Schedule for Rating Disabilities; Gynecological Conditions and Disorders of the Breast

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AE72

Schedule for Rating Disabilities; Gynecological Conditions and

Disorders of the Breast

AGENCY: Department of Veterans Affairs.

ACTION: Final regulation.

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SUMMARY: This document amends the section of the Department of Veterans

Affairs (VA) Schedule for Rating Disabilities on Gynecological

Conditions and Disorders of the Breast. This amendment is based on a

General Accounting Office (GAO) study noting that there has been no

comprehensive review of the rating schedule since 1945, and

recommending that such a review be conducted. The intended effect of

this action is to update the gynecological and breast disorders section

of the rating schedule to ensure that it uses current medical

terminology, unambiguous criteria, and that it reflects medical

advances which have occurred since the last review.

EFFECTIVE DATE: This amendment is effective May 22, 1995.

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,

Regulations Staff, Compensation and Pension Service, Veterans Benefits

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

Washington, DC 20420, (202) 273-7210.

SUPPLEMENTARY INFORMATION: In December 1988, the General Accounting

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

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

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

recommendations, VA published in the Federal Register of March 26, 1992

(57 FR 10450-53) a proposal to amend 38 CFR 4.116 and 4.116a.

Interested persons were invited to submit written comments,

suggestions, or objections on or before April 27, 1992. We received

comments from Disabled American Veterans, Veterans of Foreign Wars,

Paralyzed Veterans of America, and from several VA employees.

Two commenters suggested that we revise the proposed criteria for

rating endometriosis under diagnostic code (DC) 7629, placing the

emphasis on pain and abnormal bleeding rather than on headaches.

Upon further review, VA concurs that symptoms such as headaches and

muscle cramps are not the most appropriate criteria for evaluating

endometriosis, and we have therefore modified the proposed criteria. At

the 50 percent level, the proposed criteria specified endometriomas

larger than 2 x 2 cm., ovary or tubes bound down or obstructed by

adhesions, or obliteration of the cul-de-sac. These criteria have been

modified to call for lesions involving the bladder or bowel confirmed

by laparoscopy, pelvic pain or heavy or irregular bleeding not

controlled by treatment, and bowel or bladder symptoms. The proposed 30

percent level called for several lesions or minimal adhesions with side

effects such as headaches, muscle cramps, or edema despite treatment;

but the schedule has been revised to require pelvic pain or heavy or

irregular bleeding not controlled by treatment.

One commenter suggested that we include 10 percent and 100 percent

levels for evaluation of endometriosis.

Upon further consideration we have added a 10 percent level for

those cases in which pain or bleeding requires continuous treatment.

However, endometriosis does not in our judgment reach the level of

total disability. Some women have incapacitating symptoms, but on a

cyclic basis related to their menstrual periods. Others have milder

symptoms on a constant basis. Providing a 50 percent level recognizes

the substantial level of disability that women may experience because

of endometriosis, but we believe that, in general, the highest level of

disability assigned for a condition should not exceed the evaluation

for absence of the organ involved. In this case, 50 percent for removal

of the uterus and both ovaries is the highest post-surgical evaluation.

One individual suggested that a convalescent period of six months

at 100 percent should be provided for endometriosis following surgery

or other corrective procedure. [[Page 19852]]

VA does not concur. The most extensive surgery that is likely to be

needed for endometriosis is a hysterectomy and bilateral salpingo-

oophorectomy. Healing, convalescence, and residuals are likely to be

similar to those after such surgery for other conditions. We have

established a convalescent period for this type of surgery of three

months, which is discussed in more detail below. More conservative

surgery is often indicated, including some done on an outpatient basis.

Recovery would be even more rapid in such cases and, in our judgment,

six months of convalescence cannot be justified.

One commenter noted that 30-40 percent of patients with

endometriosis become infertile and that 10-15 percent of infertile

women have endometriosis.

While endometriosis may be associated with infertility, infertility

is not itself a disability for VA rating purposes. It does not result

in impairment of average earning capacity. If loss or loss of use of a

creative organ is established as due to endometriosis, special monthly

compensation under the provisions of 38 CFR 3.350(a) may be considered.

