulemaking.

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, 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.

In accordance with Executive Order 12291, Federal Regulation, the

Secretary has determined that this regulatory amendment is non-major

for the following reasons:

(1) It will not have an annual impact on the economy of $100

million or more.

(2) It will not cause a major increase in costs or prices.

(3) It will not have significant adverse effects on competition,

employment, investment, productivity, innovation, or on the ability of

United States-based enterprises to compete with foreign-based

enterprises in domestic or export markets.

The Catalog of Federal Domestic Assistance numbers are 64.104 and

64.109.

List of Subjects in 38 CFR Part 4

Handicapped, Pensions, Veterans.

Approved: March 5, 1993.

Jesse Brown,

Secretary of Veterans Affairs.

Editorial note: This document was received at the Office of the

Federal Register on January 11, 1994.

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

Subpart B--Disability Ratings

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

Authority: 72 Stat. 1125; 38 U.S.C. 1155.

2. Section 4.115 is amended by adding two sentences at the end of

the section to read as follows:

Sec. 4.115 Nephritis.

* * * If, however, absence of a kidney is the sole renal

disability, even if removal was required because of nephritis, the

absent kidney and any hypertension or heart disease will be separately

rated. Also, in the event that chronic renal disease has progressed to

the point where regular dialysis is required, any coexisting

hypertension or heart disease will be separately rated.

3. Section 4.115a is redesignated and revised as Sec. 4.115b and a

new Sec. 4.115a is added to read as follows:

Sec. 4.115a Ratings of the genitourinary system--dysfunctions.

Diseases of the genitourinary system generally result in

disabilities related to renal or voiding dysfunctions, infections, or a

combination of these. The following section provides descriptions of

various levels of disability in each of these symptom areas. Where

diagnostic codes refer the decisionmaker to these specific areas

dysfunction, only the predominant area of dysfunction shall be

considered for rating purposes. Since the areas of dysfunction

described below do not cover all symptoms resulting from genitourinary

diseases, specific diagnoses may include a description of symptoms

assigned to that diagnosis.

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Rating

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Renal dysfunction:

Requiring regular dialysis, or precluding more than sedentary

activity from one of the following: persistent edema and

albuminuria; or, BUN more than 80mg%; or, creatinine more

than 8mg%; or, markedly decreased function of kidney or other

organ systems, estpecially cardiovascular.................... 100

Persistent edema and albuminuria with BUN 40 to 80mg%; or,

creatinine 4 to 8mg%; or, generalized poor health

characterized by lethargy, weakness, anorexia, weight loss,

or limitation of exertion.................................... 80

Constant albuminuria with some edema; or, definite decrease in

kidney function; or, hypertension at least 40 percent

disabling under diagnostic code 7101......................... 60

Albumin constant or recurring with hyaline and granular casts

or red blood cells; or, transient or slight edema or

hypertension at least 10 percent disabling under diagnostic

code 7101.................................................... 30

Albumin and casts with history of acute nephritis; or,

hypertension non-compensable under diagnostic code 7101...... 0

Voiding dysfunction:

Rate particular condition as urine leakage, frequency, or

obstructed voiding

Continual Urine Leakage, Post Surgical Urinary Diversion,

Urinary Incontinence, or Stress Incontinence:

Requiring the use of an appliance or the wearing of absorbent

materials which must be changed more than 4 times per day.... 60

Requiring the wearing of absorbent materials which must be

changed 2 to 4 times per day................................. 40

Requiring the wearing of absorbent materials which must be

changed less than 2 times per day............................ 20

Urinary frequency:

Daytime voiding interval less than one hour, or; awakening to

void five or more times per night............................ 40

Daytime voiding interval between one and two hours, or;

awakening to void three to four times per night.............. 20

Daytime voiding interval between two and three hours, or;

awakening to void two times per night........................ 10

Obstructed voiding:

Urinary retention requiring intermittent or continuous

characterization............................................. 30

Marked obstructive symptomatology (hesitancy, slow or weak

stream, decreased force of stream) with any one or

combination of the following:

1. Post void residuals greater than 150 cc.

2. Uroflowmetry; markedly diminished peak flow rate (less

than 10 cc/sec).

3. Recurrent urinary tract infections secondary to

obstruction.

4. Stricture disease requiring periodic dilatation every 2

to 3 months................................................ 10

Obstructive symptomatology with or without stricture disease

requiring dilatation 1 to 2 times per year................... 0

Urninary tract infection:

Poor renal function: Rate as renal dysfunction.

Recurrent symptomatic infection requiring drainage/frequent

hospitalization (greater than two times/year), and/or

requiring continuous intensive management.................... 30

Long-term drug therapy, 1-2 hospitalizations per year and/or

requiring intermittent intensive management.................. 10

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Sec. 4.115b Ratings of the genitourinary system--diagnoses.

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Rating

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7500Kidney, removal of one:

Minimum evaluation........................................ 30

Or rate as renal dysfunction if there is nephritis,

infection, or pathology of the other.

7501Kidney, abscess of:

Rate as urinary tract infection........................... 30

7502Nephritis, chronic:

Rate as renal dysfunction.

7504Pyelonephritis, chronic:

Rate as renal dysfunction or urinary tract infection,

whichever is predominant.

7505Kidney, tuberculosis of:

Rate in accordance with Secs. 4.88b or 4.89, whichever is

appropriate.