One commenter suggested a language change under the criteria for

evaluation of prolapse of the uterus, DC 7621, from ``complete--through

vulva'' to ``complete--through vagina and introitus.''

The language suggested by the commenter is more technically

accurate and we have revised the language as suggested.

Four commenters expressed concern about a lack of clarity in the

criteria for evaluating residuals of breast surgery under DC 7626. One

said that the phrase ``following mastectomy or lumpectomy without

significant alteration of size or form'' at the 0 percent level is

confusing because literally ``mastectomy'' will result in significant

alteration of size or form and that therefore ``biopsy'' should be

substituted for ``mastectomy.'' Another said that it is impossible to

remove the breast (i.e., perform a mastectomy) without significant

alteration of size or form, and that therefore ``mastectomy'' should be

replaced by ``lumpectomy.'' One felt that the phrase ``significant

alteration of size or form'' is too subjective to be useful, and also

that a mastectomy or lumpectomy which requires removal of some breast

tissue together with supporting tissues will change the size and form

of the breast and should be compensated at a 10 percent level.

In response to these comments, VA has simplified the criteria for

evaluating breast surgery residuals and has clarified them by adding a

note defining the terms used for the various types of breast surgery

specified at each level of evaluation. At the 0 percent level, we have

replaced the words ``mastectomy or lumpectomy'' with ``wide local

excision,'' a term that we also define for VA purposes in the note.

Since the commenters did not offer alternative language for us to

consider, however, we have retained the phrase ``significant alteration

of size or form.'' We believe the term is objective enough to be useful

since it requires a substantial, as opposed to a subtle or minimal,

alteration in the normal size or form of the breast. Furthermore, a

mastectomy or lumpectomy or any other wide local excision that

significantly alters the size or form of the breast will be

compensated, not at 10 percent, but at 30 percent. For degrees of

alteration that are not significant, a 10 percent evaluation is not

warranted because there is no industrial impairment and little or no

cosmetic deformity.

Two commenters suggested that there be major and minor evaluations

for breast surgery under DC 7626, comparable to muscle loss under DC

5302, extrinsic muscles of shoulder girdle.

VA does not concur. Muscle loss is not the only disability that

results from a radical mastectomy. There are two additional disabling

aspects: removal of the breast and removal of lymphatic tissue. The

residuals of removal of a breast include pain and deformity, each of

variable extent, and a 30 percent level of disability has been

established for removal of one breast without involvement of muscle or

lymphatic tissue. Disability of the pectoral muscle under DC 5302 is

assessed solely on loss of function, and complete removal warrants an

evaluation of 30 percent or 40 percent, depending on whether it is on

the major or minor side. Residuals from the removal of lymphatic tissue

during a radical mastectomy may be as mild in degree as minimal

deformity or pain or as severe as massive lymphedema of an arm. Thus

the residual disability from each of the three elements has a range of

severity, and it is the combination of the three that we have taken

into account in assigning a level of disability following breast

surgery. Considering all of these facets of disability, we do not

believe that the difference between muscle loss on the major and on the

minor side significantly influences the overall disability from a

radical mastectomy. Fifty percent was the assigned level of impairment

for a unilateral radical mastectomy in the 1945 rating schedule. In our

judgment this is a reasonable assessment, and we have retained it in

this revision. In other than radical breast surgery there is no muscle

impairment at all, so the comment on major and minor evaluations is not

applicable.

One commenter, stating that there is no industrial impairment

following mastectomy with significant alteration of size or form but

without removal of axillary lymph nodes unless there are painful scars,

suggested that the proposed evaluation of 50 percent for both and 30

percent for one should be lower.

VA does not agree with the commenter. Residuals of mastectomy may

include pain, deformity, and sense of loss with psychological distress.

Any of these may have an effect on an individual's functioning and can

occur regardless of whether or not the external appearance of the

clothed individual is altered. We are retaining the current evaluations

because the residuals remain essentially the same as they have been for

many years, and, in our judgment, result in residual disability

consistent with the levels currently assigned.

We proposed to retain Sec. 4.116 of the 1945 rating schedule intact

with only minor changes, but one commenter criticized that section as

ambiguous and confusing, particularly the part which indicates that

removal of uterus, ovaries, etc., is considered disabling, but only

prior to the natural menopause.

VA agrees that the implied distinction of surgery before or after

the natural menopause is not warranted. The rating schedule spells out,

without qualification or restriction, the evaluations to be assigned

following the removal of female reproductive organs once the

convalescent period has ended. The surgical residuals from the anatomic

removal of an organ or organs do not differ depending on whether or not

natural, surgical, or any other type of menopause has occurred. The

last sentence of Sec. 4.116 has therefore been deleted.

We have also removed the sentences addressing congenital

malformations and new growths. They are redundant since they state

principles stated elsewhere, specifically in Sec. 4.9, covering

congenital or developmental defects as applied to the entire rating

schedule, in Sec. 4.10, covering functional impairment in general, and

in the criteria under DC's 7627 and 7628, covering evaluation of

neoplasms.

Finally, the first two sentences of Sec. 4.116, ``[i]n rating

disability from gynecological conditions the following will not be

considered as ratable conditions: (a) The natural menopause, (b)

amenorrhea, when this is based upon [[Page 19853]] developmental defect

or abnormality, and (c) pregnancy and childbirth and their incidents,

except surgical complications under certain circumstances'' and ``The

surgical complications of pregnancy will not be held the result of

service except when additional disability resulted from treatment

therein or they are otherwise attributable to unusual circumstances of

service,'' have been changed. The second sentence contains unclear

remarks about the surgical complications of pregnancy, seemingly

restricting service connection for many of them. Chronic disabilities

resulting from pregnancy, whether medical or surgical, are subject to

service connection if incurred during service, as with other chronic

disabilities. Since this sentence is not only ambiguous but offers no

specific information that would aid in evaluation of disabilities, it

has been deleted.

The first sentence has been shortened and the type of amenorrhea

that is not considered a ratable condition clarified as ``primary''

amenorrhea. This remaining sentence would serve better as a note, and

we have deleted Sec. 4.116 in its entirety and retained this sentence

as part of Note (1) at the beginning of this portion of the rating

schedule. We have also added a sentence to the note stating that

chronic residuals of medical or surgical complications of pregnancy may

be disabilities for rating purposes. Since Sec. 4.116 has been deleted,

Sec. 4.116a has been redesignated as Sec. 4.116.

One commenter felt that the rating schedule should include rating

criteria for cervical dysplasia.

VA does not concur. Cervical dysplasia is neither disease nor

injury, but a cellular abnormality of the cervix revealed by a Pap

smear. It may resolve without residuals or it may represent a

premalignant condition which is a forerunner of carcinoma or carcinoma

in situ of the cervix. If carcinoma develops in service, whether or not

preceded by cervical dysplasia, it will be service-connected. If

carcinoma develops after service, the diagnosis of cervical dysplasia

in service may or may not be a factor in establishing service

connection, which will be determined under either presumptive

provisions of 38 CFR 3.309(a) or the general principles relating to

service connection in 38 CFR 3.303 et seq. Since cervical dysplasia is

not itself a disability, it does not in our judgment warrant inclusion

in the rating schedule.

One commenter objected to the retention of separate sections for

genitourinary conditions and gynecological conditions, calling this a

remnant of antiquated prejudices.

VA does not concur. In fact, the separation of these disciplines is

standard throughout modern medicine, with separate specialists,

textbooks, medical school and hospital departments, etc. Urology has

developed as a specialty that includes both the urinary tract and the

male genital tract because these two systems share some common anatomy.

This is not the case in females, however, where the genital tract is

independent of the urinary tract and is the focus of the separate

specialty of gynecology. Combining these systems would be contrary to a

major focus of the current revision, which is to bring the rating

schedule in line with current medical practice, and would be of no

discernible advantage to veterans or to those using the rating

schedule.

The same commenter asserted that conditions of the gynecological

system, especially the loss of procreative organs, do not cause

impairment of earning capacity and should therefore not be compensated.