7507Nephrosclerosis, arteriolar:

Rate according to predominant symptoms as renal

dysfunction, hypertension or heart disease. If rated

under the cardiovascular schedule, however, the

percentage rating which would otherwise be assigned will

be elevated to the next higher evaluation.

7508Nephrolithiasis:

Rate as hydronephrosis, except for recurrent stone

formation requiring one or more of the following:

1. diet therapy

2. drug therapy

3. invasive or non-invasive procedures more than two

times/year............................................. 30

7509Hydronephrosis:

Severe; Rate as renal dysfunction.

Frequent attacks of colic with infection (pyonephrosis),

kidney function impaired................................... 30

Frequent attacks of colic, requiring catheter drainage...... 20

Only an occasional attack of colic, not infected and not

requiring catheter drainage................................ 10

7510Ureterolithiasis:

Rate as hydronephrosis, except for recurrent stone

formation requiring one or more of the following:

1. diet therapy

2. drug therapy

3. invasive or non-invasive procedures more than two

times/year............................................. 30

7511Ureter, stricture of:

Rate as hydronephrosis, except for recurrent stone

formation requiring one or more of the following:

1. diet therapy

2. drug therapy

3. invasive or non-invasive procedures more than two

times/year............................................. 30

7512Cystitis, chronic, includes interstitial and all etiologies,

infectious and non-infectious:

Rate as voiding dysfunction.

7515Bladder, calculus in, with symptoms interfering with

function:

Rate as voiding dysfunction

7516Bladder, fistula of:

Rate as voiding dysfunction or urinary tract infection,

whichever is predominant.

Postoperative, superapubic cystotomy...................... 100

7517Bladder, injury of:

Rate as voiding dysfunction.

7518Urethra, stricture of:

Rate as voiding dysfunction.

7519Urethra, fistual of:

Rate as voiding dysfunction.

Multiple urethroperineal fistulae......................... 100

7520Penis, removal of half or more.............................. 30

Or rate as voiding dysfunction.

7521Penis removal of glans...................................... 20

Or rate as voiding dysfunction.

7522Penis, deformity, with loss of erectile power............... 20

7523Testis, atrophy complete:

Both...................................................... 20

One....................................................... 0

7524Testis, removal:

Both...................................................... 30

One....................................................... 0

Note--In cases of the removal of one testis as the result

of a service-incurred injury or disease, other than an

descended or congenitally undeveloped testis, with the

absence or nonfunctioning of the other testis unrelated

to service, an evaluation of 30 percent will be assigned

for the service-connected testicular loss. Testis,

undescended, or congenitally undeveloped is not a ratable

disability.

7525Epididymo-orchitis, chronic only:

Rate as urinary tract infection.

For tubercular infections: Rate in accordance with Secs.

4.88b or 4.89, whichever is appropriate.

7527Prostate gland injuries, infections, hypertrophy,

postoperative residuals:

Rate as voiding dysfunction or urinary tract infection,

whichever is predominant.

7528Malignant neoplasms of the genitourinary system............. 100

Note--Following the cessation of surgical, X-ray,

antineoplastic chemotherapy or other therapeutic

procedure, the rating of 100 percent shall continue with

a mandatory VA examination at the expiration of six

months. 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 reoccurrence or metastasis, rate on residuals as

voiding dysfunction or renal dysfunction, whichever is

predominant.

7529Benign neoplasms of the genitourinary system:

Rate as voiding dysfunction or renal dysfunction,

whichever is predominant.

7530Chronic renal disease requiring regular dialysis:

Rate as renal dysfunction.

7531Kidney transplant:

Following transplant surgery.............................. 100

Thereafter: Rate on residuals as renal dysfunction,

minimum rating........................................... 30

Note--The 100 percent evaluation shall be assigned as of

the date of hospital admission for transplant surgery and

shall continue with a mandatory VA examination one year

following hospital discharge. 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.

7532Renal tubular disorders (such as renal glycosurias,

aminoacidurias, renal tubular acidosis, Fanconi's syndrome,

Bartter's syndrome, related disorders of Henle's loop and

proximal or distal nephron function, etc.):

Minimum rating for symptomatic condition.................. 20

Or rate as renal dysfunction.

7533Cystic diseases of the kidneys (polycystic disease, uremic

medullary cystic disease, Medullary sponge kidney, and similar

conditions):

Rate as renal dysfunction.

7534Atherosclerotic renal disease (renal artery stenosis or

atheroembolic renal disease):

Rate as renal dysfunction.

7535Toxic nephropathy (antibotics, radiocontrast agents,

nonsteroidal anti-inflammatory agents, heavy metals, and

similar agents):

Rate as renal dysfunction.

7536Glomerulonephritis:

Rate as renal dysfunction.

7537Interstitial nephritis:

Rate as renal dysfunction.

7538Papillary necrosis:

Rate as renal dysfunction.

7539Renal amyloid disease:

Rate as renal dysfunction.

7540Disseminated intravascular coagulation with renal cortical

necrosis:

Rate as renal dysfunction.

7541Renal involvement in diabetes mellitus, sickle cell anemia,

systemic lupus erythematosus, vasculitis, or other systemic

disease processes.

Rate as renal dysfunction.

7542Neurogenic bladder:

Rate as voiding dysfunction.

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[FR Doc. 94-1045 Filed 1-14-94; 8:45 am]

BILLING CODE 8320-01-P