A second commenter suggested that our proposed method of evaluating

disabilities of the gynecological system based on the need for or

response to treatment is inappropriate because it is not based on

impairment of earning capacity as required by 38 U.S.C. 1155. A third

related comment was an objection that the proposed evaluations covering

disease, injury, or adhesions of the female reproductive organs (DC

7610-7615) were based on optimum success in overcoming the effects of

disease and the results of surgery rather than the resultant average

impairment.

VA disagrees with the three commenters. The conditions in this

system may cause pain, abnormal bleeding, incontinence, etc., and such

symptoms undoubtedly cause women to lose time from work, which affects

the ability to obtain and retain employment, and thus affects income.

In addition, loss of procreative organs may affect endocrine function,

renal function, psychological function, etc., any of which may affect

the ability to work. How well a patient feels, which often relates to

how well or how poorly a disease or injury has responded to treatment,

is a significant factor in employment. A person who requires continuous

treatment is more disabled than one who does not, and one who has

symptoms despite continuous treatment is even more impaired. Since

evaluation criteria for conditions in other body systems (e.g., malaria

(DC 9304), leukemia (DC 7703), and hypo- and hyper-thyroidism (DC 7900

and DC 7903)) take into account the need for treatment, the evaluation

criteria which we proposed under DC's 7610 through 7615 are also

consistent with other portions of the rating schedule. Our method of

evaluating many of these conditions based on response to treatment is

therefore appropriate because it assigns those who have symptoms

despite treatment the highest level of evaluation because they are the

ones who will suffer the most adverse effects on employment.

One commenter suggested that we not compensate pelvic inflammatory

disease, which he states is most often a sexually transmitted disease,

because, short of tertiary complications of syphilis, male veterans are

not compensated for sexually transmitted diseases. He stated that the

proposed rule retains disparate ratings for the same type of disability

affecting male and female veterans.

VA again disagrees. The provisions of 38 CFR 3.301(c)(1)

specifically permit consideration of service connection for residuals

of venereal disease if the initial infection occurred during active

service. The commenter's statement that males are not compensated for

residuals of venereal disease is inaccurate. Urethral strictures, for

example, which in some cases represent residuals of venereal disease,

may be compensable disabilities. We would also point out that venereal

disease presents differently, both acutely and chronically, in males

and females, and that rating criteria and entitlement to compensation

are based on disability, not on etiology. For these reasons, we find

that the inclusion of pelvic inflammatory disease in the rating

schedule does not represent disparate evaluations of similar

disabilities for males and females, and the commenter's statements do

not, in our judgment, establish a rational basis for deleting this

condition from the rating schedule.

We proposed changing the convalescent periods for Ovary, removal of

(DC 7619) and Uterus and both ovaries, removal of (DC 7617) from six

months to three months, and two commenters objected. One stated that by

reducing certain evaluations and periods of convalescence, VA was

exceeding the GAO mandate to review the rating schedule to update

medical terminology and evaluation criteria, and that a statistical

study of impairment in earning capacity should be done. The other said

that removal of both uterus and ovaries is a far more significant

surgical procedure than the removal of the uterus alone or ovary alone

and there is a basis for continuation of the six-month convalescent

period.

VA disagrees. A convalescent period of three months after removal

of the [[Page 19854]] uterus and/or ovaries is regarded as adequate for

most patients because of improvements in surgical techniques and in

postoperative care, including the practice of early ambulation. The

average convalescent period is actually shorter than three months, with

most patients requiring no more than six to eight weeks to convalesce.

VA's mandate to readjust the schedule does not derive from GAO but from

38 U.S.C. 1155, which instructs the Secretary to revise the schedule

``in accord with experience.'' A need for shorter periods of

convalescence represents a significant medical advance since the last

revision, and changes in the rating schedule to reflect this are

appropriate.

Three commenters objected to the proposal concerning the period of

total evaluation following the completion of therapy for malignancy,

citing the wide variety of possible side effects, the varying

individual time requirements for convalescence, and the complexity of

certain medical procedures.

VA does not concur with the objections. The commenters appear to

have misinterpreted the proposed rule to mean that a convalescent

evaluation will be terminated six months after treatment has ceased.

However, under the proposed change, there cannot be a reduction at the

end of six months because the process of reevaluation does not begin

until that time. First, there must be a VA examination six months after

completion of treatment. Then, if the results of that or any subsequent

examination warrant a reduction in evaluation, the reduction will be

implemented under the provisions of 38 CFR 3.105(e), which require a

60-day notice before VA can reduce an evaluation and an additional 60-

day notice before the reduced evaluation takes effect. The revision not

only requires a current examination to assure that all residuals are

documented, but also offers the veteran more contemporaneous notice of

any proposed action and expands the veteran's opportunity to present

evidence showing that the proposed action should not be taken. In our

judgment this method will better ensure that actual side effects and

recuperation times are taken into account because they will be noted on

the required VA exam. Based on commenters' concerns, however, we have

revised the note under this code so that it cannot be misinterpreted as

requiring a reduction six months after treatment is terminated. We have

also added to the note a direction to rate on residuals, if there has

been no local recurrence or metastasis, in order to make these

provisions consistent with those we provided for malignancies of the

revised genitourinary system. This is not a substantive change, but has

been made to provide further clarity, as well as internal consistency

within the rating schedule.

Two commenters urged us to retain a minimum evaluation of 10

percent following surgery or the completion of therapy for malignancy.

VA does not agree. Residuals following the medical or surgical

treatment of malignancy are common, but vary widely in type and

severity, and a specified arbitrary level of residual disability cannot

be assumed to be present in every case. As previously discussed, we

will be requiring a VA examination for each individual before adjusting

the convalescent evaluation, and that examination will also ensure that

actual residual disabilities will be documented and assigned an

accurate evaluation, which may be more or less than 10 percent.

Two commenters suggested that we retain the evaluation for removal

of one ovary with or without partial removal of the other at 10 percent

rather than changing it to 0 percent. Another stated that removal of

one ovary is analogous to atrophy of both ovaries and should therefore

be rated at 20 percent.

VA does not concur. One ovary or even part of an ovary produces

sufficient hormone to maintain normal reproductive and endocrine

functions without hormonal replacement therapy. The ultimate test of

ovarian hormonal function is the ability to support a pregnancy, and it

is a well-established medical fact that one ovary is sufficient to

support a pregnancy. This is significantly different from complete

atrophy of both ovaries (DC 7620), where there would be no hormonal

output, and replacement therapy would be necessary.

Two commenters requested that we annotate certain diagnostic codes

in this section to indicate entitlement to special monthly compensation

(SMC) under 38 U.S.C. 1114(k) for loss of a creative organ. One

suggested annotating DC's 7617, 7618, 7619, and 7626, and the other

suggested annotations ``where appropriate.''

Because the statutory requirements for SMC are very complicated and

in some cases involve more than one body system, it is impractical to

provide detailed information at every location in the rating schedule

where the potential for entitlement to SMC might arise. Rating

specialists must be aware of the need to refer to 38 CFR 3.350, the

governing regulation, in every instance where the veteran has a

condition which potentially establishes eligibility for SMC. To that

end, we have added a note at the beginning of Sec. 4.116 requiring

rating specialists to refer to Sec. 3.350 any time they evaluate a

claim involving loss or loss of use of one or more creative organs. In

view of the comments received, we have also placed footnotes after

diagnostic codes 7617 (removal of uterus and both ovaries), 7618

(removal of uterus), 7619 (removal of ovary), and 7620 (complete

atrophy of both ovaries) instructing raters to review for entitlement

to SMC. While the conditions we have annotated clearly call for review

for entitlement to SMC, almost any condition in this section might,

under certain circumstances, establish entitlement to SMC. The note at

the beginning of Sec. 4.116 makes it clear that it is the

responsibility of the rating specialist to recognize those

circumstances and assign SMC when warranted. The lack of a footnote

does not relieve rating specialists of that responsibility.

Viewing the rating schedule as a whole, we are concerned that if

there are footnotes only for obvious grants of SMC, individual veterans

entitled to SMC in less obvious situations will be disadvantaged if

rating specialists fail to recognize potential entitlement because they

have not been prompted to do so by a footnote. We believe that the

combination of the regulatory requirement in the note and the footnotes

is the best method of making sure that potential entitlement to SMC is

considered.

On further review, we have made some additional changes to the

proposed revisions for the sake of clarity and objectivity. The title

of DC 7627 has been changed from ``Breast, removal of'' to ``Breast,

surgery of,'' since surgery often stops short of removal of a breast.

In order to eliminate the need to search in other sections of the

rating schedule for criteria to evaluate DC 7625, Fistula,

urethrovaginal, (which in the proposed rule was to be rated as voiding

dysfunction under the genitourinary schedule), we have provided the

criteria for voiding dysfunction (continual urine leakage, post

surgical urinary diversion, urinary incontinence, or stress

incontinence subset of criteria) under DC 7625. The only difference is

that we changed the word urethroperineal to urethrovaginal, as being

more specific to this system.

Similarly, we proposed that Fistula, rectovaginal (DC 7624) be

evaluated as DC 7332, rectum and anus, impairment of sphincter control

(in the digestive system section of the rating schedule). In response

to a general comment on the proposed rating schedule revisions of a

number of body systems, which strongly [[Page 19855]] favored the

elimination of subjectivity and urged its extension, we removed terms

such as ``extensive leakage'' and ``fairly frequent'', which are part

of the criteria for DC 7332, in favor of criteria that are more

precise, but still based on the extent of fecal leakage and the

necessity for wearing a pad.

We made one additional minor technical change under DC 7628, Benign

neoplasms of the gynecological system or breast. The word

``genitourinary'' has been replaced by the word ``urinary'' as being

more specific to this system.

VA appreciates the comments submitted in response to the proposed

rule, which is now adopted with the amendments noted above.

The Secretary hereby certifies that this regulatory amendment will

not have a significant economic impact on a substantial number of small

entities as they are defined in the Regulatory Flexibility Act (RFA), 5

U.S.C. 601-612. The reason for this certification is that this

amendment would not directly affect any small entities. Only VA

beneficiaries could be directly affected. Therefore, pursuant to 5

U.S.C. 605(b), this amendment is exempt from the initial and final

regulatory flexibility analysis requirements of sections 603 and 604.

This regulatory amendment has been reviewed by the Office of

Management and Budget under the provisions of Executive Order 12866,

Regulatory Planning and Review, dated September 30, 1993.

(The Catalog of Federal Domestic Assistance program numbers are

64.104 and 64.109.)

List of Subjects in 38 CFR Part 4

Individuals with disability, Pensions, Veterans.

Approved: December 22, 1994.

Jesse Brown,

Secretary of Veterans Affairs.

For the reasons set forth in the preamble, 38 CFR part 4, subpart

B, is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

Subpart B--Disability Ratings

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

Authority: 38 U.S.C. 1155.

2. The undesignated center heading appearing before Sec. 4.116 is

revised to read as follows:

Gynecological Conditions and Disorders of the Breast

3. Section 4.116 is removed.

4. Section 4.116a is redesignated as Sec. 4.116 and its heading and

text are revised to read as follows:

Sec. 4.116. Schedule of ratingsgynecological conditions and disorders

of the breast.

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Rating

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Note 1: Natural menopause, primary amenorrhea, and

pregnancy and childbirth are not disabilities for rating

purposes. Chronic residuals of medical or surgical

complications of pregnancy may be disabilities for rating

purposes.

Note 2: When evaluating any claim involving loss or loss of

use of one or more creative organs, refer to Sec. 3.350 of

this chapter to determine whether the veteran may be

entitled to special monthly compensation. Footnotes in the

schedule indicate conditions which potentially establish

entitlement to special monthly compensation; however,

almost any condition in this section might, under certain

circumstances, establish entitlement to special monthly

compensation.

7610 Vulva, disease or injury of (including vulvovaginitis).

7611 Vagina, disease or injury of.

7612 Cervix, disease or injury of.

7613 Uterus, disease, injury, or adhesions of.

7614 Fallopian tube, disease, injury, or adhesions of

(including pelvic inflammatory disease (PID)).

7615 Ovary, disease, injury, or adhesions of.

General Rating Formula for Disease, Injury, or Adhesions of

Female Reproductive Organs (diagnostic codes 7610 through

7615):

Symptoms not controlled by continuous treatment............ 30

Symptoms that require continuous treatment................. 10

Symptoms that do not require continuous treatment.......... 0

7617 Uterus and both ovaries, removal of, complete:

For three months after removal............................. \1\100

Thereafter................................................. \1\50

7618 Uterus, removal of, including corpus:

For three months after removal............................. \1\100

Thereafter................................................. \1\30

7619 Ovary, removal of:

For three months after removal............................. \1\100

Thereafter:

Complete removal of both ovaries....................... \1\30

Removal of one with or without partial removal of the

other................................................. \1\0

7620 Ovaries, atrophy of both, complete....................... \1\20

7621 Uterus, prolapse:

Complete, through vagina and introitus..................... 50

Incomplete................................................. 30

7622 Uterus, displacement of:

With marked displacement and frequent or continuous

menstrual disturbances.................................... 30

With adhesions and irregular menstruation.................. 10

7623 Pregnancy, surgical complications of:

With rectocele or cystocele................................ 50

With relaxation of perineum................................ 10

7624 Fistula, rectovaginal:

Vaginal fecal leakage at least once a day requiring wearing

of pad.................................................... 100

Vaginal fecal leakage four or more times per week, but less

than daily, requiring wearing of pad...................... 60

Vaginal fecal leakage one to three times per week requiring

wearing of pad............................................ 30

Vaginal fecal leakage less than once a week................ 10

Without leakage............................................ 0

7625 Fistula, urethrovaginal:

Multiple urethrovaginal fistulae........................... 100

Requiring the use of an appliance or the wearing of

absorbent materials which must be changed more than four

times per day............................................. 60

Requiring the wearing of absorbent materials which must be

changed two to four times per day......................... 40

Requiring the wearing of absorbent materials which must be

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

7626 Breast, surgery of:

Following radical mastectomy:

Both................................................... 80

One.................................................... 50

Following modified radical mastectomy:

Both................................................... 60

One.................................................... 40

Following simple mastectomy or wide local excision with

significant alteration of size or form:

Both................................................... 50

One.................................................... 30

Following wide local excision without significant

alteration of size or form:

Both or one............................................ 0

Note: For VA purposes:

(1) Radical mastectomy means removal of the entire

breast, underlying pectoral muscles, and regional

lymph nodes up to the coracoclavicular ligament ......

[[Page 19856]]

(2) Modified radical mastectomy means removal of the

entire breast and axillary lymph nodes (in continuity

with the breast). Pectoral muscles are left intact....

(3) Simple (or total) mastectomy means removal of all

of the breast tissue, nipple, and a small portion of

the overlying skin, but lymph nodes and muscles are

left intact...........................................

(4) Wide local excision (including partial mastectomy,

lumpectomy, tylectomy, segmentectomy, and

quadrantectomy) means removal of a portion of the

breast tissue.........................................

7627 Malignant neoplasms of gynecological system or breast.... 100

Note: A rating of 100 percent shall continue beyond the

cessation of any surgical, X-ray, antineoplastic

chemotherapy or other therapeutic procedure. Six months

after discontinuance of such treatment, the appropriate

disability rating shall be determined by mandatory VA

examination. Any change in evaluation based upon that or

any subsequent examination shall be subject to the

provisions of Sec. 3.105(e) of this chapter. If there has

been no local recurrence or metastasis, rate on residuals.

7628 Benign neoplasms of the gynecological system or breast.

Rate according to impairment in function of the urinary or

gynecological systems, or skin.

7629 Endometriosis:

Lesions involving bowel or bladder confirmed by

laparoscopy, pelvic pain or heavy or irregular bleeding

not controlled by treatment, and bowel or bladder symptoms 50

Pelvic pain or heavy or irregular bleeding not controlled

by treatment.............................................. 30

Pelvic pain or heavy or irregular bleeding requiring

continuous treatment for control.......................... 10

Note: Diagnosis of endometriosis must be substantiated by

laparoscopy.

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\1\Review for entitlement to special monthly compensation under Sec.

3.350 of this chapter.

[FR Doc. 95-9714 Filed 4-20-95; 8:45 am]

BILLING CODE 8320-01-P